Medication Adherence: Barriers, Predictors, and Strategies PDF

Medication Adherence Predictors, Barriers and Prevention Strategies Danielle M. Candelario, PharmD, BCPS Associate Professor Rosalind Franklin University of Medicine and Sciences Skills II_AY 24  Let’s think about a patient case scenario JW is a 51 year-old...

Medication Adherence Predictors, Barriers and Prevention Strategies Danielle M. Candelario, PharmD, BCPS Associate Professor Rosalind Franklin University of Medicine and Sciences Skills II_AY 24  Let’s think about a patient case scenario JW is a 51 year-old male presenting to the pharmacy-led heart failure clinic for 1-month follow-up of a heart failure with reduced ejection fraction (HFrEF) exacerbation that required hospitalization. It has been 6 months since his last office visit since he works as a truck driver and has been out of town. He asks for a prescription for compression socks as he noticed increasing swelling in his ankles. Patient states he has been out of furosemide and carvedilol for the past month. The carvedilol was added after his last hospital discharge. When asked about why he has not filled these, he stated he does not like the side effects of the furosemide and often misses the second dose of carvedilol. He begrudgingly has a cell phone for his work but does not like to use it. He states adherence to his other medication, though he sometimes makes it to the pharmacy a couple of days late due to his work. His primary care physician told him at discharge, “If you do not Adapted from Transitions of Care in Pharmacy Casebook. Available via: https://accesspharmacy.mhmedical.com/CaseContent.aspx? get it together and take your medications, you are going to die”. gbosID=580894&gbosContainerID=278&viewByNumber=false&groupid=0#264368223 2  Let’s think about a patient case scenario Past Medical History Hypertension, HFrEF, Hyperlipidemia, Myocardial Infarction, History of illicit drug use Social History Mother and father died from MI at 60 and 51 respectively Siblings: three brothers, one deceased from MI and three sisters, two of whom have had at least one MI before age 60. All siblings have hypertension Divorced and lives alone; monogamous female partner Truck driver x 30 years (self-insured; Medicaid) (+) tobacco use – 1 1/2 pack per day x 25 years (+) alcohol – 1 to 2 beers daily 3  Pre Question #1 The term ‘adherence’ refers to: A. The number of pills picked up from the pharmacy and is economically focused B. The shared-decision making between the provider and the patient C. Passive behavior in which the patient is following instructions from the provider D. Active, voluntary and collaborative involvement in a mutually accepted therapeutic course 4  Pre Question #2 Which of the following is the most common misconception about medication adherence? A. It is the provider’s role to primary manage a patient’s chronic disease state B. Patients must have a sufficient understanding of the regimen C. Cultural factors may contribute to nonadherence D. Adherence can be assessed by both subjective and objective means 5  Pre Question #3 Which of the following is a commonly known risk factor that may be contributing to JW’s nonadherence? A. Hyperlipidemia diagnosis B. History of substance abuse C. Living alone D. Job Instability 6  Pre Question #4 The following are behavioral interventions a provider could address and could benefit JW’s medication adherence EXCEPT: A. Confirm administration technique B. Use adherence aids C. Increase the frequency of visits D. Simplify the treatment regimen 7  Learning Objectives At the end of this lecture, student pharmacists should be able to … 1 2 3 4 5 6 7 Define List the Know the Identify the Identify Describe Identify medication potential advantages purpose and predictors of causes of strategies to adherence negative and types of nonadherenc medication prevent and outcomes disadvantag questions e nonadherenc resolve associated es of various used in the e (AIM nonadherenc with measures of DRAW Tool Model) e consistent nonadherenc adherence with the e underlying cause(s). 8 Change in Terminology Complian ce Adherence Suggests patient is passively following orders Preferred term as it suggests that the treatment plan is based on a Definition = “yielding to the therapeutic alliance established wishes of others” between patient and HCP 9  Defining Adherence The extent to which a person’s behavior corresponds with agreed recommendations from a healthcare provider – Taking medications correctly – Following diet and exercise plans – Attending follow-up appointments Goes beyond just medication therapy Adherence is dependent on a good patient-provider relationship 10  Defining Medication Adherence Extent to which patients take medications prescribed by their health care provider – Filling the prescription – Taking the medications at the correct time – Taking the correct dose Concordance – Forming a therapeutic alliance to optimize health from the best use of medicines, compatible with what the patient desires and is capable of achieving 11  Examples of concordance in Patient #1 practice Instructed to test blood sugars for glucose readings 6 times per day (before each meal and 2 hours after). Each box of testing strips (#100). Patient reports callused fingers and frustration with blood testing 6x per day. How do we form a therapeutic alliance with this patient to optimize their care? Patient #2 Instructed to take medication, Eliquis with evening meal. Patient reports missing several doses per week as he works 2pm-11pm. How do we form a therapeutic alliance with this patient to 12 optimize their care?  