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Medication Adherence and Compliance – the Pharmacist's Role

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  • Medication Possession Ratio is the most common measure of adherence. It is important to note that both methodologies measure prescription fill data; therefore, the results calculate how much medication the patient receives not if the patient actually took the medication as prescribed. Other methodologies such as patient self-reported data have been evaluated; however, the accuracy of self reported data is low. As a result, MPR is currently the accepted metric for adherence. A MPR of 80% or greater is generally accepted as optimal therapy.
  • The impact can be tremendous not only to the patient but to the plan sponsor/employer. Poor adherence can impact the health, welfare and productivity of your employees. Important to establish a plan to evaluate to what extent poor adherence is impacting your workforce and your bottom line.
  • Just showed you a sampling of the many statistics that exist around the impact of poor adherence. Lets use the results of this well known retrospective study on adherence (Sokol, et al.) to help illustrate the correlation between adherence and outcomes. As you can see- as medication adherence rates increase, the total medical spend (medical and rx) for those patients decreases. For example for those who were only adherent 1-19% of the time- the total medical costs were $15,186 per patient; for those who were adherent 80-100% of the time (80% or greater is generally the accepted “optimal” adherence value) the total medical spend was only $6,377 per patient. You might ask- wouldn’t my costs increase because my members would be taking more medications as they adherence increases? To answer that, this same study looked at medical cost versus pharmacy cost for a given therapeutic class……. (next slide)
  • Adherence is a multidimensional phenomenon determined by the interplay of five sets of factors, here termed “dimensions”, of which patient-related factors are just one determinant. The common belief that patients are solely responsible for taking their treatment is misleading and most often reflects a misunderstanding of how other factors affect people’s behavior and capacity to adhere to their treatment. The reasons a patient does not take their medication as prescribed are complex; for this reason, there is no “silver bullet” to solve the problem and solutions must tailored for a given population. Adherence can be active (i.e. I chose not to take my medication) or passive (i.e. I forgot, didn’t understand directions, etc) Examples: (note to presenter: in the appendix section there are additional slides with more information for each “dimension” that can be used here if appropriate for a specific audience) Social/ Economic: We will discuss later how cost/benefit design can impact adherence rates. The potential for cost to play a factor in non-adherence increases when the socio-economic status of the population is low. Patient-related: patients perception of their disease and the value of treatment is critical. Often patients indicate that they are afraid of becoming dependent on medication- even if the medication is not an addictive substance. Therapy related: The more complex the drug regimen the greater chance for non-adherence. In a recent study (Association between prescription burden and medication adherence in patients initiating antihypertensive and lipid-lowering therapy AM J Health Syst Pharm 2009 66: 1471-1477) found that among patients with 0, 1, & 2 prior medications 41%, 35% & 30% respectively were adherent to antihypertensive and lipid lowering therapy. Among patients with 10 or more prior medications, 20% were adherent. Condition-related: compliance tends to be lower for “asymptomatic disease” (i.e. hypertension, high cholesterol) vs “symptomatic disease” (back pain) Health Care System: The patient may not be clear on the physician’s instructions and/or the physician may never take the time to discuss adherence with the patient
  • None of these programs provides a “one stop solution” However these initiatives can be very useful tools in improving adherence Refill reminder programs are available through several PBM and health plan vendors. Patients are contacted via test message, email or phone to remind them it is time to order a refill. In auto-refill programs the dispensing pharmacy automatically refills a chronic medication when the days supply has lapsed. Often an outbound call from the retail pharmacy reminds the patient to pick the medication up. Mail service medications are merely refilled and the medication is sent to the patient. Typically this is a service patients may opt-into. There are several companies leveraging technology to support patients self-manage their care. For example, a company called PurpleTeal uses technology to send timely, customized and targeted messages to diabetes patients in order to support them with their self-management of the disease, including adherence to medications. Also, as part of the “tools and resources” that FMCP will tell you about during this presentation, there is a free website (www.mymedschedule.com) that offers medication reminders and/or refill reminders via text or email. In the absence of similar programs offered through a PBM or other vendor, an employer could provide a link to this site for employees and their dependents. As e-prescribing becomes more common, it will facilitate the process of getting the original prescription to the pharmacy and provide more robust prescription data for monitoring adherence In cases where member cost is a factor, employers have implemented benefits where copay has been reduced or eliminated in select therapeutic classes in order to reduce the financial barrier to adherence Several employers have linked the reduction in copay to an action or activity required by the patient such as participation in a Disease management program, participation in a MTM program and/or maintaining a specified adherence threshold for chronic medications Providing patients access to appropriate education about their disease state, medications and benefit design are critical components of addressing adherence. In fact, in a few slides I will show you survey data that suggests just how important it is.
