Chapter 13: Assessing and Promoting Medication Adherence PDF

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 13: Assessing and Promoting Medication Adherence Sharon L. Youmans; Kirsten BibbinsDomingo OBJECTIVES Objectives Define medication adherence. Describe the scope and consequences of poor medication adherence. Summarize the patient, clinician, and system factors that contribute to poor medication adherence. Describe clinician–patient communication strategies to assess and promote medication adherence. Identify interventions to promote medication adherence. INTRODUCTION Mr. Cruise is a 55yearold janitor who left his job 1 year ago because of worsening heart failure, hypertension, and diabetes. He manages to keep his regular appointments with his cardiologist and primary care physician, but over the past year, he has been hospitalized four times for management of his heart failure. During each hospitalization, his medical team suspects poor adherence with his medication regimen. Patients living with chronic disease (e.g., hypertension, diabetes, or HIV) often have complex treatment regimens and use multiple medications. Patients may find that being adherent with medications is a challenge, and poor medication adherence makes it difficult to achieve the desired goals of chronic disease management. The World Health Organization (WHO) defines adherence as “the extent to which a person’s behavior—taking medications, following a diet, and/or executing lifestyle changes—corresponds to agreed recommendations from a health care provider.”1 Many factors influence an individual’s ability to adhere to medication instructions and agreed upon lifestyle behavioral changes required to manage chronic disease. Medication adherence is an essential element to achieving positive therapy outcomes. Therefore, strategies focused on improving adherence should also strengthen the collaboration between patients, family members, caregivers, and clinicians and mitigate patient, clinician, and system barriers to adherence. This chapter describes the problem of poor medication adherence, and explores patient, clinician, and system factors that contribute to poor adherence. It provides communication strategies designed to identify factors that result in poor adherence, clarify the causes of poor adherence, and promote higher levels of adherence. SCOPE OF THE PROBLEM Mr. Cruise’s clinical picture is complex and his responses to his medication regimen are unexpectedly poor. He has had frequent hospitalizations for his chronic illnesses, and few of his medications seem to be working as predicted. Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Page 1 / 17 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Poor medication adherence is a worldwide problem and the problem is growing as the burden of chronic disease is growing.1 Studies suggest that as many as half of medical patients do not completely follow the treatment recommendations of their clinicians in developed countries such as the United adherence. It provides communication strategies designed to identify factors that result in poor adherence, clarify the causes of poor adherence, and Mount Saint Vincent College promote higher levels of adherence. Access Provided by: SCOPE OF THE PROBLEM Mr. Cruise’s clinical picture is complex and his responses to his medication regimen are unexpectedly poor. He has had frequent hospitalizations for his chronic illnesses, and few of his medications seem to be working as predicted. Poor medication adherence is a worldwide problem and the problem is growing as the burden of chronic disease is growing.1 Studies suggest that as many as half of medical patients do not completely follow the treatment recommendations of their clinicians in developed countries such as the United States; the rates are often much lower in developing countries in Africa and Asia.1,2 Poor adherence is of particular concern among those with multiple chronic medical problems, such as HIV, hypertension, and diabetes,3,4 as well as among lowerincome patients who face many barriers to adherence, including access to medications and rising medication costs.5 In resourcepoor countries such as Africa, patients on antiretroviral therapy experience barriers to adherence that include food insecurity and transportation costs.6 The consequences of poor adherence can be devastating. Over 100,000 deaths annually in the United States have been attributed to poor adherence with medication regimens.7 Poor medication adherence also leads to higher rates of hospitalizations, emergency room visits, and outpatient visits, as well as worsening health status.2,8 In addition to adverse health consequences and potential financial waste, poor adherence can lead to frustration for both patients and clinicians and thus may contribute to the breakdown in this relationship and mistrust of the healthcare system. FACTORS ASSOCIATED WITH POOR ADHERENCE ISSUES AT THE INTERFACE OF PATIENT AND TREATMENT Mr. Cruise takes nine different medications: six for management of his heart disease and three for his diabetes. Since leaving his job, he has experienced severe financial strain and now suffers from depression. Patients may experience many factors that can have an impact on their ability to properly take medications. These factors include, but are not limited to access, low resources, lack of social support, mental illness, health beliefs, substance abuse, mistrust of the healthcare system, negative personal interactions with clinicians, fear, and lack of understanding of disease and medications. Patients may believe that they are adherent to medications because they take a medication every day, when in fact how the patient takes the medication may be incorrect. It is important when assessing medication adherence that providers ask the patients, “tell me how you take this medication.” There are multiple reasons that patients choose not to follow the advice of their healthcare providers, particularly when complex medication regimens or side effects conflict with the patient’s personal identity or goals.9 Understanding the elements at the interface of patient and treatment may contribute to better assessment and management of poor adherence. INTERACTING DIMENSIONS THAT IMPACT ADHERENCE The WHO describes five dimensions that affect adherence: (1) therapy related, (2) patient related, (3) social and economic factors, (4) condition related, and (5) healthcare system related.1 These factors are often intertwined to varying degrees and influence a patient’s ability to adhere to medications (Figure 131). These dimensions are to be considered as we assess medication adherence and choose strategies to improve adherence. Figure 131. The five dimensions of adherence. Optimal treatment frequently requires addressing several barriers to adherence. Health professionals must follow a systematic process to assess all the potential barriers. (Adapted from Sabaté E. Adherence to LongTerm Therapies. Evidence for Action. Geneva: World Health Organization, 2003:27.) Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 2 / 17 Figure 131. Mount Saint Vincent College The five dimensions of adherence. Optimal treatment frequently requires addressing several barriers to adherence. Health professionals must follow a Access Provided by: systematic process to assess all the potential barriers. (Adapted from Sabaté E. Adherence to LongTerm Therapies. Evidence for Action. Geneva: World Health Organization, 2003:27.) THERAPYRELATED FACTORS Medication Effects and Side Effects All medications have potential side effects, and the number of side effects increases with the complexity of the regimen. Although clinicians may be vigilant for serious side effects, they may be less conscious of those that are not life threatening, but significantly interfere with a patient’s functioning. Moreover, the patient may perceive the desired effect of the medication as an adverse side effect. For example, patients may take diuretic medications at night, leading to disrupted sleep due to frequent need to urinate. Instead, taking diuretics in the morning may relieve this problem. However, such changes in the dosing schedule may prove challenging for individuals who do not have ready access to bathroom facilities when they are away from their homes. The seriousness of side effects is often idiosyncratic, and must be assessed for patients individually, as there will be different levels of tolerance for medication side effects. For example, although the cough associated with the use of angiotensinconverting enzyme (ACE) inhibitors is inconsequential for many patients, it may prompt avoidance in others. Patients may be reluctant to discuss certain side effects with their clinicians (e.g., loss of libido associated with some medications). Patients may not know what steps to take if they miss a dose of medication. They may not know when to take the dose of medication as soon as they remember, or to wait until the next regular dosing time. Medications used to treat depression require several weeks before any effect is seen and due to early side effects, patients may stop the medications because the side effects make them feel ill, and their depression is not yet getting any better. In addition to the actual effects and side effects of medications, unrelated new or recurrent symptoms may be attributed to a new medication by some patients and thus may contribute to poor adherence. Regimen Complexity The average older patient with two or more chronic illnesses is treated with more than six daily medications. Although many of these may be taken once daily, others may require multiple daily doses. Patients may experience scheduling conflicts associated with their medication regimens, particularly when their medication schedules change frequently, such as with warfarin, insulin, and diuretics. Some medications must be taken with food and others require an empty stomach. Patients with issues of food insecurity may not be able to adhere to the instructions of taking medications with food. This complexity is further compounded by the fact that certain medications must not be taken at the same time as others. Many work environments do not permit scheduled breaks to take medications or monitor effects of medications (e.g., blood sugar check for diabetes). Patients living in lowincome housing units or who are homeless may not have access to proper storage facilities for their medications (e.g., refrigeration). PATIENTRELATED FACTORS Downloaded Confusion 2024218 9:29 A Your IP is 63.247.225.21 Page 3 / 17 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Even if a patient chooses to follow recommendations, misunderstanding, uncertainty, and confusion about the actual recommendation can lead to poor adherence. Patients may recall and comprehend as little as 50% of what is conveyed to them in a medical visit,10,11,12,13 and often do not have a with food. This complexity is further compounded by the fact that certain medications must not be taken at the same time as others. Many work Mount Vincent College environments do not permit scheduled breaks to take medications or monitor effects of medications (e.g., blood sugar check for Saint diabetes). Patients Access Provided by: living in lowincome housing units or who are homeless may not have access to proper storage facilities for their medications (e.g., refrigeration). PATIENTRELATED FACTORS Confusion Even if a patient chooses to follow recommendations, misunderstanding, uncertainty, and confusion about the actual recommendation can lead to poor adherence. Patients may recall and comprehend as little as 50% of what is conveyed to them in a medical visit,10,11,12,13 and often do not have a clear understanding of the doses and indications for each of their medications. Additionally, patients may not appreciate that treatment of chronic conditions such as hypertension and diabetes require the ongoing use of medications, and consequently may fail to obtain refills once their prescription is completed. Administration of medications to children is challenging because most medications come in liquid form. For example, a dose of medication may be ordered in milligrams; however, the parents and caregivers may need to be taught to convert the dose to milliliters or teaspoons for administration. The mathematical conversions often times can result in errors and confusion, leading to the administration of the incorrect dose of the medication. Care must be taken to ensure that parents and caregivers have clearly marked measuring tools and understand the conversions of doses. This also applies to adult patients who may require medications in liquid form. Cognitive/Physical Impairments Patients with cognitive impairments that result from aging or complications of underlying diseases (e.g., cerebrovascular disease) may be at particular risk for confusion with their medication regimens.14 Patients require labeling instructions that they can understand. Large print may be required to accommodate those patients with visual impairment. Language and Low Functional Health Literacy Limited literacy is a worldwide problem and it is important that care be delivered at the level needed for patients. Language barriers and low functional health literacy15 have been recognized as important contributors to confusion with medication regimens. Health literacy refers to patients’ ability to “obtain, process, and understand the basic health information and services they need to make appropriate health decisions.”16 Patients who may be particularly vulnerable to low functional health literacy include older patients, those with lower levels of education and literacy, and those with limited English proficiency. As many as 50% of patients cared for at public hospitals and safetynet settings may have low functional health literacy.17 The written word may not be sufficient for patients to get a clear understanding of medication administration instructions and providers will need to use pictures and drawings to promote medication adherence (see Chapter 15).18 Health Beliefs Patients’ beliefs about health, health care, or their particular medical conditions may differ substantially from those of their healthcare providers. These beliefs may range from use of complementary and alternative medicines to religious beliefs and the conviction that there is no need to take medications if one is asymptomatic (often encountered in the treatment of hypertension).19 Such health beliefs on the part of patients do not invariably lead to poor adherence if the beliefs are acknowledged and integrated into the patient’s overall treatment plan. Clinicians who engage patients in nonjudgmental discussions of their use of complementary and alternative medicines, for example, may be better able to establish the rapport necessary to enable improved adherence, as well as identify potential serious interactions among treatments. SOCIAL AND ECONOMIC FACTORS Social Support Social support plays an important role in overall health and wellbeing, and appears to be instrumental in ensuring medication adherence.20 Social support encompasses emotional (love, affirmation) as well as practical support (food, shelter, money, transportation). Patients who have a social network and environment that supports and promotes the behaviors that contribute to medication adherence may be more successful at following instructions of the providers. Depression is common in the outpatient setting and particularly prevalent among those with multiple health problems.21 Depressed patients are less likely to follow through on medical recommendations,22 possibly because of hopelessness and lack of confidence in the effectiveness or worth of the treatment. Depressed patients areIP likely to be isolated, lacking the social support necessary for adherence. The medication regimens for Downloaded 2024218 9:29 Aalso Your is 63.247.225.21 Page 4 / 17 Chapter 13:are Assessing and Promoting Medication Adherence, L. Youmans; Kirsten BibbinsDomingo depression frequently complex and often medication alone isSharon insufficient for treatment. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Cost network and environment that supports and promotes the behaviors that contribute to medication adherence may be more successful at following Mount Saint Vincent College instructions of the providers. Access Provided by: Depression is common in the outpatient setting and particularly prevalent among those with multiple health problems.21 Depressed patients are less likely to follow through on medical recommendations,22 possibly because of hopelessness and lack of confidence in the effectiveness or worth of the treatment. Depressed patients also are likely to be isolated, lacking the social support necessary for adherence. The medication regimens for depression are frequently complex and often medication alone is insufficient for treatment. Cost The cost of medications is recognized as a common reason for medication poor adherence.3,5,23,24 With the Affordable Care Act, more patients are eligible for insurance but still may not be able to afford it, or may have insurance that does not cover the cost of medications. Even those with prescription drug benefits are often charged high copayments for each medication, which may represent a significant portion of a lowincome patient’s monthly budget. Some health plans and systems will not pay for certain medications without a prior authorization, which requires patients to selfadvocate, complete complex forms, and successfully negotiate alternatives with their clinician. Patients taking medications for chronic conditions may try to make their medications last longer (e.g., skipping doses, taking daily medications every other day), or fail to fill prescriptions when they are experiencing acute financial constraints. Studies have shown that although clinicians understand that the cost of medications may affect adherence, they rarely initiate conversations about this barrier. Paradoxically, when they do, discussions frequently are not targeted to those patients most likely to have financial problems. Additionally, physicians often lack adequate knowledge of insurance and formulary restrictions to change their prescribing patterns, which could alleviate some cost burdens.25,26,27 Pharmacists are important resources for patients and other healthcare providers to assist with medication costs. As an example, pharmacists can provide counseling for patients signing up for Medicare Part D to choose plans that cover their medications for low copay and prescription coverage plan fees. CONDITIONRELATED FACTORS Substance Use Alcohol or illicit drug use is an important independent factor contributing to poor adherence, and may be more prevalent in patients challenged by depression or social isolation, which further affect adherence. Patients actively using illicit drugs or alcohol may be prone to erratic use or nonuse of prescribed medications. The use of illicit drugs or alcohol may worsen the conditions that their medications were prescribed to treat (e.g., hypertension, depression). The advent of effective pharmacologicbased treatments for addictions has led to efforts aimed at improving adherence among patients with dependence on illicit drugs or alcohol.28 HEALTH SYSTEM–RELATED FACTORS After leaving his job, Mr. Cruise lost his private health insurance. Mr. Cruise began receiving his care at the public hospital and because of formulary differences had to switch from one type of betablocker, which is taken once a day, to another type of betablocker, which is taken twice a day. Further, the medications that he takes at home have been changed during each of his four hospitalizations. Navigating the healthcare system can be overwhelming as patients try to determine where to obtain the services and resources needed to maintain their health. These systems can be an academic medical center, a community hospital, a governmentrun hospital, a neighborhood clinic, a pharmacy, a mobile clinic van, or a traditional healer’s hut. The environment in which patients and clinicians discuss healthcare recommendations can either support adherence or undermine it. The following are factors within the healthcare system that may contribute to poor adherence. Fragmented Care Patients with multiple chronic illnesses often are treated by more than one clinician, each of whom may be prescribing or adjusting medications. Recent technological advances have facilitated communication among physicians caring for the same patient (e.g., increasing use of electronic medical records), yet faulty or lapsed communication systems still contribute to confusion over care, as well as overt medical errors. These lapses are particularly likely to occur at the time of hospital discharge, when adjustments to the outpatient medication regimen are implemented, often without adequate patient education orAcommunication with outpatient physicians. Community pharmacies are not connected with hospitals and the many Downloaded 2024218 9:29 Your IP is 63.247.225.21 Page 5lists / 17 community in one city, for example, are Adherence, not connected to oneL.another to share patient information. Maintaining updated medication Chapter 13:pharmacies Assessing and Promoting Medication Sharon Youmans; Kirsten BibbinsDomingo ©2024 McGraw Hill.technology All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility is a challenge. Using to bring these pieces of information together can result in more smooth transitions from the hospital to the pharmacy, to home, to the clinic, and back to the pharmacy. This communication needs to occur with all involved in the care of patient, such as the physician, nurse, pharmacist, social worker, dentist, patient, family members, and care givers. Mount Saint Vincent College Patients with multiple chronic illnesses often are treated by more than one clinician, each of whom may be prescribing or adjusting medications. Access Provided by: Recent technological advances have facilitated communication among physicians caring for the same patient (e.g., increasing use of electronic medical records), yet faulty or lapsed communication systems still contribute to confusion over care, as well as overt medical errors. These lapses are particularly likely to occur at the time of hospital discharge, when adjustments to the outpatient medication regimen are implemented, often without adequate patient education or communication with outpatient physicians. Community pharmacies are not connected with hospitals and the many community pharmacies in one city, for example, are not connected to one another to share patient information. Maintaining updated medication lists is a challenge. Using technology to bring these pieces of information together can result in more smooth transitions from the hospital to the pharmacy, to home, to the clinic, and back to the pharmacy. This communication needs to occur with all involved in the care of patient, such as the physician, nurse, pharmacist, social worker, dentist, patient, family members, and care givers. Time Constraints When arriving at their treatment recommendations, clinicians often do not have sufficient time to offer clear explanations or assess whether patients understand them. Unfortunately, very few health systems provide standardized education tools that clinicians can employ with patients who have been prescribed a new medication. Additionally, clinicians often feel that they do not have adequate time to explore differing health beliefs or any of the other patient factors that may