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Medication Adherence 
[Primary care educators may use the following slides for 
their own teaching purposes] 
CDC’s Noon Conference 
March 27, 2013
Overview of This Educational Module 
 Medication adherence 
 Burden of non-adherence 
 Effective interventions to improve adherence 
 Measuring medication adherence 
 Provider’s role in improving medication adherence 
 Tools and resources 
 Case studies
DEFINITION
What is Adherence? 
 Cluster of behaviors 
 Simultaneously affected by multiple factors 
 The extent to which a person’ s behavior—taking 
medication, following a diet, or making healthy lifestyle 
changes—corresponds with agreed-upon 
recommendations from a health-care provider 
 World Health Organization, 2003 
Source: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
What is Medication Adherence? 
 Medication Adherence: The patient’s conformance with the 
provider’s recommendation with respect to timing, dosage, 
and frequency of medication-taking during the prescribed 
length of time 
 Compliance: Patient’s passive following of provider’s orders 
 Persistence: Duration of time patient takes 
medication, from initiation to discontinuation 
of therapy 
Source: 
http://www.effectivehealthcare.ahrq.gov/ehc/products/296/1248/EvidenceReport208_CQGMedAdherence_FinalReport_ 
20120905.pdf
OBJECTIVES
Objectives of This Module 
 Learn ways to improve medication adherence rates 
 Develop a summary of existing evidence-based 
knowledge 
 Inform, raise awareness, and promote discussion 
among patients, clinicians, pharmacists, payers, public 
health practitioners, and decision makers about ways 
to improve medication adherence
BACKGROUND
Background 
 Medication prescriptions never filled: 20% to 30% 
 Medication not continued as prescribed in about 50% of 
cases 
 The World Health Organization estimated that by 2020, 
the number of Americans affected by at least one chronic 
condition requiring medication therapy will grow to 157 
million 
Sources: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf ; Osterberg 2005, NEJM; Ho 2009, Circulation
Medication Adherence in United States 
 Rates of medication adherence drop after first six 
months 
 Only 51% of Americans treated for hypertension are 
adherent to their long-term therapy 
 About 25% to 50% of patients discontinue statins within 
one year of treatment initiation 
Source: Choudhry 2011, N Engl J Med; Yeaw 2009, J Manag Care Pharm; Script Your Future press release, November 2, 2011; 
accessed here: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf.
BURDEN OF NON-ADHERENCE
Non-Adherence—Economic 
 Direct cost estimated at $100 billion to $289 billion 
annually 
 Costs $2000 per patient in physician visits annually 
 Improved self-management of chronic diseases results 
in an approximate cost-to-savings ratio of 1:10 
 Cost-related non-adherence reported by 11.4% 
(~543,000 individuals) of stroke survivors, mostly 
among the uninsured and younger (45 to 64 years) 
Sources: Ho 2009, Circulation; Levine et al. 2013, Annals of Neurology
Non-Adherence—Clinical Outcomes 
 High adherence to antihypertensive medication is 
associated with higher odds of blood pressure control 
 Each incremental 25% increase in proportion of days 
covered (PDC ) for statins is associated with ~3.8 mg/dl 
reduction in LDL cholesterol 
Source: Ho 2009, Circulation
Non-adherence—Mortality, Hospitalizations, 
ED Visits 
 Non-adherence causes ~30% to 50% of treatment failures and 
125,000 deaths annually 
 Non-adherence to statins increased relative risk for mortality 
(~12% to 25%) 
 Non-adherence to cardioprotective medications increased 
risk of cardiovascular hospitalizations (10% to 40%) and 
mortality (50% to 80%) 
 Poor adherence to heart failure medications increased the 
number of cardiovascular-related emergency department 
(ED) visits 
Sources: Ho 2009, Circulation; Edmondson 2013, Br J of Health Psychology; George & Shalansky 2006, Br J Clin Phar
DIMENSIONS OF NON-ADHERENCE
Five Interacting Dimensions of 
Non-Adherence 
Health-care 
system/team 
factors 
Source: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf 
Patient-related 
factors 
Therapy-related 
factors 
Condition-related 
factors 
Social and 
economic 
factors
Health-care Factors 
Health-care Team 
 Stress of health-care visits 
 Discomfort in asking providers 
questions 
 Patient’s belief or 
understanding 
 Patient’s forgetfulness or 
carelessness 
 Stressful life events 
 Lack of immediate benefit of 
therapy 
Health-care System 
 Access to care 
 Continuity of 
care 
 Patient education 
material not 
written in plain 
language 
Sources: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
Provider Factors 
 Communication skills 
 Knowledge of health literacy issues 
 Lack of empathy 
 Lack of positive reinforcement 
 Number of comorbid conditions 
 Number of medications needed per day 
 Types or components of medication 
 Amount of prescribed medications or 
duration of prescription 
Source: Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane 
Database Syst Rev 2008;(2):CD000011
Patient, Condition, and Therapy Factors 
Condition- and therapy-related 
 Complexity of medication 
 Frequent changes in regimen 
 Treatment requiring mastery of 
certain techniques 
 Unpleasant side effects 
 Duration of therapy 
 Lack of immediate benefit of therapy 
 Medications with social stigma 
Patient-related 
 Physical 
 Psychological 
Sources: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
Economic and Social Factors 
Social 
 Limited English proficiency 
 Inability to access or difficulty 
accessing pharmacy 
 Lack of family or social support 
 Unstable living conditions 
Economic 
 Health insurance 
 Medication cost 
Source: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
What May Providers Do to Overcome These 
Challenges? 