  • The other initiatives are working –but why arent pharmacists involved?
  • The BI adherence report has tons of great examples in the MAPS section – there are those 11 dimensons. Rather then “copy their ideas” maybe can use those talking points and just put some random bullets like these on the slide?
  • The BI adherence report has tons of great examples in the MAPS section – there are those 11 dimensons. Rather then “copy their ideas” maybe can use those talking points and just put some random bullets like these on the slide?
  • Transcript

    • 1. Medication Adherence and Compliance – the Pharmacist’s Role Baeteena M. Black, D.Ph. Executive Director Tennessee Pharmacists Association October 23, 2010
    • 2. Acknowledgments
      • Some content within this presentation came from:
        • Foundation for Managed Care Pharmacy
        • William Shrank, MD, Harvard University
        • David Nau, Ph.D., R.Ph., CPHQ, Pharmacy Quality Alliance
      3
    • 3. Learning Objectives
      • Define medication adherence and compliance.
      • Describe effects of lack of medication adherence and compliance.
      • Identify possible factors affecting medication adherence and compliance.
      • Discuss potential pharmacist interventions and strategies to improve patient medication use.
      4
    • 4. Background
      • “ Keep watch also on the fault of patients which makes them lie about taking of things prescribed.” - Hippocrates, circa 500 B.C.
      • “ Drugs don’t work if people don’t take them.”
        • - C. Everett Koop, 1985
      5
    • 5. Some Statistics
      • 32 million Americans are taking three or more medications daily.
      • 75% of patients are expected to be non-adherent at any given time
      • Almost 29 percent of Americans stop taking their medicine before it runs out.
      • More than half of all Americans with chronic diseases don't follow their physician's medication and lifestyle guidance.
      American Heart Association http://www.americanheart.org/presenter.jhtml?identifier=107 and National Council on Patient Information and Education. Enhancing Prescription Medicine Adherence: A National Action Plan 2007. http://www.talkaboutrx.org/documents/enhancing_prescription_medicine_adherence.pdf 6
    • 6. Understanding the Terminology
      • Adherence
        • The act of filling new prescriptions, or refilling prescriptions on-time.
      • Compliance
        • The act of taking medication on schedule, or taking medication as prescribed
      Boehringer Ingelheim 2009 Medication Adherence Report 7
    • 7. Understanding the Terminology (cont.)
      • Persistence
        • The act of taking medication for the duration prescribed
      • Gaps in Therapy
        • 12 percent of Americans don't take medication at all after they buy the prescription.
      Boehringer Ingelheim 2009 Medication Adherence Report and American Heart Association http://www.americanheart.org/presenter.jhtml?identifier=107 8
    • 8.
      • Medication Possession Ratio (MPR) and Proportion of Days Covered (PDC) are the two most common formulas used to estimate patients’ adherence to chronic medications. Both formulas use prescription fill data to calculate the percentage of days for which the patient has medication on-hand to take for their chronic conditions.
      • Examples of adherence measures for diabetes and cardiovascular medications can be obtained from the Pharmacy Quality Alliance (PQA) at: www.PQAalliance.org
      How Do We Measure Adherence? 9
    • 9. Why Should I Care About Adherence?
      • “ Lack of medication adherence is America’s other drug problem and leads to unnecessary disease progression, disease complications, reduced functional abilities, a lower quality of life, and even death”
      National Council on Patient Information and Education (NCPIE), Enhancing Prescription Medication Adherence: A National Action Plan-August 2007 www.talkaboutrx.org 10
    • 10. The Impact of Poor Adherence
      • Consequences:
        • Unnecessary disease progression and complications 1
        • Reduced functional abilities and quality of life 1
        • Additional $2,000 per patient per year in medical costs and physician visits 1
        • 33% to 69% of medication-related hospital admissions 2
        • Increased use of expensive, specialized medical resources. 3
        • Unneeded medication changes. 4
      Sources: 1 National Council on Patient Information and Education; Enhamcing Prescription Medicine Adherence: A National Action Plan August 2007. 2 Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497. 3 Gottlieb H. Medication nonadherence: finding solutions to a costly medical problem. Drug Benefit Trends. 2000;12(6):57-62; World Health Organization. Adherence to Long-term Therapies. Geneva, Switzerland: World Health Organization; 2003; Sackett DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore: Johns Hopkins University Press; 1979: 11-22. 4 Dailey G, Kim MS, Lian JF. Patient compliance and persistence with antihyperglycemic drug regimens: evaluation of a Medicaid patient population with type 2 diabetes mellitus. Clin Ther. 2001;23(8):1311-1320; Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27(5): 1218-1224. 11
    • 11. Effects of Poor Adherence and Compliance
      • The average length of stay in hospitals due to medication noncompliance is 4.2 days.