The Leaky Bucket: What happens to every 100 new prescriptions 13 Non-Adherence Statistics Nonadherence to medications is estimated to cause 125,000 deaths annually Overall, about 20% to 50% of patients are nonadherent to medical therapy People with chronic conditions only take about half of their prescribed medicine Adherence drops when there are long waiting times at clinics or long time lapses between appointments 14  Non-Adherence Rates Adherence rates for acute diseases tend to be better than chronic diseases Estimated adherence rates for chronic diseases are approximately 50% – Hypertension – Hypercholesterolemia Primary non-adherence in asthma reported at 17- 48% – Not filling the initial prescription for an inhaler 15  The Cost of Nonadherence Annually, nonadherence is responsible for: 30 – 50 125K 5% Annual increase in % Preventable deaths prescription costs of medications are not taken Multiple adherence as to barriers lead to $100B Significant financial burden for patients, prescribed Preventable health increasing each year serious problems for patients and health care costs systems 16  Consequences of Poor Adherence Will not achieve desired clinical response Progression of the disease – Hypertension: Stroke, Atrial fibrillation, Myocardial infarction – HIV/AIDS: Increased drug resistance, opportunistic infections Hospitalizations – Emergency room visits for asthma exacerbations – Hospital admission for exacerbation of heart failure – Medication non-adherence cost approximately $100 billion/year due to hospital admissions Disability and death 17  Provider Misconceptions If we explain the risk of We “manage” We can motivate nonadherence, the patient’s patient’s to adhere patients will chronic disease automatically be motivated “Who’s disease Motivation is self- This threatening, is it anyway?” motivation and the chastising approach, cheerleading style like the cheerleader approaches have approach, has limited limited utility and utility and may lead to may lead to results that are decreasing rates of opposite of what they adherence are trying to 18 accomplish.  Provider Misconceptions Cont’d Providing education Elderly patients should be enough to have lower adherence rates ensure optimal adherence Studies show that while the Studies repeatedly elderly generally take more show that traditional medications and have more educational programs barriers to adherence, their have little or no effect actual adherence rates are on medication better than younger adherence populations! in asymptomatic 19 chronic diseases. Predictors of Poor Medication Adherence In your experiences, what do you think are predictors of poor adherence? 20  Predictors of Poor Medication Adherence Presence of depression or cognitive impairment Treatment of asymptomatic illness Inadequate follow-up/discharge planning Side effects of medication Poor patient-provider Complexity relationship Missed/skipped appointments Complexity of medication regimen High medication cost/copayments Presence of barriers 21 Barriers to Adherence: COST One MAJOR barrier to adherence is the cost of medicine – Patients consistently report out-of-pocket costs as a top reason for medication nonadherence Almost ¼ of discharge medications have access barriers Nonadherence is further exacerbated by lack of insurance of underinsurance 22  FYI: Defining the Federal Poverty Line (FPL) https://www.healthcare.gov/glossary/federal-poverty-level-fpl/ 23  Who are the Uninsured Webinar: Spotlight Please! Innovations in Improving Medication Access. APhA. 24 December 2022 Causes of Non-adherence (AIM Model) Informatio n Motivati Ability on 25  AIM Model Ability –related causes Treatment is too complicated Unable to swallow pills Difficulty getting the medication out of the Informatio package Cognitive problems or is n forgetful Medication is not suited to the patient’s lifestyle Physical handicap Too many tablets to take each day Motivati Ability on 26  AIM Model Information-related causes Patient does not understand or has not been informed about the disease or its complications Informatio Does not know how long he/she must take the medication n Does not know how to administer the medication Does not know what to do to reduce and to