Disclosure. Learning Objectives 6/4/2014. Medication Adherence: Challenges and Opportunities

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1 Medication Adherence: Challenges and Opportunities Jessica W. Skelley, Pharm D., BCACP Assistant Professor of Pharmacy Practice McWhorter School of Pharmacy, Samford University Disclosure I, Jessica Skelley, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. DO NOT anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation. Learning Objectives At the end of this program, attendees should be able to: Identify benefits of medication adherence, including those related to financial and health considerations. Recognize barriers to medication adherence for different patient demographics and disease states. Develop strategies to promote adherence within the general population, and special populations. List existing community resources and technology to assist in promoting medication adherence. 1

2 Outline Background Causes of nonadherence Assessing adherence Potential solutions Resources Introduction Drugs don t work in patients who don t take them. C. Everett Koop, MD Audience Response Answer yes or no to the following questions: I ve provided care to a patient where I ve Ive noticed adherence was an issue. I ve questioned a patient about their medication adherence. What was the patient s response to this interaction? 2

3 Background Adherence has been defined as the active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result. 1 Adherence vs compliance Adherence vs persistence 1. Delamater AM. Improving patient adherence. Clin Diabetes. 2006;24: Background Prescriptions never filled: 20-30% Patients with chronic medical illnesses adherent with treatment only 50% of time 1 Dramatic decrease after 6 months Examples: 56% of asthma patients nonadherent to inhaler therapy % patients discontinue statin use after 2 years 3 1.Variations in patients adherence to medical recommendations: a quantitative review of 50 years of research. Medical Care. 2004;42(3): Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288: Background Clinical trials: average adherence rates of only 43-78% among patients receiving treatment for chronic conditions 1,2 General rate defined in literature as good adherence: 80% 1. Cramer J, Rosenheck R, Kirk G, Krol W, Krystal J. Medication compliance feedback and monitoring in a clinical trial: predictors and outcomes. Value Health. 2003;6: Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther 2001;23:

4 Background Patterns in medication use through electronic monitoring: Most deviations occur as omission of doses or delays in timing of dose White coat adherence Background Six general patterns of medication use for chronic illnesses: Close to perfect adherence Take nearly all doses, but with some timing irregularity Miss an occasional single day s dose and some timing inconsistently Take drug holidays 3-4 times annually, and occasional omissions of doses Have a drug holiday monthly or more often, with frequent dose omissions Take few or no doses while giving impression of good adherence Background Poor adherence: causes approximately 33% to 69% of medication-related hospitalizations adds an estimated $290 billion to overall health-care spending annually creates a $188 billion revenue gap in US for industry, PBM s and pharmacies 4

5 Background Audience Response Which of the following is NOT associated with decreased adherence? A. Socioeconomic status B. Side effects of treatment C. Poor provider-patient relationship D. Depression Causes of Nonadherence Intentional nonadherence Results from planned action due to reasons such as side effects, belief medication is harmful or ineffective, etc. Unintentional nonadherence Results from unplanned action due to reasons such as forgetfulness, complex regimen, etc. 5

6 Causes of Nonadherence Osterberg L, Blaschke T. N Engl J Med 2005;353: Causes of Nonadherence Causes may vary based on factors related to age and health status Race, sex, and socioeconomic status have not been consistently associated with levels of adherence Osterberg L, Blaschke T. N Engl J Med 2005;353:

7 Assessing Adherence Direct: DOT, measurement of drug concentration Indirect: asking patient, assessing clinical response, pill counts, refill history, electronic monitoring Potential confounders for all! Assessing Adherence Pharmacy data: Medication possession ratio: # days medication supplied within refill interval number of days in refill interval Max value is >1: accounts for oversupply Proportion of days covered: total days all drug(s) available days in follow-up period Day is only counted if all medications are available that day (max value is 1) Both correlate well with quantity of taken doses, but not timing of doses Assessing Adherence 7

8 Assessing Adherence Questionnaires Morisky Medication Adherence Questionnaire (aka, MAQ, MMAS-4, Morisky-4; also an 8 question version) Self-Efficacy for Appropriate Medication Use Scale (SEAMS) Brief Medication Questionnaire (BMQ) Medication Adherence Rating Scale (MARS) Patient Empowerment Program Assessing Adherence Patient Empowerment Program: (look for PEP pharmacy in app store) Free app for ipad designed for use in pharmacy 3-5 minute self-assessment that identifies top 3 dimensions affecting adherence 8

9 Assessing Adherence Choosing adherence scale based on disease of interest: Metabolic disorders: HTN, dyslipidemia, DM MAQ (shortest to administer), SEAMS (assesses self-efficacy), BMQ (diabetes only), Hill-Bone Compliance Scale (hypertension in predominantly black populations) Mental health: Schizophrenia, psychosis, depression MARS (schizoprenia and psychosis), BMQ (depression) Lavsa SM et al. J Am Pharm Assoc. 2011;51(1):90-94 Assessing Adherence In general practice, the simplest and most practical way to assess adherence is to ask patients nonjudgmentally how often they miss doses. Potential Solutions Unimodal vs multimodal solutions Interventions Should be Patient-Tailored Behavior-related Daily alerts 90 days medication supplies Automatic renewals Clinical Questions or concerns about medication Pharmacist consultation Linguistically and culturally appropriate Cost-related Payment assistance programs Lower cost medication alternatives Lower cost pharmacy option 9

10 Potential Solutions Simple dosing helps to maximize adherence Osterberg L, Blaschke T. N Engl J Med 2005;353:4877. Potential Solutions Community pharmacy-run programs Home visits: (ex: Moose Pharmacies in NC) 90 day fills Chain store programs (ex: Rite Aid) Medication synchronization programs Star ratings and adherence programs Potential Solutions Medication synchronization programs Prescriptions filled on the same day each month Provides intentional, monthly encounter with pharmacist to review medications Patients averaged >100 additional days of therapy annually 30% more likely to take medications as prescribed 10

11 Medication synchronization programs Patients averaged >100 additional days of therapy annually 30% more likely to take medications as prescribed Potential Solutions Star Ratings: Medicare Part D/Advantage plans Plans tracking data to determine what pharmacies can participate in preferred networks Providing financial incentives for good patient outcomes in areas such as adherence Potential Solutions Other strategies: Emphasize the value of the regimen and the effect of adherence Elicit patient s feelings about his or her ability to follow the regimen, and if necessary, design supports to promote adherence Provide simple, clear instructions and simplify the regimen as much as possible Encourage the use of a medicationtaking system (pill box, etc) Customize the regimen in accordance with the patient s wishes 11

12 Potential Solutions Other strategies, cont. Obtain help from family members, friends, and community services when needed Reinforce desirable behavior and results when appropriate Consider more forgiving medications when adherence appears unlikely: Medications with long half lives Depot (extended release medications) Transdermal medications Patient Resources Smartphone Apps Study published in JAPhA in 2013 by Dayer, et al. on available adherence apps 160 adherence apps were identified and ranked Among the apps, MyMedSchedule, MyMeds, and RxmindMe rated highest for ease of use and reminder features Patient Resources 12

13 Patient Resources Patient Resources Adherence Aids: nce/adherence_aids.pdf Script your future: Provides wallet cards, medicine management tools, and medication guides for common disease states Educator Resources NCPA Educator Toolkit: dherence-educators-toolkit Teaches classroom and experiential students about adherence 13

14 Questions? 14