contribute to poor adherence. Pharmacists and pharmacy staff may feel pressured by similar time constraints limiting their potential to act as resources. In response to patients receiving inadequate medication counseling, the Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) passed by Congress mandated that states improve their practices of educating patients about their medications. States responded in a variety of ways to provide the counseling and education to patients with 90% of states mandating that pharmacists provide facetoface medication counseling for all patients receiving new prescriptions.29 Another missed opportunity to discuss any medicationrelated problems and reinforce directions for taking the medications is when patients are picking up medication refills at the pharmacy. Refill Restrictions Many insurance plans impose restrictions on quantities of medications and the timing of medication refills. Such restrictions include limiting each prescription to a 30day supply, allowing refills only when there are 2–3 days of medications left, and requiring physician approval for more than six total medications in a month. These restrictions can pose significant challenges for patients who need to fill prescriptions around complex work or family schedules, have difficulties navigating the bureaucratic processes, or have multiple chronic conditions whose medications may need to be filled on different days of the month. Formulary Restrictions Within a given class of medications, there are often multiple options with equivalent efficacy. Frequently payers reimburse for only one or two of the medications within a particular class, and require higher copayments or complete payments for other medications within the class. Clinicians usually treat a panel of patients with a variety of different insurance plans; therefore, they may be unaware of formulary restrictions and may fail to choose those with the lowest cost (and equivalent efficacy). Within a given plan, formularies often change (reflecting the availability of generic medications or negotiation of a lower price for a particular brand), requiring the patient to request another prescription from the clinician, or leading to confusion about pills of a different color or shape. Patients switch or lose jobs necessitating changes in, or loss of, their health insurance and subsequent formulary changes. New medications within a given class, simply substituted in accordance with the formulary rules of the insurer, will likely appear different, and may be given on a different dosing schedule and may have a different side effect profile or interactions with other chronic medications. All of these can result in considerable confusion for patients. THE HEALTHCARE PROVIDER’S ROLE IN ASSESSING AND PROMOTING ADHERENCE The clinician, within the context of the patient–clinician relationship, can play an important role in promoting adherence by (a) recognizing poor adherence; (b) identifying the factors that may be contributing to poor adherence; and (c) pursuing strategies that enhance the partnership with the patient (see Key Concepts). PATIENT–CLINICIAN COMMUNICATION Effective communication is critical to ensuring adherence, and is a hallmark of strong patient–clinician partnerships. Clear explanations of health recommendations minimize patient confusion. An environment that encourages bidirectional communication; establishes rapport; conveys Downloaded 2024218 A Your IP nonadherence is 63.247.225.21 compassion and respect;9:29 and normalizes all make it more likely that factors impeding adherence will be elicited. Such an environment Page 6 / 17 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo increases patient satisfaction and trust in medical care, and contributes to a shared process of decision making about medical recommendations. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Patients who are poor, are members of race/ethnic minority groups, or have limited health literacy or English proficiency are often more likely to 16 patient (see Key Concepts). PATIENT–CLINICIAN COMMUNICATION Mount Saint Vincent College Access Provided by: Effective communication is critical to ensuring adherence, and is a hallmark of strong patient–clinician partnerships. Clear explanations of health recommendations minimize patient confusion. An environment that encourages bidirectional communication; establishes rapport; conveys compassion and respect; and normalizes nonadherence all make it more likely that factors impeding adherence will be elicited. Such an environment increases patient satisfaction and trust in medical care, and contributes to a shared process of decision making about medical recommendations. Patients who are poor, are members of race/ethnic minority groups, or have limited health literacy or English proficiency are often more likely to report less effective patient–clinician communication.16 Increasing clinician awareness of the sociocultural context of their patients’ health may improve patient–clinician communication, adherence, and overall health care. Cultural competence education and training is essential for clinicians and staff to gain a wider perspective of the factors that interfere with effective communication. The use of interpreters is a must when a patient prefers to have their instructions given to them in their native language (other than English). Effective use of interpreters requires training (see Chapter 31). IDENTIFYING PATIENTS WITH ADHERENCE DIFFICULTIES Mr. Cruise returns to his primary care physician after his last two hospitalizations. She expresses concern for his frequent admissions, and asks Mr. Cruise to speculate about the factors that might be leading to his worsening heart failure. She also states that sometimes it is difficult for patients to take a lot of medications every day, and wonders whether Mr. Cruise has ever experienced any difficulties taking his medications. Adherence must be reassessed at regular intervals for all patients, particularly when new medications are started or existing medications are changed. Patients may be reluctant or embarrassed to admit that they are having difficulty with adherence. Patients may be unwilling to reveal their confusion, difficulty reading or understanding instructions, financial problems, or lack of the social supports necessary to maintain their regimens. They may feel that their health beliefs will not be understood or respected by their physicians. Some clinicians may make patients feel that their difficulty with adherence is unusual, further inhibiting discussion. There are a number of ways to initiate discussions of adherence with outpatients (Table 131). These conversations should acknowledge that adherence can be difficult. Ideally such conversations use openended questions to engage patients and allow them to reveal the barriers that are most important to them, as well as more probing questions to discern the contribution of specific barriers. Table 131. Strategies for Assessing Adherence Use introductory statements that acknowledge the difficulty with adherence. “Taking pills every day can be hard. Most people have problems taking their pills at some point. I am going to ask you about problems you may have had taking your pills. I’m asking because I want to find a way to make it easier for you to take them. Can you tell me or show me how you take your medications?” Confirm an understanding of the regimen. Have patients bring in their pill bottles or make use of visual aids. If patients are confused, use strategies for increasing recall and comprehension of regimen. Ask about their medication schedule over the past 3 days, one day at a time. Start with the day prior to the visit and go through the entire day, asking how medications were taken or about missed doses. Then proceed with the day 2 days before the visit. If no doses were missed in the preceding 3 days, ask about the last time a dose was missed. Again make use of visual aids or pill bottles. Ask about reasons for missed doses. Begin with openended questions and then prompt if unable to elicit a response, suggesting common reasons why adherence may be difficult— forgot, too busy with other things, too many side effects, feeling sick or depressed, ran out of pills, difficulty paying for medications, etc. Ask about effects that are particular to the medication regimen. Again, prompts may be necessary—nausea, headaches, depression, sexual side effects, difficulty swallowing pills, lack of access to refrigeration, difficulty obtaining pills from pharmacy. Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 7 / 17 Source: Machtinger E, Bangsberg DR. Adherence to HIV antiretroviral therapy. Accessed September 27, 2005. Available at http://hivinsite.ucsf.edu/InSite.jsp/InSite? page=kb030209. adherence is unusual, further inhibiting discussion. Mount Saint Vincent College There are a number of ways to initiate discussions of adherence with outpatients (Table 131). These conversations should acknowledge that Access Provided by: adherence can be difficult. Ideally such conversations use openended questions to engage patients and allow them to reveal the barriers that are most important to them, as well as more probing questions to discern the contribution of specific barriers. Table 131. Strategies for Assessing Adherence Use introductory statements that acknowledge the difficulty with adherence. “Taking pills every day can be hard. Most people have problems taking their pills at some point. I am going to ask you about problems you may have had taking your pills. I’m asking because I want to find a way to make it easier for you to take them. Can you tell me or show me how you take your medications?” Confirm an understanding of the regimen. Have patients bring in their pill bottles or make use of visual aids. If patients are confused, use strategies for increasing recall and comprehension of regimen. Ask about their medication schedule over the past 3 days, one day at a time. Start with the day prior to the visit and go through the entire day, asking how medications were taken or about missed doses. Then proceed with the day 2 days before the visit. If no doses were missed in the preceding 3 days, ask about the last time a dose was missed. Again make use of visual aids or pill bottles. Ask about reasons for missed doses. Begin with openended questions and then prompt if unable to elicit a response, suggesting common reasons why adherence may be difficult— forgot, too busy with other things, too many side effects, feeling sick or depressed, ran out of pills, difficulty paying for medications, etc. Ask about effects that are particular to the medication regimen. Again, prompts may be necessary—nausea, headaches, depression, sexual side effects, difficulty swallowing pills, lack of access to refrigeration, difficulty obtaining pills from pharmacy. Source: Machtinger E, Bangsberg DR. Adherence to HIV antiretroviral therapy. Accessed September 27, 2005. Available at http://hivinsite.ucsf.edu/InSite.jsp/InSite? page=kb030209. Clearly, detailed comprehensive adherence assessment is a timeconsuming process. However, many experts have suggested that for certain highrisk patients (e.g., the elderly, those with multiple chronic conditions, those with cognitive impairment or communication barriers, those on medications with a narrow therapeutic window), visits solely for the purpose of medication review are necessary. Such visits can be conducted by physicians, nurses, or clinical pharmacists,30 who can focus on a review of the medications, their proper administration (e.g., metered dose inhalers, insulin), and potential side effects. IDENTIFYING FACTORS CONTRIBUTING TO POOR ADHERENCE Mr. Cruise states, “the doctors in the hospital keep changing my meds around.” He admits to being confused about what medications he is supposed to be taking. Mr. Cruise acknowledges sometimes missing doses of medications, especially at the end of the month when “money is tight.” His physician asks, “When you go to pick up your medications from the pharmacy do you ask to speak to the pharmacist or does the pharmacist ask you to describe any issues you have with taking your medications?” Mr. Cruise replies, “No, I have not.” Finally, Mr. Cruise expresses increasing hopelessness at the loss of his job and his worsening medical condition. “I just didn’t think my life would turn out this way.” Assessing medication adherence requires a dialogue involving not only what the patient is doing, but how they are doing it. Other issues can be elicited from the patient by asking, “What gets in the way of you taking your medications regularly?” There often are health issues, psychosocial issues, environmental issues, behavioral issues, and other competing demands of life that gets in the way. Adherence first requires that patients have a clear understanding of their healthcare providers’ recommendations. Clinicians directly contribute to poor adherence when explanations of instructions are not clear and there is no assessment of whether the patient understands the recommendations. Comprehension can be increased by using techniques that ask patients to restate information to assure that it was understood,14,31,32 such as with the “teachback method” (Figure 132). This interactive communication loop is useful for gauging the extent to which recommendations are understood by patients and for initiating9:29 a dialogue between clinicians and patients about other specific challenges to adherence. The “teachback” method may help Downloaded 2024218 A Your IP is 63.247.225.21 Page This 8 / 17 Chapter 13: Assessing and Promoting Medication L. Youmans; Kirsten BibbinsDomingo uncover cognitive impairments or literacy limitationsAdherence, and promptSharon the clinician to refocus educational efforts to accommodate these challenges. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility dialogue may uncover differing patient perceptions or health beliefs about their medications and serve as an entry point for further exploration of these beliefs. Mount Saintcontribute Vincent College Adherence first requires that patients have a clear understanding of their healthcare providers’ recommendations. Clinicians directly to Access Provided by: poor adherence when explanations of instructions are not clear and there is no assessment of whether the patient understands the recommendations. Comprehension can be increased by using techniques that ask patients to restate information to assure that it was understood,14,31,32 such as with the “teachback method” (Figure 132). This interactive communication loop is useful for gauging the extent to which recommendations are understood by patients and for initiating a dialogue between clinicians and patients about other specific challenges to adherence. The “teachback” method may help uncover cognitive impairments or literacy limitations and prompt the clinician to refocus educational efforts to accommodate these challenges. This dialogue may uncover differing patient perceptions or health beliefs about their medications and serve as an entry point for further exploration of these beliefs. Figure 132. Interactive communication loop for educating patients regarding a change in their medication regimen. (Adapted from Schillinger D, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163(1):8390.) Clinicians must explore factors unique to particular patients or to the environment in which the clinician practices. Awareness should include accurate and uptodate knowledge regarding medication side effects, costs, prescriptions from other clinicians, and restrictions to formularies. Steps Clinicians Can Take to Identify Patients With Medication Adherence Difficulties Recognize that poor adherence to medications is common. Engage in effective patient–clinician communication to assess and promote medication adherence among all patients. Accurately identify patients who have difficulty with medication adherence. Identify the patient, clinician, and systems factors that may pose barriers to medication adherence. Target specific interventions that are appropriate to particular medication adherence barriers. INTERVENTIONS TO PROMOTE MEDICATION ADHERENCE Mr. Cruise and his physician review his medication regimen together. She asks him to return the following week to meet with the clinic pharmacist in order to reinforce his understanding of his current regimen, and asks that he bring all of his pill bottles so that outdated medications and those no longer indicated can be properly discarded. She arranges for Mr. Cruise to see a social worker to review services he might qualify for to alleviate his financial crisis. Finally, she discusses Mr. Cruise’s depressive symptoms with him, including options for treatment. Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Chapter 13: Assessing Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo Interventions to promoteand adherence must be customized to the patient’s needs. Multiple strategies may be needed to assist patients to takePage their9 / 17 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility medications correctly. Identifying the barriers that impede the success of patients and matching them up with an intervention is essential to overcoming the barriers. A “onesizefitsall” approach is not appropriate; strategies to promote adherence should be tailored to the specific needs of Target specific interventions that are appropriate to particular medication adherence barriers. Mount Saint Vincent College Access Provided by: INTERVENTIONS TO PROMOTE MEDICATION ADHERENCE Mr. Cruise and his physician review his medication regimen together. She asks him to return the following week to meet with the clinic pharmacist in order to reinforce his understanding of his current regimen, and asks that he bring all of his pill bottles so that outdated medications and those no longer indicated can be properly discarded. She arranges for Mr. Cruise to see a social worker to review services he might qualify for to alleviate his financial crisis. Finally, she discusses Mr. Cruise’s depressive symptoms with him, including options for treatment. Interventions to promote adherence must be customized to the patient’s needs. Multiple strategies may be needed to assist patients to take their medications correctly. Identifying the barriers that impede the success of patients and matching them up with an intervention is essential to overcoming the barriers. A “onesizefitsall” approach is not appropriate; strategies to promote adherence should be tailored to the specific needs of the patient. Several interventions have been studied that have the potential to promote adherence. These interventions, in concert with a clinician’s recommendations, may help enhance adherence if targeted appropriately. SIMPLIFIED TREATMENT REGIMENS Single daily dosing of medications, reduced numbers of medications, and coordination of doses should be used, as appropriate. A regular review of medications can identify ones that are not working or not needed. This strategy has been shown to be consistently effective in a variety of chronic conditions.33,34 COLLABORATIVE PLANNING Patients and clinicians should collaborate to develop dosing schedules that accommodate the patient’s daily schedule. Side effects should be discussed whenever new therapies are initiated. Followup visits should address side effects and dosing schedules; plans should be designed as these conditions change. Collaborative planning also may include discussion of financial barriers to the initiation of medications and may include referrals to social workers or inhome support services to facilitate adherence. Pharmacists are the most accessible healthcare provider in the community, and patients should be encouraged to partner with their community pharmacist to ensure that the management of the medication regimens is correct and to assess if the patient is experiencing any side effects. The pharmacist serves as a resource to answer medicationrelated questions and address concerns. PATIENT EDUCATION Patients should be educated about their disease and the ways in which adherence to their medication regimens can alter the course of their disease. Educational interventions of this type are particularly important for chronic illnesses that require ongoing medications. Clinicians providing the education should assess and ask the patient by what methods they learn best. It may be a combination of print and pictorial materials, or other media to reinforce key concepts. Pharmacists, physicians, nurses, dentists, and health educators may all effectively describe disease processes (for chronic diseases such as diabetes, asthma, HIV) or the proper use of difficulttoadminister medications (e.g., insulin, metered dose inhalers). Education efforts should be readdressed at regular intervals as repetition helps solidify the patient’s comprehension of important concepts and instructions. MEDICATION REVIEW VISITS Patients may benefit from a visit devoted exclusively to a review of their medications. Pharmacists are particularly well suited to conduct such visits, as they are able to focus exclusively on medications, their proper administration, and potential side effects. It has been shown that the inclusion of pharmacists on a multidisciplinary care team increases adherence and reduces adverse events.35,36 Review of medications is important not only at the initiation of a new medication regimen, but also for patients whose medications may not have changed substantially. Such reviews should address whether treatment for a particular condition is still indicated and consistent with the latest evidence, as well as whether a regimen can be simplified. CASE MANAGEMENT Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Page 10 / 17 For many13: patients, the complexity of their disease (e.g., heart failure, HIV),L.their comorbid illnesses (e.g., psychiatric illness, substance use), or their Chapter Assessing and Promoting Medication Adherence, Sharon Youmans; Kirsten BibbinsDomingo ©2024situation McGraw(e.g., Hill. homelessness) All Rights Reserved. Terms of Usechallenges Privacy Policy Noticethat Accessibility social may pose additional to adherence can be most effectively addressed with intensive, multidisciplinary interventions. In these interventions, clinicians may partner with nurses, social workers, health educators, pharmacists, dieticians, 37,38 pharmacists on a multidisciplinary care team increases adherence and reduces adverse events. Mount Saint Vincent College Review of medications is important not only at the initiation of a new medication regimen, but also for patients whose medications may not have Access Provided by: changed substantially. Such reviews should address whether treatment for a particular condition is still indicated and consistent with the latest evidence, as well as whether a regimen can be simplified. CASE MANAGEMENT For many patients, the complexity of their disease (e.g., heart failure, HIV), their comorbid illnesses (e.g., psychiatric illness, substance use), or their social situation (e.g., homelessness) may pose additional challenges to adherence that can be most effectively addressed with intensive, multidisciplinary interventions. In these interventions, clinicians may partner with nurses, social workers, health educators, pharmacists, dieticians, community health educators, and others to provide followup to support and identify ongoing barriers to adherence.37,38 SYSTEM REMINDERS Integrated health systems and largechain pharmacies have employed