 Communication is key! 
 Effective interventions 
 Measure medication adherence 
Sources: Ratanawongsa 2012 Arch Intern Med ; Bramley 2006 J Manag Care Pharm 12(3):239-245; Martin 2011 Am J Health 
Promot 25(6):372-378
INTERVENTIONS
SIMPLE 
 S— Simplify the regimen 
 I — Impart knowledge 
 M—Modify patient beliefs and behavior 
 P —Provide communication and trust 
 L —Leave the bias 
 E —Evaluate adherence 
Source: http://www.acpm.org/?MedAdherTT_ClinRef
S—Simplify the Regimen 
 Adjust timing, frequency, amount, and dosage 
 Match regimen to patient’s activities of daily living 
 Recommend taking all medications at the same time of 
day 
 Avoid prescribing medications with special requirements 
 Investigate customized packaging for patients 
 Encourage use of adherence aids 
 Consider changing the situation vs. changing the patient 
Source: http://www.acpm.org/?MedAdherTT_ClinRef
I—Impart Knowledge 
 Focus on patient-provider shared decision making 
 Keep the team informed (physicians, nurses, and 
pharmacists) 
 Involve patient’s family or caregiver if appropriate 
 Advise on how to cope with medication costs 
 Provide all prescription instructions clearly in writing 
and verbally 
 Suggest additional information from Internet if patients 
are interested 
 Reinforce all discussions often, especially 
for low-literacy patients 
Source: http://www.acpm.org/?MedAdherTT_ClinRef
M—Modify Patient Beliefs and Behavior 
 Empower patients to self-manage their condition 
 Ensure that patients understand their risks if they don’t 
take their medications 
 Ask patients about the consequences of not taking their 
medications 
 Have patients restate the positive benefits of taking their 
medications 
 Address fears and concerns 
 Provide rewards for adherence 
Source: http://www.acpm.org/?MedAdherTT_ClinRef
P—Provide Communication and Trust 
 Improve interviewing skills 
 Practice active listening 
 Provide emotional support 
 Use plain language 
 Elicit patient’s input in treatment decisions 
Source: http://www.acpm.org/?MedAdherTT_ClinRef
L—Leave the Bias 
 Understand health literacy and how it affects outcomes 
 Examine self-efficacy regarding care of racial, ethnic, and 
social minority populations 
 Develop patient-centered communication style 
 Acknowledge biases in medical decision making 
 Address dissonance of patient-provider, race-ethnicity, and 
language 
Sources: http://www.acpm.org/?MedAdherTT_ClinRef; Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. 
Freeman; Bandura, A. (1994). Self-efficacy. In V.S. Ramachaudran (Ed.), Encyclopedia of human behavior;4. New York: Academic 
Press, pp. 71-81.