manage side adverse effects Motivati Ability on 27 AIM Model Motivation-related causes Does not believe he/she is sick Does not trust the health professional Believes natural products are Informatio better than “chemicals” n Afraid of becoming dependent Doesn’t see the beneficial effects Doesn’t believe he/she is susceptible to the complications of the disease Heard news or media reports that Motivati the medication is “dangerous” Ability on 28  Assessing Medication Rates of adherence Adherence – Varying ways of reporting medication adherence % of the prescribed medications taken by the patient over a period of time Some investigators include the correct dose taken at the correct time No standard for what constitutes “adherence” – Some studies use 80% of doses taken correctly – Others studies use 95% Particularly among patients with serious conditions such as with human immunodeficiency virus (HIV) 29 The many forms of non-adherence make it difficult to assess Omissions of doses Not taking the medication at the correct time – Incorrect dose, increasing or decreasing the frequency of doses Stopping treatment too soon Primary non-adherence – Not filling the initial prescription “White coat” adherence – Phenomenon where patients will be adherent to their medications around the time of appointments “Drug holidays” 30 Measures of Adherence Two methods available for measuring adherence Direct Indirect Methods Methods Both have advantages/disadvantages and no method is considered gold standard 31  Direct Examples of Direct Methods Methods Directly observed therapy – i.e. watch someone take a medication Measure concentration of drug in 1. Expensive blood and/or urine levels 2. Burdensome to the – i.e. Phenytoin, Valprioc Acid, Warfarin HCP 3. Susceptible to Measuring biologic markers distortion by the patient – i.e. HIV viral load, Cholesterol, Hemoglobin A1C 32  Examples of Indirect Indirect Methods Methods Patient self-report/questionnaire Pill counts – Pill dumping – Patient can switch medications or therapy 1. Each can be Prescription refills confounded by many factors – Same pharmacy, same medication, same therapy? Assessment of clinical response (ex. BP) Medication diaries Electronic medication monitors 33  Verbal Approaches to Assess Adherence One approach is the supportive adherence probe – “I noticed there were some missing refills of your blood pressure medication and I’m concerned that there might be a problem.” This use of an “I” message makes your concern the main issue and not their behavior and encourages them to talk about issues (cost, side effects, etc.) that caused them not to refill the medication. Alternatively – “What’s been your experience with the new medication?” Look for pink flags during the interview that may indicate adherence issues. Answers such as “The doctor wants me to take it….” or “I’m supposed to take it….” are clear indicators that they are not taking it the way it is prescribed. Alternatively – “Since your last visit, what kind of problems have you been having remembering to take your medications” 34  Verbal Approaches to Assess Adherence Another approach is the universal statement – “Many of my patients have some difficulties remembering to take their medication. What kind of problems have you experienced?” – “I know it must be difficult to take all of your medications regularly. How often do you miss taking them?” – “I take the time to ask all of my patients about medication adherence because it is important. What have been your experiences with being adherent?” If the patient shares the fact that they are having problems, the provider needs to probe for more details with questions such as – “How many times has it happened since the last visit? Why do you think it happened? Tell me about the circumstances the last time it happened.” 35  Avoid the Threatening The way to prevent Approach patients from altering their responses to prevent chastisement is to avoid the threatening approach and instead “set the stage” at the initial visit – Confirming it is the patient’s disease and their accurate input is important. Introduce your perspective on taking medication. a. “Together, we want to find a medicine that you are genuinely interested in taking because it controls your disease without side effects. You are the one who is putting the medication into your body, so it’s your opinion that is most important, not mine. So please always let me know exactly what you think about the medicines we are trying. I’m counting on your input. In addition, most people have problems figuring out how to fit taking medication and other changes into their existing life.” b. “I realize that there will be some difficulties in working medication taking into their daily routine and I will work with you to get the best possible results.” Tell them at each visit you are going to ask about each of those three issues. c. “Therefore, because I need your honest input to make this medicine work best for you, at each visit I’m going to ask you how it’s working, what kind of problems you think the medication might be causing, plus ask about problems you may be having in remembering to take your medicines. We can then work together to resolve any issues that may arise.” 