automated reminder systems to enhance adherence with chronic medications. Patients may receive reminders to refill their medications several days prior to finishing their current prescription and may be reminded again if they fail to fill prescriptions in a timely manner.39 Some systems identify patients who persistently under fill their prescriptions for a particular chronic disease and may use this information to target referrals for case management or other more intensive interventions.40 Some disease management programs incorporate regular automated telephone contact with patients to screen for a variety of potential difficulties with disease management, including medication adherence. These systems permit timely identification of adherence difficulties as well as targeted use of nurse, health educator, pharmacists, and physician time to focus on particular patients with adherence difficulties.41 DIRECTLY OBSERVED THERAPY In this approach, patients receive their medications each day from a health provider (or reliable surrogate) and are observed taking them. It has been used successfully to address poor adherence in the treatment of tuberculosis,42 and has been suggested for treatment of HIV and substance use.43,44 MEDICATION ADHERENCE DEVICES The following devices are particularly useful for patients who are confused or have complicated medication regimens. Medication Organizers Pillboxes, medisets, and other versions of medication organizers are readily available in clinics and pharmacies. Pharmacists, case managers, or nurses can help facilitate filling the organizer correctly. Pharmacies may prefill pillboxes or bubble packs that may further enhance use of these devices. Visual Medication Schedules Visual medication schedules are tools in which pictures of the prescribed medications are placed on a weekly calendar in the corresponding doses. One such visual medication schedule designed, developed, and piloted by Edward Machtinger and Dean Schillinger and produced by Tim Peters and Company, a health product software company, is displayed in Figure 133. Such schedules are now available through some computer programs and from drug manufacturers. Many clinicians create these schedules by simply affixing the actual pill to a paper calendar. Figure 133. Visual medical schedule for warfarin therapy. (Adapted from Machtinger EL, Wang F, Chen LL, Rodriguez M, Wu S, Schillinger D. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;33:625635.) Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 11 / 17 Figure 133. Mount Saint Vincent College Access Provided by: Visual medical schedule for warfarin therapy. (Adapted from Machtinger EL, Wang F, Chen LL, Rodriguez M, Wu S, Schillinger D. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;33:625635.) Reminders Reminder devices such as alarms on watches or beepers can enhance adherence. Medication reminder applications for smart phones can be another option for patients. This is particularly true of regimens that require frequent daily dosing and regimens in which doses must be taken on a tightly timed schedule. This strategy has been used effectively in the treatment of HIV.45 NONCLINICIAN FACTORS It is important to note that a number of the interventions described in the preceding sections would be most effective were they to be implemented systematically, but have not been for a variety of reasons, and are often out of control of the individual clinician. As such, advocacy efforts also should occur outside of clinicians’ offices for substantive reform to occur. Reduction in pill burden by combining preparations into a single pill (e.g., HIV) could greatly simplify the regimens of patients with chronic diseases. Innovative packaging (e.g., oral contraceptives) and labeling of pharmaceutical products could enhance understanding for patients with linguistic or literacy barriers, and widespread use of assertive technology by pharmacy systems could enhance refill adherence. CONCLUSION Vulnerable patient populations are at risk for poor medication adherence. It is crucial to engage these patients as partners in the maintenance of their health. Patients can help identify contributing factors to their poor adherence and facilitate the development of targeted interventions to promote adherence. Clinicians who work alone trying to solve the problem of poor medication adherence are not as effective as those who use a team approach that includes the patient, nurses, and pharmacists all working together. There is no “one” solution that will work for all patients and individual patients may require multiple strategies. Accurately identifying the specific factor(s) contributing to nonadherence for a specific patient can allow for targeted intervention. Effective communication strategies, strong patient– clinician relationships, use of available resources aimed at improving patients’ understanding of medications, and health system improvements can together facilitate and promote medication adherence. DISCUSSION QUESTIONS 1. What factors identified in this chapter most commonly pose challenges for medication adherence in your patients? 2. How might you initiate a discussion about medication adherence with a patient? How might followup discussions assess and promote medication adherence? 3. What additional interventions are you aware of for promoting medication adherence and how have they been used? KEY CONCEPTS Assessing And Promoting Medication Adherence Establish an effective patient–provider partnership. Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Chapter 13: Assessing and Promoting Medication Adherence, L. Youmans; Kirsten BibbinsDomingo Recognize that medication adherence is a major challenge Sharon for patients and they need to be supported. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Recognize that there are other factors beyond those related to the patient that contribute to poor medication adherence. Page 12 / 17 2. How might you initiate a discussion about medication adherence with a patient? How might followup discussions assess and Saint promote medication Mount Vincent College adherence? Access Provided by: 3. What additional interventions are you aware of for promoting medication adherence and how have they been used? KEY CONCEPTS Assessing And Promoting Medication Adherence Establish an effective patient–provider partnership. Recognize that medication adherence is a major challenge for patients and they need to be supported. Recognize that there are other factors beyond those related to the patient that contribute to poor medication adherence. Employ interactive communication techniques to assess recall and comprehension about medications to minimize confusion and elicit patient concerns. Identify the various patient, clinician, and system factors that may make medication adherence a challenge and develop communication strategies to identify these. Tailorspecific interventions designed to improve medication adherence to the needs of your patient. RESOURCES Educate before You Medicate. National Council on Patient Information and Education. http://www.talkaboutrx.org Medline Plus. Drug Information Service of the US National Library of Medicine (NIH). http://www.nlm.nih.gov/medlineplus/druginformation.html Safe Medication. Drug Information site of the American Society of HealthSystems Pharmacists. http://www.safemedication.com Rx Assist. Patient Assistance Program Center. Programs run by pharmaceutical companies to provide free medications to people who cannot afford to buy their medicine. http://www.rxassist.org A Program Guide for Public Health: Partnering with Pharmacists in the Prevention and Control of Chronic Diseases http://www.cdc.gov/dhdsp/programs/nhdsp_program/docs/Pharmacist_Guide.pdf CORE COMPETENCY Summary of Barriers to Adherence and Potential Solutions Barrier Potential Intervention Side effects