Let's Talk: Medication Adherence

Medication adherence is a multidimensional component of the medication-use process that impacts quality and length of life, health outcomes, and overall health care costs.^1,2 Approximately 50% of patients are nonadherent to chronic medications, and this is thought to be driven by difficulty recognizing the long-term consequences of nonadherence.² Additionally, nonadherence may account for up to 50% of treatment failures. In the United States, it is estimated that nonadherence causes 125,000 deaths and up to 25% of hospitalizations each year. Although services to improve adherence are not reimbursed, these improvements could mitigate up to $300 billion in costs annually.³ Furthermore, nonadherence has been regarded as a public health dilemma such that pay-for-performance measures are evolving to tackle the problem.^4-6

Effective communication is one of the biggest challenges to improving adherence. Pharmacists have been known to collaborate with providers in the community, ambulatory, and hospital settings, but provider acceptance rates vary greatly between these patient care settings.^7-9 Studies have shown that ambulatory care and inpatient pharmacist medication recommendations are well-received, with acceptance rates by physicians ranging 70-90%.^7-9 A prototypic example is a randomized trial with high-risk cardiac patients at several US Veterans Affairs Medical Centers. This multifaceted 1-year intervention followed hospital discharge for acute coronary syndrome patients. The intervention consisted of pharmacist-led medication reconciliation and synchronization (within 7-10 days of hospital discharge), pharmacist-provided patient education, collaborative care between pharmacist and primary care clinician and/or cardiologist (including cosignature of pharmacists notes), pharmacist educational voice messaging and telephone calls, and medication refill reminder calls. The collaborative intervention group had significantly higher adherence than the usual care group (89.3% vs. 73.9%, p=0.003), including improved adherence to clopidogrel (P<0.001), statins (P<0.001), and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (p=0.03), showing that ambulatory and inpatient pharmacists involvement in post-hospital transitions of care can improve adherence.¹⁰

Community pharmacist recommendations have lower acceptance rates ranging from 42-60%.⁷ This is alarming due to the fact that the community pharmacist is vital for improving and monitoring adherence, being accessible to patients and having direct insight into prescription histories. Even so, these numbers indicate that community pharmacists can still substantially impact patient care. There are many factors attributing to the differences in clinical intervention acceptance rates. One of the most apparent differences is pharmacist interaction with the care team based on practice setting. In the ambulatory care and inpatient settings, pharmacists are more available for interdisciplinary team members, which can optimize acceptance of interventions. The reality in the community setting is that many interventions are via telephone or fax, and access to and communication via electronic health record may be limited.

So how can community pharmacists best convey recommendations to prescribers? A small study surveyed several prescribers to identify characteristics of an ideal fax template to increase provider response rates. The ideal template would notify the prescriber of notable patient information, avoiding superfluous information in order to minimize the time needed for prescriber review. The fax must go beyond stating a patient is nonadherent and should have a succinct description of barriers accompanied by a plan to increase adherence.¹¹ The strategy learned from this survey on faxes, simplifying the message and offering a plan of action, can be extrapolated to other points of prescriber interaction such as telephone or email.

A few promising pharmacist-prescriber interventions to improve adherence include switching maintenance medications to 90-day prescriptions and enrolling patients in automatic refill programs. One study focused on patients with 30-day prescriptions for oral antihypertensives and statins, and faxed provider requests for 90-day prescriptions as well as prescription refill reminder letters. The provider response rate was 54%, the approval rate was 47% for 90-day refills, and adherence rates were significantly higher.¹² For automatic prescription refill programs, there is a concern that these programs can lead to medication oversupply if not properly managed. In a study evaluating the CVS Caremark automatic refill program, both the 30-day and 90-day prescription refillers had significantly higher adherence measured by medication possession ratio with adjusted differences across all classes of medications of 3% and 1.4% respectively (P<0.001). Patients enrolled in automatic refill also had significantly fewer days of oversupply than the control groups (P <.001).¹³

Regarding pharmacist-to-patient communication, strategies have also been explored using various models, with face-to-face and electronic interventions holding the most promise. A retrospective cohort reviewed face-to-face counseling, which directly targeted statin adherence barriers in 1,102 patients. Those who participated in these brief counseling sessions were significantly more adherent (P <.01 at 12 months, P<0.05 comparing medication possession ratios ≥ 80%) and persistent to statin therapy (P<.05 at 120 days, P=.05 at 365 days).¹⁴ Another adherence study in type 2 diabetes patients found a positive association in patients who spent more time with pharmacists, in female patients, and in those who received individualized education and adherence support.¹⁵ In-person pharmacist education through Asheville Project medication therapy management services has demonstrated adherence benefits in asthma, diabetes, hypertension, dyslipidemia, and cardiovascular disease, translating to significantly improved disease management control, as well as reduced clinical event rates and costs.^16-18

