Multimed Packaging Impact on Medication Adherence and Clinical Outcomes

Low adherence to prescribed self-administered medication is well documented and presents significant challenges in the treatment of chronic conditions. In developed countries, adherence to long-term therapy is estimated to average 50%.¹ Despite more than 4 decades of research regarding the proper measurement of medication adherence (MA), our most widely adopted methods for assessing adherence, Proportion of Days Covered (PDC), Medication Possession Ratio (MPR), and Average Days on Therapy (ADT), all use prescription-refilling patterns as surrogate measures for patient medication-taking behavior.² This underscores a tremendous need for pharmacists to help patients self-manage adherence beyond the point of obtaining their medications from the pharmacy. Evidence supports multimedication packaging as a primary tool to meet this need.

Forgetting to take a medication is the most frequently patient-reported reason for nonadherence.^{3 4} In a survey of over 24,000 adults, 70% reported unintentional non-adherence behaviors, including forgetting to take their medications (62%), running out of medication (37%), and being careless about taking medication (23%).⁵ Multimed packaging is a highly useful tool for addressing each of these areas of non-intentional nonadherence.⁶ It provides a convenient method for patients to self-monitor medication consumption, eliminating the need to remember whether a certain dose has been consumed. It also gives both patients and caregivers an immediate visual verification of doses previously removed from the device.⁷ Further, multimed packaging is especially effective for medications that should be consumed at different times of day, as it eliminates the need decision-making regarding which medications to consume at different times.⁸ It also mitigates nonadherence by eliminating the need for patients to open multiple containers for each administration.⁸ Additionally, patients favor the ease of opening the blisters, and the capacity of the multimed blister card, which, depending on manufacturer, may accommodate up to a 14-medication regimen.⁹

Multiple studies have documented improved MA over time using multimed packaging. This result is in contrast with MA behavior following most other MA interventions, which generally reveal a pattern of diminished MA over time. A systematic review/meta-analysis that looked at the overall effect of packaging interventions found that blister packs were the most effective of all packaging interventions used, with an overall mean weighted standardized difference effect size of 0.802 compared to that of pill boxes at 0.384. Interventions were found to be more effective when delivered by a pharmacist, 0.782, than interventions without a pharmacist, 0.475.¹⁰ Additionally, MA interventions that exclusively used multimed packaging were as effective as interventions that combined packaging with other adherence interventions.^4,7 Since medication persistence is necessary for the achievement of desired health outcomes, this is an important benefit of multimed packaging.

In addition to medication adherence, several studies demonstrated improvement in clinical outcomes associated with multimed blister packaging. The FAME study showed adherence improved from 61.2% to 96.9%, with a reduction in mean systolic blood pressure from 133.3 to 124.4.¹¹ Similar results were shown in two studies conducted in 2017 by Bosworth et al. and Tan, et al., both of which found packaging to improve blood pressure due to improved adherence to the medication(s) prescribed.^{12 13}

Pharmacies that have integrated multimed packaging into their practices are seeing positive results in terms of patient satisfaction and quality performance. However, pharmacy adoption of multimed packaging in the U.S., as compared to other countries, represents a clear opportunity. In the U.K., for example, multimed packaging is mainstream, with nearly every pharmacy offering the service. This includes approximately 20% of all patients who receive 4 or more chronic medications.⁹ Technology and automation offer innovative options for pharmacies who wish to move beyond manual blister packaging, and capture greater efficiency. By automating the multimed packaging process, pharmacy teams are able to dedicate more of their time providing much needed patient care services.

As we prepare for value-based care, and consider ways to improve medication adherence, patient safety, patient loyalty, quality measure performance, and profitability, multimed packaging offers a rewarding, innovative option for pharmacists, support staff, and patients.

About the Author

Rebecca W. Chater, RPh, MPH, FAPhA, is a career-long pioneer in innovative community-based clinical pharmacy practice. Chater is director of clinical healthcare strategy with Omnicell, Inc., a leading provider of patient engagement solutions, inspired to create safer and more efficient ways to manage medications and supplies across all care settings. Throughout her career, Chater has championed the pharmacist as a medication expert, integral to the healthcare team in optimizing medication use.

References:

• WHO. Adherence to long-term therapies: Evidence for Action. Geneva: WHO; 2003
• Lam W, Fresco P. BioMed Research International. (2015); Article ID 217047, 12 pages, http://dx.doi.org/10.1155/2015/217047
• Zedler BK, Kakad P, Colilla S, Murrelle I, Shah NR. Does packaging with a calendar feature improve adherence to self-adminstered medication form long-term use? A systematic review. Clin Ther. 2011 Jan. 33; 62-73 [PubMed: 21397775]
• Mahtani KR, Heneghan C, Clasziou PP, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database Syst Rev. 2011
• Gadkari AS, McHorney CA Unintentional non-adherence to chronic prescription medications: how unintentional is it really? BMC Health Serv Res. 2012;12: 98. Published online 2012 Jun 14. doi: 10.1186/1472-6963-12-98
• Mahtani KR, Heneghan C, Clasziou PP, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database Syst Rev. 2011
• Rivers PH. Compliance aids—do they work? Drugs Aging. 1992 Mar-Apr 2: 103-111. [PubMed: 1596593]
• 26 Borenstein M, Hedges L, Higgins JPT, Rothstein H. Introduction to Meta-Analysis. West Sussex, England: John Wiley and Sons, Ltd; 2009.
• The True Cost of Medication Non-Adherence. Authored by Pat Hagan, national health journalist, on behalf of Omnicell UK and the Lets Take Care of It campaign
• Curr Med Res Opin 2015 January; 31(1): 145-160 Packing interventions to increase medication adherence: systematic review and meta-analysis
• Lee JK et al. JAMA 2006; 296(21): 2563-2571
• Bosworth et al. Am J Manag Care. 2017;23(9):e280-e286
• Tan BY et al. SAGE Open Med. 2017; 5: 1-9