Medication Adherence Improve Patient Outcomes and Reduce Costs
Medication adherence –A patient is considered adherent if they take 80 percent of their prescribed medicine(s). If patients take less than 80 percent of their prescribed medication(s), they are considered non-adherent.
How common is medication non-adherence?
Patients don’t take their medicine as prescribed about half the time
Why is it important to assess adherence?
Patients are often reluctant to tell their doctor if they do not take their medication as prescribed. Barriers to adherence can include a lack of understanding around the medical diagnosis, the need for treatment, or an inability to obtain medication due to cost, scarcity, or time conflicts. Patients may feel shame or mistrust about the issues that limit their disclosure of whether they take medications as prescribed. Unless a patient’s medication-taking behaviour is understood, therapy may be needlessly escalated.
Medication non-adherence can lead to unnecessary hospitalisation and emergency room (ER) visits, increased costs to the patient and health care system, potential harm to the patient, and unnecessary work on the part of the practice during the visit. The following STEPS can help identify and improve patients’ adherence to their medications.
Eight STEPS to improve medication adherence
- Consider medication non-adherence first as a reason a patient’s condition is not under control.
- Develop a process for routinely asking about medication adherence.
- Create a shame- and blame-free environment to discuss medications with the patient.
- Identify why the patient is not taking their medicine.
- Respond positively and thank the patient for sharing their behaviour.
- Tailor the adherence solution to the individual patient.
- Involve the patient in developing their treatment plan.
- Set the patient up for success.
STEP 1 Consider medication non-adherence first as a reason a patient’s condition is not under control.
Think about non-adherence when reviewing patient medications, especially when considering escalating therapy or adding another medication. Many physicians are surprised to learn that:
- Patients typically do not take their medications half of the time.2,3
- Approximately a quarter of new prescriptions are never filled.4,5
- Most patients who decide not to fill a prescription or take a medicine do not tell their doctor.
Escalating therapy when non-adherence is hidden can be very dangerous, costly, and time-consuming. If a physician prescribes another medicine to an already non-adherent patient, this can have catastrophic results if the patient suddenly starts taking all their medicines. For example, consider a patient who is hospitalised and is given medication according to their home medication list. The hospital physician is unaware that the patient had not previously been taking all their prescribed medications. When the patient begins their medications (suddenly adherent), the patient may develop severe hypo-tension or hypoglycemia, resulting in the need for additional care and management.
STEP 2 Develop a process for routinely asking about medication adherence.
Every practice should develop a tailored process to assess adherence. Simply asking “Are these your meds?” only addresses whether the current list of prescribed medications is correct and does not address the patient’s medication-taking behaviour. One option is for the medical assistant (MA) and/or receptionist to offer the patient a pre-visit questionnaire at check-in that includes questions about medication usage. The questionnaire may be accompanied by a list of the patient’s current medications with directions to cross out medications they are no longer taking and circle any they don’t take regularly or would like to discuss. You can then review this questionnaire with the patient during their visit. It is often more convenient for the patient to look at a simple paper list in their hand rather than a computer screen at some distance.
Another option is having the MA or nurse gather medication information when rooming the patient, alerting the physician of any potential issues to discuss during the visit.
STEP 3 Create a shame- and blame-free environment to discuss medications with the patient.
The patient may have good reasons for not taking their medications and should be reassured that they can share their true medication-taking behaviour without judgement. Some patients may be less reluctant to reveal their true medication-taking behaviour to a MA or nurse; often due to concerns that their physician may be disappointed or angry to learn of their non-adherence.
STEP 4 Identify why the patient is not taking their medicine.
Medication non-adherence may often be intentional. Patients may make a rational decision to not take their medicine based on their knowledge, experience, and beliefs.
STEP 5 Respond positively and thank the patient for sharing their behaviour.
Physicians are often surprised to hear that their patient is choosing not to follow their advice. Once a patient shares their non-adherence with care team or the physician, the physician should respond positively. For example, the physician may consider saying, “Thank you for letting us know that you are not taking your medications as prescribed. Can we talk through this together?” A positive and thankful response will make patients more comfortable with sharing their reasons for not taking the medicine. On the other hand, scolding patients may encourage them to withhold their true medication-taking behaviour.
STEP 6 Tailor the adherence solution to the individual patient.
Each patient may have a unique reason for not taking their medicine. By identifying and discussing these unique reasons you can develop a personalised approach that promotes adherence in the future.
STEP 7 Involve the patient in developing their treatment plan.
Patients who are included in decisions about the medications are more likely to adhere to their treatment plan. Before starting a new medication, you might offer the patients a choice: “We could either start a blood pressure medication today or you could make some other changes to see if you can control your blood pressure without medication. To control your blood pressure without medication, try to exercise more often and start a low salt diet. It’s also important that you monitor your blood pressure at home three times a week to make sure you’re on track. When you come back in a few weeks, we can re-assess your blood pressure and discuss options. Which do you prefer?”
STEP 8 Set the patient up for success.