36  Assessing Medication Adherence in Practice Historically, experts cite the lack of accuracy of the interview and in effect feel that patients routinely lie about their medication adherence. – If patients do “lie” about their adherence, it is due to atrocious provider-patient communication techniques on the part of the provider! Let’s Practice! Scenario #1 You receive an alert “Overdue (Late) Refill” for a beclomethasone inhaler. How can you address this ? At your table, take a moment to come up with a 37  How to Assess Medication Adherence using structured patient interview Utilizing the Drug Adherence Work-up Tool: DRAW® tool 1. Please tell me how you take your medication every day 2. Do you feel like you have too many medications or too many doses per day? 3. Do you sometimes forget to take your medication on routine days? 4. Do you forget on non-routine days such as weekends or when traveling? 5. Do you have a concern that your medication is not helping you? We will use this 6. Do you feel that you do not need this medication? tool in lab 7. Have you had any side effects? 8. Are you concerned about side effects? 9. Is the cost of this medication too much? Pharmacist: At any time during the interview, did you sense an issue about decreased cognitive function? Is there a limitation on instrumental activities of daily living to affect adherence and/or use of adherence aids? 38  In Summary: Identifying Poor Adherence Be familiar with predictors of poor adherence Ask the patient about their adherence to medications in a non-judgmental fashion Acknowledge that taking the medications can be difficult Ask patients if they are having any side effects Ask about barriers to treatment Keep the questions from the DRAW tool in your ‘toolbox’ and use them when needed 39 Strategies for Improving Adherence  Stop and Discuss Case: 52 yo male with past medical history of Diabetes and high blood pressure reports limited health literacy and is unable to read (English or Spanish). He reports consistent medication adherence issues. What are some specific strategies that can be employed for improving medication adherence in this patient? 41  Tailored Guidance and Service CDC focuses on tailored guidance which includes medication counseling or motivational interviewing sessions. – Tailored services include one or more of the following: patient tools, such as pillboxes, medication cards, and calendars; medication refill synchronization; and enhanced follow-up. – Other strategies include: Medication Therapy Management (MTM), Appointment based Model (ABM), Collaborative Practice Agreement (CPA) and text messaging https://www.cdc.gov/dhdsp/pubs/medication- adherence.htm 42  Improving Adherence: Reminder Tools Reminder tools, adherence or alarms Encourage the use of a medication-taking system – Texts, alarms, apps, smart bottles, pill boxes – Use of special blister packs, if available – Institute a medication calendar – Linking: Link medication taking to a daily routine – Visible and easily accessible medication lists 43  Improving Adherence: Guided Guided counseling Counseling addressed concerns about the effectiveness or necessity of the medication Use open-ended questions to divulge their concerns and motivations – Example: Ask, “On a scale of 1 to 10, 10 being the most important, how important is it to you that you take this mediation?” – If the score is low, a follow-up question could be, “Why a 3?” and not a 7” or “What could help raise your score to 9 or 10” Listen for indicators of DESIRE, ABILITY, REASONS and NEED to make changes. Listen for their COMMITMENT and TAKING STEPS to make changes. 44 –  Improving Adherence: Cost Reduction Strategies Reducing number of medications Generic Substitution Use of combination drugs when Therapeutic Interchange possible 45  Improving Adherence: Cost Reduction Strategies Consider alternative methods to help with cost (1) Dispensary of Hope - charitable medication distributor (2) Medicaid Expansion -Qualify based on your income alone. (3) Section 340B of the Public Health Service Act requires pharmaceutical manufacturers participating in Medicaid to sell outpatient drugs at discounted prices to health care organizations that care for many uninsured and low-income patients. (4) Prescription Assistance Programs (PAP) - Manufacturers may provide financial assistance or drug free product (5) Discount Programs – ex. GoodRx Webinar: Spotlight Please! Innovations in Improving Medication Access. APhA. 46 December 2022  Improving Adherence: Symptom Management If patient expresses concerns of side effects: Consider if the symptoms are consistent with side