Rich Segal, R.Ph., Ph.D. Professor and Associate Dean University of Florida

Transcription

1 Exploring Barriers to Medication Adherence and Strategies for Improving Adherence for Asthma Rich Segal, R.Ph., Ph.D. Professor and Associate Dean University of Florida

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3 Presentation Objectives Understand how people with asthma actually use the medications prescribed for them as well as use of self-medication Identify barriers to medication adherence Describe the effectiveness of pharmacists, physicians, and other healthcare personnel in addressing adherence barriers Identify strategies for resolving barriers to medication adherence.

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5 Drug Related Medical Accidents are Responsible for How Many Deaths? Tip of the Iceberg! 76,000 to >100,000 deaths from ADRs in U.S. Hospitals Alone What about those in Community Settings?

6 Objectives of Beneficent Care Not to inflict harm To prevent harm To remove harm To promote good 6

7 Simplified Medication Use Process Recognize Patient Problem Clinical Impression (Diagnosis) PLAN Prescribe Medicine Drug Related Morbidity Drug Therapy Problem Develops IMPLEMENT PLAN (Dispense and Advise) IMPLEMENT PLAN (Administer/Consume)

8 Drug Therapy Problems Categories Cipolle, Strand, Moley. Pharmaceutical Care Practice, 3 rd edition 8

9 Medication Adherence Barriers Does not understand instructions: the patient does not understand how to properly take or use the drug product and dosage regimen leading to the underuse of the medication Cannot afford drug product: the patient cannot afford the drug therapy recommended or prescribed Patient prefers not to take: the patient prefers not to take the drug therapy as instructed. Does not feel its needed. Concerned about side effects. Patient forgets to take: the patient does not remember to take sufficient doses of the medication Cannot swallow/administer drug: the patient is not able to swallow or administer the drug therapy as intended Substituting self-medication for prescribed medication or altering the use of prescribed medication in other ways due to the complementary use of self-medication

10 Example Meet Katherine Dicha 10 year old female Healthy except bronchial asthma Under care of Dr. Michael Admitted to hospital on 5 occasions over past four years with status asthmaticus 10

11 Today is July 10 and Mrs. Dicha has returned to the pharmacy for a refill of KD s albuterol 11

12 Asthma Deaths are Usually Preventable Literature indicates 3 major causes of asthma death: Delay in seeking or receiving appropriate care Medication misuse; poor adherence - under-use of corticosteroids and overuse of ß-agonists; interaction and toxicity Inappropriate care: insufficient corticosteroids Hindi Alexander MC, Middleton E,Jr. Asthma deaths: are they preventable? N Engl Reg Allergy Proc 1986; 7:

13 Overuse of inhaled ß-agonists associated with increased asthma death risk Matched 129 patients who had fatal or near-fatal asthma with 655 controls (who had received medications for asthma but had not had fatal or near- fatal events) with respect to region of residence, age, receipt of social assistance, and previous hospitalization for asthma. An increased risk of death or near death from asthma was associated with the regular use of inhaled beta 2- agonist bronchodilators. Heavy use of these agents should alert clinicians that it is necessary to reevaluate the patient's condition. Spitzer, W.O., et al.. N Engl J Med 326: , 1992.

14 Use of inhaled steroids is associated with reduced asthma death risk Same sample and design as above, with the additional matching criterion of at least one hospitalization for asthma in the prior 2 years... subjects who had been dispensed, on average, one or more metered-dose inhalers of beclomethasone per month over a 1-year period had a significantly lower risk of fatal and near-fatal asthma (odds ratio, 0.1; 95% confidence interval, 0.02 to 0.6). Ernst, P.,et al.. JAMA 268: , 1992.