E—Evaluating Adherence 
 Self-report 
 Ask about adherence behavior at every visit 
 Periodically review patient’s medication containers, 
noting renewal dates 
 Use biochemical tests—measure serum or urine 
medication levels as needed 
 Use medication adherence scales—for example: 
 Morisky-8 (MMAS-8) 
 Morisky-4 (MMAS-4, also known as the Medication Adherence 
Questionnaire or MAQ) 
 Medication Possession Ratio (MPR) 
 Proportion of Days Covered (PDC) 
Sources: http://www.acpm.org/?MedAdherTT_ClinRef; Morisky, DE & DiMatteo, MR. Journal of Clinical Epidemiology 2011; 64:262- 
263; https://www.urac.org/MedicationAdherence/includes/Nau_Presentation.pdf
MEDICATION ADHERENCE SCALES
General Guide to Choosing Medication Adherence 
Scales Based on Disease of Interest 
Therapeutic Area Medication Adherence Scales 
Metabolic Disorders: 
hypertension, dyslipidemia, diabetes 
MAQ (shortest to administer) 
SEAMS (assesses self-efficacy) 
BMQ (diabetes only) 
Hill-Bone Compliance Scale 
(hypertension in predominantly 
black populations) 
Mental Health: 
schizophrenia, psychosis, depression 
MARS (schizophrenia and psychosis) 
BMQ (depression) 
Abbreviations used: 
BMQ = Brief Medication Questionnaire 
MAQ = Medication Adherence Questionnaire (also known as the Morisky-4 or MMAS-4 scale) 
MARS = Medication Adherence Rating Scale 
SEAMS = Self-Efficacy for Appropriate Medication Use Scale 
Source: Lavsa SM et al. J Am Pharm Assoc. 2011;51(1):90-94;
Interventions Should be Patient-Tailored 
 Behavior-related 
 Forgetfulness of patients 
• Daily alerts 
• 90 days medication supplies 
• Automatic renewals 
 Clinical—Questions or concerns about medication 
 Pharmacist consultation 
 Linguistically and culturally appropriate 
 Cost-related 
 Payment assistance programs 
 Lower cost medication alternatives 
 Lower cost pharmacy option (e.g. , home delivery)
STRATEGIES TO IMPROVE 
MEDICATION ADHERENCE
Effective Strategies for Improving Hypertension 
Medication Adherence 
 Team-based care 
 Pharmacist-led multicomponent interventions 
 Education with behavioral support 
 Pill counting 
 Blister packaging 
 Electronic monitoring 
 Telecommunication systems for monitoring and counseling 
 Single dose vs. multiple dose prescribed 
Sources: Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic 
review. Medical Care 2006;44:646-57; Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to 
improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern 
Med 2012; 157(11):785-795.
How to Overcome Challenges or 
Barriers by System Change 
 Introduce team-based care 
 Collaborate with pharmacists and/or nurses 
 Educate patients on how to take medications 
 Monitor by pill box 
 Improve access and communication 
 Offer patients the opportunity to contact the provider’s office with any 
questions 
 Use telemedicine, particularly in rural areas 
 Use technologies and analytical services that facilitate measuring 
and improved adherence
Script Your Future 
 National multiyear campaign to raise awareness about 
medication adherence 
 This campaign brings together stakeholders in health 
care, business, and government in six regional target 
markets 
 For health-care professionals, the campaign offers 
guidance on how to improve communication with 
patients 
 For patients, the campaign offers practical tools to 
improve medication adherence 
Sources: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf
US Surgeon General Regina Benjamin, MD 
“Doctors, nurses, pharmacists and other health care 
professionals can help prevent many serious health 
complications by initiating conversations with their patients 
about the importance of taking medication as directed. This is 
especially important for people with chronic health 
conditions such as diabetes, asthma and high blood pressure, 
who may have a number of medicines to take each day.” 
Source: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf
Take-Home Messages for Providers 
 Display patience and empathy when interacting with 
patients 
 Be mindful of the number of medications prescribed and 
their frequency and dosages 
 Prescribe lower-cost medications and/or provide 
manufacturer coupons to help lower costs 
 Explain the consequences of non-adherence and suggest 
ways to improve adherence 
 Introduce team-based care to improve medication 
adherence 
 Identify roles and responsibilities in team-based care to 
deliver improved patient-centered health care
Tools 
 American Heart Association 
 Medicine Management Tool 
 American College of Cardiology 
 CardioSmart Med Reminder (mobile app) 
 National Heart, Lung, and Blood Institute, National 
Institutes of Health 
 Tips to Help You Remember to Take Your Blood Pressure Drugs 
 American Society of Consultant Pharmacists Foundation 
 Adult Meducation: Improving Medication Adherence in Older Adults 
 Script Your Future 
 Wallet card for patients 
 Tools for providers 
Sources: URLs added to notes section of this slide
CDC Resources 
 Educational Materials for Professionals. Division for 
Heart Disease and Stroke Prevention. 
 Fact Sheets, Data and Statistics, Maps, Reports, Guidelines and 
Recommendations. Available at 
http://www.cdc.gov/dhdsp/materials_for_professionals.htm 
 Million Hearts: Prevention at Work. 
 Achieve excellence in the "ABCS" (A=Aspirin for people at risk, 
B=Blood pressure control, C=Cholesterol management, S=Smoking 
cessation). Available at 
• http://www.cdc.gov/24-7/prevention/MillionHearts/ 
• http://millionhearts.hhs.gov/index.html
CDC Resources—(cont.) 