effects of medications that patient is taking Consider if the symptoms need to be treated or if there is a need to make a change in treatment 47  Improving Adherence: Simplifying Regimen Improve dosing schedule – Use medications with longer half- lives – Depot injections or transdermal Adherence to medication according to patches frequency of doses – Reduce number of medications Combination formulations 48  Improving Adherence: Digital Health Digital Health is a broad, multidisciplinary concept that includes concepts from an intersection between technology and healthcare. Digital health applies digital transformation to the healthcare field, incorporating software, hardware and services. Examples include: 1. Medical Apps – Major draw of these apps is their cost-effectiveness: most apps are free, though some will collect data for resale. Many apps also encourage adherence through the use of gamification and metrics. – Free to $9.99 2. Smart pill bottles – These devices can track when patients take their medications through sensors in a cap that detect when a bottle is open, or through AdhereTech’s design incorporates sensors and cellular technology into the sensors in the bottle itself that determineplastic thewalls weight ofSensors can of a bottle. accurately measure a single pill of solid the remaining pills. medication and down to one milliliter of liquid medication. If a patient misses a dose, the bottle reminds them with an on-bottle light, then a chime, and finally https://www.pharmacytimes.com/view/5-digital-tools-for-improving-medication-adherence an automated text message or49 phone call.  Improving Adherence: Digital Health Digital Health is a broad, multidisciplinary concept that includes concepts from an intersection between technology and healthcare. Digital health applies digital transformation to the healthcare field, incorporating software, hardware and services. Examples include: 3. Smart package systems – High-tech versions of blister and strip packaging, smart package devices serve as reminders for patients and provide tracking of dispensed doses. Smart package systems are particularly useful for patients with multiple medications, and they can integrate with drugs packaged by a pharmacy. 4. Smart pill dispensers – These devices incorporate home voice assistants, remote access to health care professionals, and other activation features while dispensing medication. Pria – Smart – $30 to $150 Automated Dispensing Machine https://www.pharmacytimes.com/view/5-digital-tools-for-improving-medication-adherence 50  Improving Adherence: Physical Instrumental activities of daily living (IADL): – Consider whether the patient is able to prepare their meals, phone for refills, or use an adherence aid without assistance. – Consider the following Visual restrictions (Macular Degeneration, Cataracts) Quality of hearing Manual dexterity (Arthritis, Neuropathy) Consider these limitations when considering the type of compliance aid 51  Improving Adherence: Other Cognitive Issues: – Enlist the help of others Additional assistance from alternative care givers such as competent relative, visiting nurse, assisted living staff, other community resources that provide assistance in daily activities to maintain medication regimen. Maintaining a current list of local and/or best available resources is recommended – Multidiscipline, Utilize other HCP’s Consider other medications: – Consider whether or not (1) anticholinergics could be contributing to cognitive memory decline, (2) any cholinesterase inhibitors are being counteracted by anticholinergics. Consider a and recommend physician/patient resolution. 52  In summary Adherence to medications for chronic diseases is poor Non-adherence can lead to increased health care costs, disease progression, and death Patients should be asked about their adherence in a non- judgmental way Health care providers need to recognize indicators of poor adherence and work collaboratively with patients to improve medication adherence rates Development of a genuine patient-provider relationship can help pharmacists recommend appropriate adherence tools or mechanisms based on the individual patient need 53 Let’s check your understanding  Let’s think about a patient case scenario JW is a 51 year-old male presenting to the pharmacy-led heart failure clinic for 1-month follow-up of a heart failure with reduced ejection fraction (HFrEF) exacerbation that required hospitalization. It has been 6 months since his last office visit since he works as a truck driver and has been out of town. He asks for a prescription for compression socks as he noticed increasing swelling in his ankles. Patient states he has been out of furosemide and carvedilol for the past month. The carvedilol was added after his last hospital discharge. When asked about why he has not filled these, he stated he does not like the side effects of the furosemide and often misses the