A review article evaluated an assortment of pharmacist-to-patient adherence intervention models for cardiovascular disease and diabetes. Studies consisted of randomized controlled trials, and among the in-person pharmacist counseling interventions, the most successful were face-to-face within a pharmacy (83%), followed by hospital discharge (67%), clinic-based interventions (47%), and phone calls (38%). Indirect methods such as electronic, mailed, or faxed materials resulted in similar efficacy, showing overall success rates of 56% for indirect interventions compared to 52% for in-person. Of the indirect interventions used, electronic (e.g. automated phone calls, electronic pill boxes, computer-generated targeted interventions) were more successful (67%) than paper such as mailed education material (33%). This study concluded that new electronic approaches to medication adherence should be explored in addition to in-person interventions at the site of medication distribution and identifying times of increased patient receptivity such as hospital discharge. ¹⁹

In an evolving and technology-driven world, mobile text messaging is a feasible electronic option to improve adherence, as more people from all socioeconomic classes and age groups are using this technology.²⁰ A recent meta-analysis examined mobile text messaging and its effect on medication adherence in chronic disease. The analysis included variable text messaging designs from 16 randomized controlled trials. Among the text messaging designs, 50% of trials involved 2-way communication, 50% implemented daily text message frequency, 31% were personalized, and 63% were managed by automation or computer programs. For the 2,742 patients included in analysis, text messaging doubled the odds of medication adherence (odds ratio 2.11; P<.001). This increase correlates to adherence rates improving from a baseline of 50% to 67.8%, or an absolute increase of 17.8%.²⁰ Mobile telephone text messaging can be a new tool for both providers and pharmacists to promote adherence.

All in all, pharmacists play a pivotal role and are well positioned to impact outcomes via medication adherence. Regardless of the approach used or setting of practice, enhancing pharmacist-provider and pharmacist-patient communication can lead to significant breakthroughs in medication adherence. In-person methods appear to be the most effective overall, but gains can be made using various strategies. Although acceptance rates vary based on setting, prescribers are generally receptive to pharmacist recommendations, especially when messages are simple and offer solutions. For patients, electronic adherence tools hold much promise and should be explored further.

References:

• Sabaté E. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization. 2003. http:///www.who.int/chp/knowledge/publications/adherence_report/en/.
• DiMatteo MR, Giordani PJ, Lepper HS, et al. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794-811.
• American College of Preventive Medicine. Medication Adherence Clinical Reference. 2011. http://www.acpm.org/?MedAdherTT_ClinRef.
• Pagès-Puigdemont N, Mangues MA, Masip M, et al. Patients' perspective of medication adherence in chronic conditions: A qualitative study. Adv Ther. 2016 Oct;33(10):1740-175
• Bosworth, HB. Enhancing medication adherence: The public health dilemma. Springer Healthcare. 2012.2:8. DOI: 10.1007/978-1-908517-66-1_2.
• Pharmacy Quality Alliance. Update on medication quality measures in Medicare Part D Plan Star Ratings-201 http://pqaalliance.org/measures/cms.asp.
• Michaels NM, Jenkins GF, Pruss, DL, et al. Retrospective analysis of community pharmacists' recommendations in the North Carolina Medicaid medication therapy management program. J Am Pharm Assoc (2003). 2010 May-Jun;50(3):347-53.
• Nichol, A, Downs, GE. The pharmacist as physician extender in family medicine office practice. J Am Pharm Assoc (2003). 2006 Jan-Feb;46(1):77-83.
• Bourne, RS, Choo, CL, Dorward, BJ. Proactive clinical pharmacist interventions in critical care: effect of unit speciality and other factors. Int J Pharm Pract. 2014 Apr;22(2):146-54.
• Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial. JAMA Intern Med. 2014;174(2):186-193.
• Johnson A, Chui MA, Moore M, Jensen B, Kieser M. Optimizing medication adherence communication with prescribers. J Pharm Soc Wis. 2013;16(3): 53—56.
• Leslie RS, Gilmer T, Natarajan L, Hovell M. A Multichannel Medication Adherence Intervention Influences Patient and Prescriber Behavior. J Manag Care Spec Pharm. 2016;22(5):526-38.
• Matlin OS, Kymes SM, Averbukh A, et al. Community pharmacy automatic refill program improves adherence to maintenance therapy and reduces wasted medication. Am J Manag Care. 2015;21(11):785-791.
• Taitel M, Jiang J, Rudkin K, Ewing S, Duncan I. The impact of pharmacist face-to-face counseling to improve medication adherence among patients initiating statin therapy. Patient Prefer Adherence. 2012;6:323-9.
• Odegard PS, Carpinito G, Christensen DB. Medication adherence program: adherence challenges and interventions in type 2 diabetes. J Am Pharm Assoc (2003). 2013 May-Jun;53(3):267-72.
• Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173—84.
• Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc. 2006;46:133—47.
• Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc (2003). 2008 Jan-Feb;48(1):23-31.
• Cutrona SL, Choudhry NK, Fischer MA, et al. Modes of delivery for interventions to improve cardiovascular medication adherence. Am J Manag Care. 2010;16(12):929-42.
• Thakkar J, Kurup R, Laba TL, et al. Mobile Telephone Text Messaging for Medication Adherence in Chronic Disease: A Meta-analysis. JAMA Intern Med. 2016;176(3):340-349.