An Introduction to Medication Adherence Medication Adherence Project (MAP) A project of the Cardiovascular Prevention & Control Program and the Fund for Public Health in New York
Drugs don t work in patients who don t take them. C. Everett Koop
Epidemiology of Nonadherence 50% of the US population is prescribed medication for chronic conditions Of those prescribed medication, only 50% are taking it as directed Sources: Angell SY et al. City Health Information. 2009;28:1-8; Haynes RB. Compliance in Health Care. Johns Hopkins University Press;1979.
MAP Approach to Improving Adherence Promotes patient-provider communication Encourages self-management support Based on evidence Grounded in quality improvement principles
Adherence Improves Outcomes
Proportion with subsequent cardiovascular (CV) event (myocardial infarction, stroke, or coronary heart disease Adherence death) by the percentage of and time in the CVD past month Events when participants reported taking medications as prescribed (P =.20 for proportion with events across all 4 adherence categories; P =.03 for proportion with events in patients with adherence <=75% vs >75% of the time) CVD = cardiovascular disease. Source: Gehi AK et al. Arch Intern Med. 2007;167:1798-1803. Copyright restrictions may apply.
Survival after Heart Attack Adherent Nonadherent Source: Ho PM et al. Arch Intern Med. 2006;166:1842-1847. Copyright restrictions may apply.
Adherence and HbA1c HbA1c = hemoglobin A1c. Source: Rhee MK et al. Diabetes Educ. 2005;31;240-250.
Mean, Median, and Interquartile Range of the Proportion of Days Covered (PDC) by Statin for Each Interval Adherence Diminishes Over Time* *Data shown is for adherence to statins Source: Benner JS et al. JAMA. 2002;288:455-461. Copyright restrictions may apply.
Adherence Rates of medication to CV use for Medications the entire cohort Source: Ho PM. et al. Arch Intern Med. 2006;166:1842-1847. Copyright restrictions may apply.
Starting Early Patients receiving brief in-office medication counseling after a new statin prescription were 17% more likely to continue filling prescriptions at 6 months Casebeer L et al. BMC Fam Pract. 2009 Jun 30;10:48.
Non-adherence Costs Nonadherence is linked to higher medical costs for patients with diabetes, high cholesterol, or hypertension Source: Sokol MC et al Med Care. 2005;43(6);521-530.
Total Costs and Adherence* *total healthcare costs for one year for patients with diabetes Source: Sokol MC et al Med Care. 2005;43(6);521-530.
Barriers to Adherence
Patient Barriers Complexity: There are so many pills, I can t keep them straight! Cost: I can t afford my medicine so I will only take half a pill today. Difficulty remembering: I forget to take them. Lack of understanding: Why do I need them? Not feeling sick: I feel fine. I don t need them. Side effects: The yellow pills make me feel sick. Embarrassment/Stigma: I don t want my friends to know. Depression: I don t care What s the point? Health literacy: I can t understand these instructions! Belief systems: My sister took insulin then had her leg amputated.
Provider Barriers Lack of time: The 15 minutes I have does not allow enough time to talk to my patients. Lack of resources and training: I m afraid to ask don t want to open up Pandora s Box! Lack of understanding: Why don t my patients just do what I tell them to do? Lack of reimbursement: I don t get paid to tell them how to take their medications and therefore cannot afford to make time. Unaware of how to simplify regimens: How can I simplify especially when my prescribing options are limited? Unaware of options for lower-cost medicines: I don t know what to tell patients if they don t have the money I can t tell them to take half a pill.
Pharmacist Barriers Difficulty communicating with the prescriber: It s hard to reach the prescribers to recommend changes in medication in a timely manner. Language barriers: As a small business owner, I cannot afford to staff my pharmacy with translators for all of the different languages my clients speak. Lack of time to remind patients to pick up medications: There are systems in place to flag patients who don t pick up, but not enough time to call them all.
Provider Solutions Normalize nonadherence Ask about adherence at every visit Reconcile medications Simplify dosing and administration Prescribe long-lasting supply (90 vs 30 days) Ask about costs, prescribe generics and refer to prescription assistance programs
Simplify Schedules Rate of Adherence (%) 85 80 75 70 65 60 55 50 45 Adherence decreases with increasing dosage frequency Once a day Twice a day Three times/day Four times/day Medication Schedule Sources: Osterburg L, Blaschke T. NEJM. 2005;353:487-497; Claxton AJ et al. Clin Ther. 2001;23:1296-310.
Prescribe Longer-Lasting Supply Patients receiving 60-day supply (vs 30-day) of statins were 1.4 times more likely to be adherent Increasing prescription drug supply by 30 days was associated with a 5.7% increase in mean adherence Sources: Batal et al. BMC Health Services Research 2007; 7: 175, Schectman et al. Medical Care 2002; 40: 1294-1300.
Pharmacist Solutions Use systems that flag patients who missed refills Use stickers on bottles to identify patients who are late picking up refills. Speak to them about adherence Synchronize refill timings Suggest to patients to use one pharmacy for all of their medications Communicate with patients health care providers directly
Conclusions Medication adherence improves health outcomes and results in lower healthcare costs Nonadherence is widespread There are numerous barriers to adherence Regularly assessing patient adherence, improving communication, and addressing identified barriers can improve adherence
This slide set complements the Medication Adherence Project (MAP) Training Manual and Toolkit. For these and other resources related to medication adherence, go to www.nyc.gov/heart