Simplify treatment regimens Patient–clinician discussion of effects and potential side effects within context of daily activities Medication review (inquire about common side effects, overthecounter medication use, herbal supplements) Complexity Simplify treatment regimens Collaborative planning Ongoing patient education to reinforce key concepts (particularly for chronic diseases such as asthma, diabetes, heart failure, HIV) Medication review visits Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Case management (multidisciplinary thatL.may be particularly effective for chronic diseases such as heart failure, Page 13 / 17 Chapter 13: Assessing and Promoting Medication Adherence,teams Sharon Youmans; Kirsten BibbinsDomingo HIV) Terms of Use Privacy Policy Notice Accessibility ©2024 McGraw Hill. All Rightsdiabetes, Reserved. Adherence devices Mount Saint Vincent College Ongoing patient education to reinforce key concepts (particularly for chronic diseases such as asthma, diabetes, heart failure, Access Provided by: HIV) Medication review visits Case management (multidisciplinary teams that may be particularly effective for chronic diseases such as heart failure, diabetes, HIV) Adherence devices Medication organizers Visual medication schedule: may be particularly useful for regimens with changing daily doses (e.g., warfarin) Reminder devices: particularly if doses must be taken on strict time schedule System refill reminder Confusion Simplify treatment regimen Collaborative planning Medication review visits; encourage patients to bring pill bottles, have the patients describe how they take the medications, correct any errors, and clarify instructions Adherence devices Medication organizers: consider prefilled pill boxes Visual medication schedule: may be useful even for regimens that do not change daily System refill reminders Health beliefs Collaborative planning to explore health beliefs and possible integration of medication regimen into these beliefs (readdress at subsequent visits as well) Social support Collaborative planning: include family members and care givers in education about disease and proper medication use Case management may be particularly useful in patients lacking adequate social supports Depression and Treat underlying depression and/or substance use substance use Case management programs that target individuals with psychiatric or substance use problems Cost Simplify treatment regimen: be aware of formulary restrictions and financial consequences of the introduction of a new medication Collaborative planning: address financial barriers to medication use directly; elicit help from social worker, for questions about insurance and social services Medication review: consider discussion of essential versus nonessential medications, and the consequence of restricting different classes of medications Fragmented care Enhance communication among clinicians, particularly during hospitalizations Medication review visits: encourage patients to bring pill bottles and review medications changed or initiated by other clinicians Time constraints Multidisciplinary healthcareteam Collaborative planning: identify financial problems and elicit assistance of social workers, inhome support, etc. Medication review visits: pharmacists Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Additional patient education: nurses, pharmacists, health educators Page 14 / 17 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo Case management: approach that may be appropriate for particular disease management or highrisk ©2024 McGraw Hill. All Rights Reserved. Terms ofintegrated Use Privacy Policy Notice Accessibility populations Medication review visits: encourage patients to bring pill bottles and review medications changed or initiated by other clinicians Mount Saint Vincent College Access Provided by: Time constraints Multidisciplinary healthcareteam Collaborative planning: identify financial problems and elicit assistance of social workers, inhome support, etc. Medication review visits: pharmacists Additional patient education: nurses, pharmacists, health educators Case management: integrated approach that may be appropriate for particular disease management or highrisk populations Refill restrictions Be aware of refill restrictions when choosing medications Collaborative planning: explicit discussion of how to fill medications System refill reminders Formulary Be aware of formulary restriction when choosing medications REFERENCES 1. Sabaté E. Adherence to LongTerm Therapies. Evidence for Action. 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Health insurance status, costrelated medication underuse, and outcomes among diabetes patients in three systems of care. Med Care 2004;42(2):102–109. [PubMed: 14734946] 24. Steinman MA, Sands LP, Covinsky KE. Selfrestriction of medications due to cost in seniors without prescription coverage. J Gen Intern Med 2001;16(12):793–799. [PubMed: 11903757] 25. Heisler M, Wagner TH, Piette JD. Clinician identification of chronically ill patients who have problems paying for prescription medications. Am J Med 2004;116(11):753–738. [PubMed: 15144912] 26. Reichert S, Simon T, Halm EA. Physicians’ attitudes about prescribing and knowledge of the costs of common medications. Arch Intern Med 2000;160(18):2799–2803. [PubMed: 11025790] 27. Alexander GC, Casalino LP, Meltzer DO. Patientphysician communication about outofpocket costs. JAMA 2003;290:953–958. [PubMed: 12928475] 28. Weiss RD. Adherence to pharmacotherapy in patients with alcohol and opioid dependence. Addiction 2004;99(11):382–392. 29. 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Terms of Use Privacy Policy Notice Accessibility 33. Stone VE et al. Perspectives on adherence and simplicity for HIVinfected patients on antiretroviral therapy: Selfreport of the relative importance of multiple attributes of highly active antiretroviral therapy (HAART) regimens in predicting adherence. J Acquir Immune Def Syndr 2004;36(3):808– 30. Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe CJ. Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. BMJ 2001;323(7325):1340–1343. [PubMed: 11739221] Mount Saint Vincent College Access Provided by: 31. Ong LM, de Haes JCJM, Hoos AM, Lammes FB. Doctorpatient communication: A review of the literature. Soc Sci Med 1995;40(7):903–918. [PubMed: 7792630] 32. Schillinger D et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163(1):83– 90. [PubMed: 12523921] 33. 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The effect of automated calls with telephone nurse followup on patientcentered outcomes of diabetes care: A randomized, controlled trial. Med Care 2000;38(2):218–230. [PubMed: 10659695] 41. WHO. Treatment of tuberculosis: Guidelines for national programmes. Geneva, Switzerland: World Health Organization, 1997. 42. Conway B et al. Directly observed therapy for the management of HIVinfected patients in a methadone program. Clin Infect Dis 2004;38(Suppl 5):S402–S408. [PubMed: 15156430] 43. Foisy MM, Akai PS. Pharmaceutical care for HIV patients on directly observed therapy. Ann Pharmacother 2004;38(4):550–556. [PubMed: 14990778] 44. Chesney MA, Ickovics JR, Chambers DB, Gifford AL, Neidig J, Zwicki B, Wu AW. Selfreported adherence to antiretroviral medications among participants in HIV clinical trials: The AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG). AIDS Care 2000;12:255–266. [PubMed: 10928201] 45. Machtinger E, Bangsberg DR. Adherence to HIV antiretroviral therapy. Accessed September 16, 2014. Available at http://hivinsite.ucsf.edu/InSite? page=kb030209#S2X. Downloaded 2024218 9:29 A Your IP is 63.247.225.21 Chapter 13: Assessing and Promoting Medication Adherence, Sharon L. Youmans; Kirsten BibbinsDomingo ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 17 / 17

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