second dose of carvedilol. He begrudgingly has a cell phone for his work but does not like to use it. He states adherence to his other medication, though he sometimes makes it to the pharmacy a couple of days late due to his work. His primary care physician told him at discharge, “If you do not Adapted from Transitions of Care in Pharmacy Casebook. Available via: https://accesspharmacy.mhmedical.com/CaseContent.aspx? get it together and take your medications, you are going to die”. gbosID=580894&gbosContainerID=278&viewByNumber=false&groupid=0#264368223 55  Let’s think about a patient case scenario Past Medical History Hypertension, HFrEF, Hyperlipidemia, Myocardial Infarction, History of illicit drug use Social History Mother and father died from MI at 60 and 51 respectively Siblings: three brothers, one deceased from MI and three sisters, two of whom have had at least one MI before age 60. All siblings have hypertension Divorced and lives alone; monogamous female partner Truck driver x 30 years (self-insured; Medicaid) (+) tobacco use – 1 1/2 pack per day x 25 years (+) alcohol – 1 to 2 beers daily 56  Question #1 The term ‘adherence’ refers to: A. The number of pills picked up from the pharmacy and is economically focused B. The shared-decision making between the provider and the patient C. Passive behavior in which the patient is following instructions from the provider D. Active, voluntary and collaborative involvement in a mutually accepted therapeutic course 57  Question #2 Which of the following is the most common misconception about medication adherence? A. It is the provider’s role to primary manage a patient’s chronic disease state B. Patients must have a sufficient understanding of the regimen C. Cultural factors may contribute to nonadherence D. Adherence can be assessed by both subjective and objective means 58  Question #3 Which of the following is a commonly known risk factor that may be contributing to JW’s nonadherence? A. Hyperlipidemia diagnosis B. History of substance abuse C. Living alone D. Job Instability 59  Question #4 The following are behavioral interventions a provider could address and could benefit JW’s medication adherence EXCEPT: A. Confirm administration technique B. Use adherence aids C. Increase the frequency of visits D. Simplify the treatment regimen 60  Medication Adherence Predictors, Barriers and Prevention Strategies Danielle M. Candelario, PharmD, BCPS Associate Professor Rosalind Franklin University of Medicine and Sciences Skills II_AY 24  Lab Activity: Part I (50 minutes) Activity Objectives:  Identify different physical limitations and their impact on medication adherence  Reflect on how these physical limitations can be overcome to improve adherence Activity Description: This lab activity allows student pharmacists to experience first-hand how physical limitations, can impact medication adherence. Spend a few minutes with each of the simulated experiences and reflect on how each limitation can impact adherence. Activity Debrief 62  Lab Activity: Part II (50 minutes) Activity Objectives: As a result of participation in this activity, the student pharmacist should be able to: 1. Collect a current medication list from a simulated patient 2. Identify patient non-adherence with a medication regimen using the DRAW © tool 3. Identify potential strategies to improve medication adherence Activity Description: Student pharmacists will begin to identify address patient non-adherence with a medication regimen. Student pharmacists will work in groups of three to interview a “patient” and investigate potential reasons for nonadherence and identify possible solutions. Student pharmacists will rotate to each have the opportunity to play a patient. Page 3-4: DRAW Tool Page 5,6,7: Patient Scenarios (Don’t peak. Only look at the patient you plan to play) Activity Debrief 63  Take Home Assignment Activity Description: You will complete a Medication Adherence Activity over the next three weeks. Pick up your prescription in the pharmacy. Please take your “medication” per the label and take your first dose NOW and then tomorrow morning. 64  Take Home Assignment Adherence Scenarios: There are FIVE scenario’s for this activity which will be emailed to the class listserve on specific dates. Each email will come from [email protected] and will include “ALERT_Your prescription (Activity)” or “ALERT_Your appointment (Activity)” Once you return on January 7th, we will spend the first 20-30 minutes reflecting and discussing the activity. Bring your medication vial back with you. During this exercise, you are asked to track how adherent you are with your medication. I expect that you may miss doses – after all, this is a real-life learning exercise, so just keep track of how you do and jot down the reason why you miss the dose and be honest. You are not graded on how adherent you are but rather how self-aware of how easy/difficult adherence can be. 65