Medication Adherence and Patient Engagement in Patients with Type 2 Diabetes

The Problem

Medication Adherence

Medication adherence is a patient’s conformance with a provider’s recommendations concerning the timing, dosage, frequency, and duration of medication use.¹ Unfortunately, 20% to 30% of prescriptions are never filled, and about 50% of medications filled are not taken as prescribed.¹ This poor medication adherence is responsible for unnecessary illness, hospitalizations, disability, and premature death, particularly among patients with chronic diseases.

Scope of Type 2 Diabetes

According to the Centers for Disease Control and Prevention, about 29.1 million individuals in the United States had diabetes in 2014. Approximately 21 million of these individuals had received a diagnosis; the other 8.1 million individuals had not yet been given a diagnosis. This number is projected to increase substantially in the next 15 years. In addition, 86 million Americans have prediabetes. Without intervention, 15% to 30% of these individuals will develop type 2 diabetes (T2D) within 5 years.²

Treatment adherence problems are common in patients with T2D because they may look and feel perfectly fine. It may be hard to fathom that they have a serious disease that can cause significant problems in the future, such as hypertension, dyslipidemia, heart disease, neuropathy, kidney failure, blindness, amputation, and death. Sometimes patients do not understand that many of these conditions can be better managed or even eliminated by adhering to treatment plans.

Uncontrolled diabetes is defined as not having met and/or sustained the goal glycated hemoglobin (A1C) level. The American Diabetes Association recommends individualized A1C goals for patients with diabetes. The goal is usually under 7%; however, it may be higher or lower in certain individuals. About one-third of adults with diabetes do not reach their goal A1C level.³

Cost of Poor Medication Adherence in T2D

Medication nonadherence results in $100 billion to $289 billion in annual costs.¹ The results of many studies have evaluated the resulting health care cost increase in nonadherent patients with T2D, and generally support the correlation of reduced costs with increased adherence. For example, Egede et al published a study in 2012 in which they measured health care costs of medication adherent and nonadherent patients with diabetes, which indicated a 41% higher inpatient cost in nonadherent patients between 2002 and 2006.⁴ Balkrishnan et al found that a mere 10% increase in adherence was associated with an 8.6% to 28.9% decrease in total annual health care costs.⁵

Patients with diabetes who follow prescriber guidelines have a 13% yearly risk of hospitalization, whereas nonadherent patients have a 30% risk.⁶ Similarly, patients with diabetes and hypertension have a 6.7% mortality rate when adherent to their treatment versus a 12.6% rate of mortality for nonadherent patients.⁷

Causes of Poor Medication Adherence in T2D

Approximately half of adults with diabetes have at least 1 comorbid condition, and approximately 40% have 4 or more comorbid conditions, and many of these individuals have more than 1 health care provider.⁸ This results in high out-of-pocket costs and burdensome, sometimes complex, treatment regimens. The requirement for multiple long-term medications is closely linked to problems with medication adherence.

Patients with T2D benefit most from individualized treatment plans; however, time limitations of health care providers are a significant barrier to successful individualization and care coordination. Patients are often left with unanswered questions, a lack of motivation, and confusion about their disease. If patients do not understand the disease and its possible long-term effects, they are less likely to adhere to their treatment plans.

In addition, frequent changes to medications, adverse effects (AEs), and drug interactions may cause patients to become nonadherent. Personal factors, such as forgetfulness, fear of needles, physical illness, and mental illness, can all conspire to make medication adherence problematic.

The Solution

Improving Care Coordination

The Agency for Healthcare Research and Quality defines care coordination as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.”⁹ As stated, a care coordination team can consist of anyone; however, for T2D patients, there is usually a large team, including a primary care physician, an endocrinologist, an ophthalmologist, a podiatrist, a diabetes coach, a nutritionist/dietician, and a pharmacist. If the disease progresses enough to affect kidney or heart function, a nephrologist or cardiologist may join the team, as well.