 Team Up. Pressure Down. 
 Providers may inform patients with high blood pressure to team up 
with their pharmacist to better understand their condition and any 
medications they are taking. Available at 
 http://www.cdc.gov/features/tupd/ 
 http://millionhearts.hhs.gov/resources/teamuppressuredown.html# 
Partners 
 A Program Guide for Public Health Partnering with 
Pharmacists in the Prevention and Control of Chronic 
Diseases. Division for Heart Disease and Stroke 
Prevention and Division of Diabetes Translation. 
 This guide focuses on medication therapy management services 
provided by pharmacists to improve medication adherence. Available 
at 
http://www.cdc.gov/dhdsp/programs/nhdsp_program/docs/Pharma 
cist_Guide.pdf
Health Literacy Resources 
 American Medical Association Health Literacy Video 
 http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/ 
our-programs/public-health/health-literacy-program/ 
health-literacy-video.page 
 http://www.youtube.com/watch?v=cGtTZ_vxjyA 
 AHRQ’s Health Literacy Universal Precautions Toolkit 
 http://www.innovations.ahrq.gov/content.aspx?id=2684 
 http://www.rihlp.org/pubs/Complete_toolkit_224pgs.pdf 
 American College of Physician Foundation Health 
Literacy Programs and Resources on Medication 
Labeling 
 http://www.acpfoundation.org/health-literacy-programs/ 
medication-labeling-2/
References 
1. Casula M, Tragni E, Catapano AL. Adherence to lipid-lowering treatment: the patient 
perspective. Patient Prefer Adherence 2012; 6:805-814. 
2. Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al. Full 
coverage for preventive medications after myocardial infarction. N Engl J Med 
2011;365(22), 2088-2097. 
3. Edmondson D, Horowitz CR, Goldfinger JZ, Fei K, Kronish IM. Concerns about 
medications mediate the association of posttraumatic stress disorder with 
adherence to medication in stroke survivors. Br J Health Psychol 2013 Jan 7; doi: 
10.1111/bjhp.12022. [Epub ahead of print]. 
4. Elliott RA, Barber N, Horne R. Cost-effectiveness of adherence-enhancing 
interventions: a quality assessment of the evidence. Ann Pharmacother 2005; 
39(3):508-515. 
5. Fongwa MN, Evangelista LS, Hays RD, Martins DS, Elashoff D, Cowan MJ, et al. 
Adherence treatment factors in hypertensive African American women. Vasc Health 
Risk Manag 2008; 4(1):157-166. 
6. Fretheim A, Aaserud M, Oxman AD. Rational prescribing in primary care (RaPP): 
economic evaluation of an intervention to improve professional practice. PLoS Med 
2006; 3(6):e216. 
7. George J, Shalansky SJ. Predictors of refill non-adherence in patients with heart 
failure. Br J Clin Pharmacol 2007; 63(4):488-493.
References (cont.) 
8. Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood 
pressure control among United States adults with hypertension: the National Health 
and Nutrition Examination Survey, 2001 to 2010. Circulation 2012; 126(17):2105- 
2114. 
9. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in 
cardiovascular outcomes. Circulation 2009; 119(23):3028-3035. 
10. Ito K, Shrank WH, Avorn J, Patrick AR, Brennan TA, Antman, EM et al. Comparative cost-effectiveness 
of interventions to improve medication adherence after myocardial 
infarction. Health Serv Res 2012; 47(6):2097-2117. 
11. Kronish IM, Edmondson D, Goldfinger JZ, Fei K, Horowitz CR. Posttraumatic stress 
disorder and adherence to medications in survivors of strokes and transient ischemic 
attacks. Stroke 2012; 43(8):2192-2197. 
12. Levine DA, Morgenstern LB, Langa KM, Piette JD, Rogers MA, Karve SJ. Recent trends in 
cost‐related medication nonadherence among US stroke survivors. Annals of Neurology 
2013 Feb 22; doi: 10.1002/ana.23823. [Epub ahead of print]. 
13. Lyles CR, Karter AJ, Young BA, Spigner C, Grembowski D, Schillinger D, et al. Patient-reported 
racial/ethnic healthcare provider discrimination and medication 
intensification in the Diabetes Study of Northern California (DISTANCE). J Gen Intern 
Med 2011; 26(10):1138-1144. 
14. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication 
adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008; 
10(5):348-354.
References (cont.) 
15. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication 
nonadherence: response to authors. J Clin Epidemiol 2011; 64(3):255-257. 
16. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353(5):487-497. 
17. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based 
pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA 
2007;297:177–186. 
18. Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, Moffet HH, et al. 