      • Preventable deaths due to non-adherence are estimated to be at least 125,000 each year.
      • Costs to our nation's health care system due to medication non-adherence are estimated to be over $290 billion dollars . This represents 13% of the total healthcare spend in this country.
      Vermeire, E., et al. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001 Oct;26(5):331-42.and American Heart Association 12
    • 12. Adherence and Total Medical Spending Note: Adherence is the extent to which patients take medicines as prescribed, in terms of dose and duration. Source: Sokol et al., cited by the Pharmaceutical Research and Manufacturers of America (PhRMA), Value of Medicines: Facts and Figures 2006 , August 10, 2006, p. 37. 13
    • 13. Five Dimensions of Adherence
      • World Health Organization (WHO) identified five dimensions of adherence
        • Social- and economic- related factors
        • Health system/health care team-related factors
        • Therapy-related factors
        • Condition-related factors
        • Patient-related factors
      World Health Organization 2003 14
    • 14. *Adherence to long-term therapies: evidence for action. World Health Organization 2003 The Five Dimensions of Non-Adherence* Social/ Economic Patient- related Therapy- related Condition- related HealthCare System Adapted from the Foundation for Managed Care Pharmacy Five Dimensions of Adherence 15
    • 15. Three Pillars of Improved Adherence 16
    • 16. What Solutions Have Been Tried?
      • Refill reminder programs
      • Auto-refill programs
      • E-prescribing
      • Reducing member cost share for chronic meds
      • Pharmacist-provided medication therapy management (MTM) programs
      • Incentives tied to participation in a MTM program
      • Education and communication materials for patients
      17
    • 17. e-Prescribing: Rates of Primary Non-adherence Fischer & Shrank, JGIM supplement 2010 18 Characteristic ePrescriptions Filled % Filled Nutritional Products 1,505 1,227 81.53 Genitourinary Products 12,140 9,880 81.38 Cardiovascular Agents 133,445 107,319 80.42 Central Nervous System Drugs 66,191 52,757 79.70 Gastrointestinal Agents 30,979 24,370 78.67 Respiratory Agents 123,258 96,448 78.25 Topical Products 35,023 27,324 78.02 Neuromuscular Drugs 16,231 12,433 76.60 Endocrine And Metabolic Drugs 123,224 93,759 76.09 Analgesics And Anesthetics 52,424 38,862 74.13 Anti-Infective Agents 123,841 90,822 73.34 Hematological Agents 11,673 7,193 61.62 Antineoplastic Agents 828 428 51.69 Results show an overall primary non-adherence rate of 22.1%.
    • 18. Complexity is a Problem
      • Study of statin users in a 90-day period showed many types of complexity are common
      • The average statin user studied
        • Takes 11 medications; nine are maintenance medications
        • Make five pharmacy visits
        • Has only half of refills synchronized
      • Ten percent of statin users studied
        • Take 23 or more medications; 12 are maintenance medications
        • Make 11 or more pharmacy visits
        • Have 10% of refills synchronized
        • Have four or more prescribers
        • Use at least two pharmacies
      Choudhry & Shrank, Arch Intern Med, 2010 19
    • 19. Adherence Interventions
      • Adherence initiatives that pharmacists have lead have been shown to improve patient outcomes for those patients with various chronic conditions
        • Appointment Based Model
      • Other adherence initiatives
        • Value Based Insurance Design
        • Federal Study of Adherence to Medications in the Elderly
      20
    • 20. Appointment Based Model
      • Patients have a monthly appointment - chronic prescriptions are synchronized to come due on the same day each month
      • The pharmacist has a more efficient practice, resulting in expected improved medication adherence rates and decreased gaps in therapy
      21
    • 21. Simplifying Therapy Can Improve Adherence ( Harvard – CVS/Caremark Study)
      • Adherence is greater when patients:
        • Synchronize refills
        • Fill all their prescriptions at a single pharmacy
      22 A simple prediction rule may help us design interventions to reduce complexity and improve adherence. - William Shrank, Harvard University
    • 22. Value-Based Insurance Design (VBID)
      • Most VBID initiatives have focused on co-pay reductions and have shown some adherence increase
      • Adding clinical services to financial incentives may lead to better value than co-pay reduction alone
        • A large employer cut co-pays in half for diabetes and CVD medications in addition to a nurse telephonic consultation; adherence improved 7-14% compared to usual care
        • Asheville Project included co-pay waivers in addition to pharmacist consultations and the combined effect of these interventions led to improved outcomes and lower medical expenditures