Enhancing Patient Engagement and Education

In their 2014 study results, Graffigna et al reported that patient engagement must include patients’ cognitive, emotional, and behavioral responses toward their health condition.¹⁰ This article describes 4 sequential phases for patient engagement. The first phase is disengagement, which typically occurs at diagnosis, and often includes denial. The patient feels helpless and at the mercy of the health care system. At this time, it is important to provide patients with a knowledge base—enough information to get them on the road to health management. The second phase follows when patients acknowledge their illness but still delegate the majority of management to the health care system. This is the ideal time to provide psychological support and broaden the patient’s knowledge base. Phase 3 begins when patients fully accept their diagnosis and have a broad base of knowledge about their disease; however, they do not quite comprehend and manage their treatment. At this point, understanding of the rationale behind their medications is crucial, as it allows patients to successfully participate in their health decision-making process. Finally, phase 4 comes when patients are fully engaged and active in their health management.¹⁰ To sustain this phase, patients need continuous counseling and individualized information to empower their self-management.

Motivating patients to become adherent to medications can be difficult. The use of motivational interviewing (MI) can help. MI was described in the early 1980s by American psychologist William R. Miller, PhD.¹¹ MI begins with a collaborative, open relationship between the provider and the patient. The provider needs to support self-efficacy and allow patients to be responsible for their own progress, permitting them to explore their intrinsic values and goals while considering other courses of action along with associated benefits and costs. There are 4 key points to remember when using MI. The first is to ask open-ended questions to allow patients to respond without the fear of a right or wrong answer. The second is to provide affirmations, expressing empathy during challenging times and celebrating accomplishments. The third is to provide reflective listening to allow patients to express their thoughts, then capturing the essence of what they have said with the purpose of expanding the conversation and helping them arrive at a solution for change. Finally, summarize what the patient has said to clarify anything that is not clear and add anything that was missed.¹¹The use of MI is also a great way to help patients identify specific, achievable goals. The overall goal for these patients is to prevent the complications of diabetes and improve quality of life. This goal may often seem out of reach because so many factors have to be addressed before achievement of this goal is possible. Between taking medications and dealing with their associated AEs, changing eating habits and exercise behaviors, and monitoring blood glucose levels, this can all be overwhelming. Allowing patients to set goals through MI has been shown to increase the likelihood of achieving those goals.

Patient accountability and joint responsibility are essential for goal achievement in patients with diabetes. Patients must be honest with themselves about what they are eating and how much they are exercising, how often they count the carbohydrates they are consuming, how often they are recording their blood glucose level, and whether they are following their medication regimen. Touching base with an educator or coach weekly or biweekly has been shown to improve adherence.¹²

With recent technologic advances in mobile health (mHealth) tools, various types can now deliver a cost-effective approach to patient engagement challenges while providing daily support to patients with T2D. mHealth tools can also help socially underprivileged patients by overcoming some of the challenges of adherence, such as language and transportation. mHealth tools can provide educational support in the right format at the right time to patients. Daily or weekly educational messages, health reminders, and diet and exercise tips can be sent directly to patients.

Using Counseling and Medication Management

A pharmacist’s role in counseling patients is to (1) ensure they have sufficient understanding, knowledge, and skill to follow their regimens and monitoring plans, and (2) motivate patients to take an active role in their health care. The results of a 2013 survey¹³ acknowledged that pharmacist-led discharge counseling from a health care facility improves patient outcomes and safety, resulting in stricter adherence to treatment and leading to better outcomes and faster convalescence. The same holds true for community pharmacists. Interactive patient counseling is imperative. The MI methods described above can be used to verify that patients know how to correctly take their medications, understand the major AEs of those medications, and understand the importance of medication adherence. Any gaps in knowledge should be filled in by the pharmacist, and a summary from the patient concludes the counseling session.

Medication therapy management (MTM) is also an important part of ensuring medication adherence in patients with T2D. MTM is a service, or group of services, designed to optimize therapeutic outcomes for individual patients. Pharmacists provide MTM services in an effort to obtain the best possible outcome for patients by managing drug therapy and identifying, preventing, and resolving medication-associated complications.¹⁴

Expanding Screening and Assessment

Expanding the use of screening and assessment tools to target patients at risk for nonadherence is necessary for increasing medication adherence for maximal benefit. Patients with language barriers, a low socioeconomic status, mental disorders, or unstable living conditions, or who are elderly, are at high risk for nonadherence.

The Value Proposition

Medication adherence in patients with T2D is often a challenge, resulting in poor outcomes. Engaged patients increase their knowledge about their disease, which increases their confidence in their ability to manage it. This confidence can help to decrease their anxiety and pessimism about their disease, thereby increasing their personal accountability. Increased accountability results in increased adherence, leading to increased efficacy and better outcomes, which, in turn, decrease health care costs.