Make it easy for patients to adhere to their medication regimen. One simple way for your practice to achieve this is to give patients an updated medication list at the end of each visit that highlights any changes to their treatment plan. If the patient agrees, you may also ask if the family or caregiver would like an extra copy. Patients who need assistance may give family members permission (proxy) to access their electronic chart.
Conclusion – Addressing medication non-adherence is critical for patient health and safety, and will allow your practice to deliver the most effective care possible. This module provides information on medication non-adherence and suggests how you can discuss this subject with your patients. Use the strategies and tactics in this module to improve your patients’ medication adherence.
- Reductions in hospitalisations and emergency department visits are key drivers of declining health costs associated with improved medication adherence.
- Using integrated pharmacy and medical administrative claims data on American individuals who had continuous health insurance coverage from 2005 to 2008, one study indicated that across four major conditions (congestive heart failure, hypertension, diabetes, and dyslipidemia) adherence was associated with significantly lower annual inpatient hospital days, ranging from 1.18 fewer days for dyslipidemia to 5.72 fewer days for congestive heart failure.
- An analysis conducted for five chronic diseases using data compiled in the U.K., Germany, and the Netherlands showed direct productivity benefits from improved adherence. These diseases (hypertension, asthma/ chronic obstructive pulmonary disease (COPD), chronic back pain, depression, and rheumatoid arthritis) were responsible for driving huge annual productivity losses, reaching €28 to €50 billion in the U.K., €38 to €75 billion in Germany, and €9 to €13 billion in the Netherlands.
- In the U.S., the link between use of prescription medicines and spending on other health care services has been acknowledged by the U.S.’s nonpartisan Congressional Budget Office (CBO). In 2012, the CBO announced a change to its scoring methodology to reflect savings in medical spending associated with policies that increased use of medicines in Medicare. The CBO estimates that a 1 percent increase in the number of prescriptions filled by beneficiaries would cause Medicare’s spending on medical services to fall by roughly one-fifth of 1 percent.
- Payers recognise the cost-offset value of drug adherence as more plans implement a variety of adherence management strategies. According to a recent survey of over 102 U.S. health plans representing over 106 million lives, approximately 70 percent of plans consider adherence management among their most valuable services.
Social Health and Potential Economic Impact on Specific Diseases
- High Blood Pressure: Using population life tables and cause of-death statistics from the U.S.’s National Center for Health Statistics (NCHS), one study translated these risks into changes in life expectancy and found that if all patients with stage 1 or 2 hypertension who reported being untreated had been treated in accordance with clinical guidelines, and if all treated patients achieved normal blood pressure, an additional 89,000 fewer premature deaths from major cardiovascular disease would have occurred in 2001.
- High Cholesterol: Using combined population and clinical data, one study calculated anti-cholesterol (statin) drug therapy’s social value to consumers for the period of 1987 to 2008. Survey data from the National Health and Nutrition Examination Study (NHANES) (a repeated survey of the health status of the U.S. civilian, non institutionalised population) suggested that statin therapy reduced low-density lipoprotein by roughly 19 percent, which translated into roughly 40,000 fewer deaths, 60,000 fewer heart attacks, and 22,000 fewer strokes in 2008.
- Heart Failure: Using a simulation model that quantified the impact of Part D on adherence and medical expenditures for Medicare beneficiaries, a recent study published in the American Journal of Managed Care, showed that improved adherence to medication following the expansion of drug coverage under Medicare Part D in the U.S. led to nearly $2.6 billion in savings to medical expenditures annually among beneficiaries with congestive heart failure. The study, also found that improving adherence to recommended levels could save Medicare another $1.9 billion annually, leading to $22.4 billion over 10 years.
- Diabetes: A study conducted in 2012 using data extracted from a large US managed-care company that provides pharmacy management services to a range of clients including employers and health plans, found that improved adherence to diabetes medications was associated with 13 percent lower odds of subsequent hospitalisations or emergency department visits. Based on these and other effects, the study authors projected that improved adherence to diabetes medication could avert 699,000 emergency department visits and 341,000 hospitalisations annually, for a saving of $4.7 billion.
- Osteoporosis: Adherence to osteoporosis medicines have been shown to greatly reduce medical costs, especially hospitalisation and long-term care costs. A study conducted in 2007 used a validated model of osteoporosis, populated with epidemiological and cost data to estimate the total number of incident fractures and associated costs for the U.S. population 50 years of age and above from 2005 through 2025. By 2025, annual fractures and costs were projected to grow by 50 percent and will surpass 3 million and $25 billion, respectively. Using data collected from 45 employers and 100 health plans in the continental U.S. from two claims databases during a five year period (1999–2003) another study13 found that patients who were refill compliant and persistent showed 20–45% relative-risk reductions in fractures.
- Rheumatoid Arthritis: Researchers at the Integrated Benefits Institute found that a decrease in rheumatoid arthritis medicines led to increased incidence and longer duration of short-term disability leave. Researchers estimated that when workers with arthritis take their medication as directed, their lost productivity drops by 26 percent.