15 THE PROBLEM About 50% of medications prescribed for chronic conditions are not taken as prescribed Adherence to controller medications varies among studies but most report adherence in the range from 17 to 50 percent based on refill records from pharmacies Dispensing data show patients treated with inhaled corticosteroids have, on average, only a two to four month supply of inhalers dispensed per year Despite the Work of Pharmacists

16 Refill Intervals for Albuterol MDI (Gainesville Florida) n=175 % of Total Refills About 40% of refills were too soon. 0 (Actual data) >21 Days from Last Refill

17 Refill Intervals for Beclomethasone MDI Florida) n=131 (Gainesville % of Total Refills About 60% of refills were too late. 0 (Actual data) Very Early Early "On-Time" Late Very Late Time of Refill

18 Looking toward Prevention Do we need to change the medications use system?

19 The Ideal of Pharmaceutical Care responsible, cooperative provision of drug therapy for the purpose of achieving definite outcomes intended to improve a patient s quality of life 19

20 A DRUG THERAPY SYSTEM RECOGNIZE PATIENT PROBLEM PRESCRIBING INFLUENCE (EDUCATION, FORMULARIES, ETC.) CLINICAL IMPRESSION (DIAGNOSIS) PLAN Prescribe Medicine PRESCRIBING EVALUATION PRESCRIBING DATA DEFINE & RESOLVE DTPs before coming DRMs IMPLEMENT PLAN (DISPENSE, ADVISE) MONITOR PATIENT PROGRESS IMPLEMENT PLAN (ADMINISTER/CONSUME)

21 Today is July 10 and Mrs. Dicha has returned to the pharmacy for a refill of KD s albuterol 21

22 Today is July 10 and Mrs. Dicha has returned to the pharmacy for a refill of KD s albuterol 22

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26 SUMMARY: KEY PROBLEMs with Asthma DTPs Indication for Controller medication in a poorly controlled patient with asthma but controller not prescribed Safety problem associated with overuse of albuterol, which masks the signs of worsening asthma disease Adherence associated with underuse of controller 70% of people show poor administration technique of inhalers Dr. House Despite the Work of Pharmacists

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28 The Backstory For some, culturally derived beliefs and values about disease shape health behaviors Challenges in learning how patients really use their medications and the barriers they face

29 THE PROBLEM Adherence to controller medications in the range from 17 to 50 percent based on refill records from pharmacies CAM use for treating asthma for adults ranged from 4% to 79%, and for children from 33% to 89%. Most commonly used were breathing techniques, herbal products, homeopathy and acupuncture and higher use in certain ethnic populations When asked whether CAMs were effective for asthma, >50% report they were satisfied with the CAMs used CAMs used due to concerns about long-term effects of steroid use; frustration that asthma does not resolve with conventional therapies; dissatisfaction with physician-patient interactions; belief that CAM therapies are natural and therefore safe; and desire of patients to have autonomy in making health choices

30 THE PROBLEM Low-income inner-city Black adults tended to use CAMs along with conventional asthma treatment, and considered CAM as natural, effective and potentially curative even while most of them said they also trusted prescribed asthma medicines. However, many admitted they were often not adherent to medications prescribed to control asthma. Significantly, several studies about the use of CAM for treating asthma found that most patients did not tell their healthcare providers they were using CAMs.

31 Training Objectives Describe and understand the CHW- MTM care process, role of the CHW and other health care providers. Create an accurate and complete personal medication list that includes prescription, OTC, Herbals, and home remedies. Gather accurate, understandable and complete health care information that will enable providers to make appropriate therapeutic decisions. Apply Motivational Interviewing skills to the medication history and patient interviewing Determine medication adherence, reasons for nonadherence and potential solutions through the analysis of the prescription claims data, patient interview, administration and interpretation of a set of questions to reveal medication use patterns and barriers. Create a care plan that provides clear, concise and credible actions for the client. Be HIPAA compliant Know when, which and how to refer the client to appropriate providers and/or support organizations.

32 CHW CHW and the Pharmacist Gathering Discovering Presenting Collaborating Implementing Pharmacist Reviewing Evaluating Problem Solving Collaboration

33 Molina CHW Program

34 Building and Intervention Toolkit Financial Assistance Regimen Simplification Refill Synchronization Connect to CHW Access to Meds Prescriber Correspondence Patient Education Connect to Community Pharmacist Mail Order Delivery 90 Day Supply Reminder Tools

35 We are in this together