Consider the Ashville Project and its measure of quality of life and return on investment. The Ashville Project was initiated in 1997 to assess clinical, economic, and humanistic outcomes of a community-based MTM program for patients with chronic diseases during a 5-year period.¹⁵ Patients attended educational classes and had regular meetings with pharmacists and physicians. Positive results were seen in A1C and lipid levels. Costs shifted to prescriptions from inpatient and outpatient physician services, resulting in a decrease of total mean direct medical costs from $1872 to $1200 per patient per year. Results of published data show a savings of $4.00 per every $1.00 invested.¹⁵

“Project IMACT: Diabetes,” a similar study, launched in 2010, targeted patients with diabetes who were uninsured, underinsured, living below poverty level, and homeless. These patients received care from an interdisciplinary team including pharmacists, physicians, diabetes educators, and others. This study also resulted in decreased A1C levels and positive effects on lipids.¹⁶

A plethora of studies show similar results, indicating that consistent interaction with health care providers leads to positive health outcomes, particularly in patients with chronic diseases. Please educate your patients with T2D on the importance of adherence. Look for patients who may benefit from extra counseling. Watch for timely refills. Ask patients about AEs. And, above all, engage!

This article is published in collaboration with the Directions in Pharmacy CE Conference program.

Dr. Kenny earned her doctoral degree from the University of Colorado Health Sciences Center. She has 20-plus years’ experience as a community pharmacist and works as a clinical medical writer based out of Colorado Springs, Colorado. Dr. Kenny is also the Colorado education director for the Rocky Mountain Chapter of the American Medical Writer’s Association.

References

• Medication adherence. Centers for Disease Control and Prevention website. cdc.gov/primarycare/materials/medication/docs/medication-adherence-01ccd.pdf. Accessed January 20, 2016.
• 2014 National Diabetes Statistics Report. Centers for Disease Control and Prevention website. cdc.gov/diabetes/data/statistics/2014statisticsreport.html. Accessed January 20, 2016.
• America’s diabetes challenge. American Diabetes Association website. diabetes.org/diabetes-basics/americas-diabetes-challenge/?loc=db-slabnav. Accessed January 20, 2016.
• Egede LE, Gebregziabher M, Dismuke CE, et al. Medication nonadherence in diabetes: longitudinal effects on costs and potential cost savings from improvement. Diabetes Care. 2012;35(12):2533-2539. doi: 10.2337/dc12-0572.
• Balkrishnan R, Rajagopalan R, Camacho FT, et al. Predictors of medication adherence and associated health care costs in an older population with type 2 diabetes mellitus: a longitudinal cohort study. Clin Ther. 2003;25(11):2958-2971.
• Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521-530.
• Ho PM, Magid DJ, Masoudi FA, McClure DL, Rumsfeld JS. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovascular Disord. 2006;6:48.
• Diabetes patient engagement. High Value Healthcare website. highvaluehealthcare.org/what-we-do/clinical-areas/diabetes-chf. Accessed January 27, 2016.
• Care coordination. The Agency for Healthcare Research and Quality website. ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html. Accessed January 20, 2016.
• Graffigna G, Barello S, Libreri C, Bosio CA. How to engage type-2 diabetic patients in their own health management: implications for clinical practice. BMC Public Health. 2014;14:648. doi: 10.1186/1471-2458-14-648.
• Stewart EE, Fox CH. Encouraging patients to change unhealthy behaviors with motivational interviewing. Fam Pract Manag. 2011;18(3):21-25.
• Liddy C, Johnston S, Irving H, Nash K, Ward N. Improving awareness, accountability, and access through health coaching: qualitative study of patients’ perspectives. Can Fam Physician. 2015;61(3):e158-e164.
• Carollo A, Adamo A, Di Georgio C, Polidori P. The Importance of clinical pharmacists counselling in improved patient medication adherence. Eur J Hosp Pharm. 2013;20:A121. doi:10.1136/ejhpharm-2013-000276.335.
• APhA MTM Central: What is medication therapy management? APhA website. pharmacist.com/mtm. Accessed January 27, 2016.
• The Ashville Project. American Pharmacists Association website. aphafoundation.org/asheville-project. Accessed January 30, 2016.
• Project IMPACT: Diabetes. American Pharmacists Association website. aphafoundation.org/project-impact-diabetes. Accessed January 31, 2016.