      23
    • 23. Federal Study of Adherence to Medications in the Elderly (FAME)
      • Randomized, controlled trial involving 200 community-based older adults who took at least 4 chronic medications
      • Intervention delivered by Walter Reed Army Medical Center, and included:
        • Multi-medication blister packs with time-specific instructions
        • Pharmacists provided 1 hour personalized counseling and 30 minute follow-up visits every other month
      Lee JK, et al. , JAMA 2006 24
    • 24. Federal Study of Adherence to Medications in the Elderly (FAME)
      • After six months of intervention:
        • Medication adherence increased from 61% to 97%
        • Significant decrease in systolic BP, but not LDL
      • After first six months, patients were randomly assigned to either continue the intervention or return to usual care (no blister pack and no pharmacist counseling/monitoring). After another six months:
        • >95% of intervention group remained adherent
        • 69% of usual care patients remained adherent
      Lee JK, et al. , JAMA 2006 25
    • 25. Cochrane Collaborative: Summary of Adherence Interventions
      • “ For long-term treatments, simplifying the dosage regimen and several complex strategies, including combinations of more thorough patient instructions and counseling, reminders, close follow-up, supervised self-monitoring, rewards for success, family therapy, couple- focused therapy, psychological therapy, crisis intervention, and manual telephone follow-up can improve adherence and treatment outcomes. If there is a common thread to these at all, it is more frequent interaction with patients with attention to adherence.”
      26
    • 26. Pharmacist Interventions and Strategies
      • Must be individualized – need to understand the reasons why patients are not adherent/compliant
      • Many different strategies to consider
        • Improve Drug Regimen
          • Create complete drug profile
          • Conduct comprehensive med review
          • Work with prescribers
      27
    • 27. Pharmacist Interventions and Strategies
      • Many different strategies to consider (cont.)
        • Reduce Cost Barriers
          • Generics
          • Formulary compliance
          • Prescription Assistance plans
        • Address Patient Behavior
          • Counsel patient
          • Address patient concerns
          • Appointment based model
          • Patient reminders
          • Special packaging
      28
    • 28. Pharmacist Interventions and Strategies
      • If not pharmacists, then who should lead adherence?
        • Pharmacists, as the medication experts should be leading the way to ensuring optimal medication use
        • Pharmacists are in an excellent position to improve medication adherence
        • Many programs available – where is the pharmacist involvement?
      29
    • 29. PQA Adherence Measures
      • Adherence measures for 7 drug classes:
        • Beta blockers
        • Calcium-channel blockers
        • ACEI/ARBs
        • Lipid-modifying agents (statins)
        • Sulfonylureas
        • Biguanides
        • TZDs
      30
    • 30. PQA Adherence Measures
      • A significant gap is defined as 30 days or greater
      • Individual measures focus on a specific drug class (e.g., beta blockers)
      31 Measure Title Measure Description/Definition Gap in Therapy Percentage of prevalent users who experienced a significant gap in medication therapy.
    • 31. PQA Adherence / Persistence Measures
      • The denominator in this measure is the number of days between the initial claim and the end of the measurement period.
      • The numerator is the number of days that the patient had the drug on-hand (based on the date of the prior fill and the days supply).
      • PDC is calculated at the therapeutic category level, without regard for the specific drug or dose.
      • A threshold of 80% is used to identify patients with good adherence.
      32 Measure Title Measure Description/Definition Proportion of days covered (PDC) Proportion of patients using a targeted class of medication who meet the PDC threshold.
    • 32. Are you asking the right questions…
      • Do you know the adherence rates for your patients?
      • Are you able to identify your patients who are late for refills or have stopped their medications?
      • Is your workflow designed to facilitate interaction between the pharmacist and patient?
      33
    • 33. Questions? 34
    • 34. Contact Information
      • Baeteena Black, D.Ph. Executive Director Tennessee Pharmacists Association 500 Church St., Suite 650 Nashville, TN 37219 (615) 256-3023 [email_address] www.tnpharm.org
      35

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