Communication and medication refill adherence: the Diabetes Study of Northern 
California. Arch Intern Med 2012 Dec 31;1-9. 
19. Steiner JF, Ho PM, Beaty BL, Dickinson LM, Hanratty R, Zeng C, et al. Sociodemographic 
and clinical characteristics are not clinically useful predictors of refill adherence in 
patients with hypertension. Circ Cardiovasc Qual Outcomes 2009; 2(5):451-457. 
20. Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions 
to improve adherence to self-administered medications for chronic diseases in the 
United States: a systematic review. Ann Intern Med 2012; 157(11):785-795. 
21. Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for 
hypertension management: a systematic review. Medical Care 2006;44:646-57. 
22. Yeaw J, Benner JS, Walt JG, Sian S, Smith DB. Comparing adherence and persistence 
across 6 chronic medication classes. J Manag Care Pharm 2009; 15(9), 728-740.
Acknowledgements 
Farah M. Chowdhury, MBBS, MPH 
Deesha Patel, MPH 
Mary G. George, MD, MSPH, FACS 
David Callahan, MD, FAAFP 
For more information please contact Centers for Disease Control and Prevention 
1600 Clifton Road NE, Atlanta, GA 30333 
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov 
The findings and conclusions in this report are those of the authors and do not necessarily represent the official 
position of the Centers for Disease Control and Prevention. 
Division for Heart Disease and Stroke Prevention (DHDSP) 
National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)

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Medication adherence-01ccd 2

  • 1. Medication Adherence [Primary care educators may use the following slides for their own teaching purposes] CDC’s Noon Conference March 27, 2013
  • 2. Overview of This Educational Module  Medication adherence  Burden of non-adherence  Effective interventions to improve adherence  Measuring medication adherence  Provider’s role in improving medication adherence  Tools and resources  Case studies
  • 4. What is Adherence?  Cluster of behaviors  Simultaneously affected by multiple factors  The extent to which a person’ s behavior—taking medication, following a diet, or making healthy lifestyle changes—corresponds with agreed-upon recommendations from a health-care provider  World Health Organization, 2003 Source: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
  • 5. What is Medication Adherence?  Medication Adherence: The patient’s conformance with the provider’s recommendation with respect to timing, dosage, and frequency of medication-taking during the prescribed length of time  Compliance: Patient’s passive following of provider’s orders  Persistence: Duration of time patient takes medication, from initiation to discontinuation of therapy Source: http://www.effectivehealthcare.ahrq.gov/ehc/products/296/1248/EvidenceReport208_CQGMedAdherence_FinalReport_ 20120905.pdf
  • 7. Objectives of This Module  Learn ways to improve medication adherence rates  Develop a summary of existing evidence-based knowledge  Inform, raise awareness, and promote discussion among patients, clinicians, pharmacists, payers, public health practitioners, and decision makers about ways to improve medication adherence
  • 9. Background  Medication prescriptions never filled: 20% to 30%  Medication not continued as prescribed in about 50% of cases  The World Health Organization estimated that by 2020, the number of Americans affected by at least one chronic condition requiring medication therapy will grow to 157 million Sources: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf ; Osterberg 2005, NEJM; Ho 2009, Circulation
  • 10. Medication Adherence in United States  Rates of medication adherence drop after first six months  Only 51% of Americans treated for hypertension are adherent to their long-term therapy  About 25% to 50% of patients discontinue statins within one year of treatment initiation Source: Choudhry 2011, N Engl J Med; Yeaw 2009, J Manag Care Pharm; Script Your Future press release, November 2, 2011; accessed here: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf.
  • 12. Non-Adherence—Economic  Direct cost estimated at $100 billion to $289 billion annually  Costs $2000 per patient in physician visits annually  Improved self-management of chronic diseases results in an approximate cost-to-savings ratio of 1:10  Cost-related non-adherence reported by 11.4% (~543,000 individuals) of stroke survivors, mostly among the uninsured and younger (45 to 64 years) Sources: Ho 2009, Circulation; Levine et al. 2013, Annals of Neurology
  • 13. Non-Adherence—Clinical Outcomes  High adherence to antihypertensive medication is associated with higher odds of blood pressure control  Each incremental 25% increase in proportion of days covered (PDC ) for statins is associated with ~3.8 mg/dl reduction in LDL cholesterol Source: Ho 2009, Circulation
  • 14. Non-adherence—Mortality, Hospitalizations, ED Visits  Non-adherence causes ~30% to 50% of treatment failures and 125,000 deaths annually  Non-adherence to statins increased relative risk for mortality (~12% to 25%)  Non-adherence to cardioprotective medications increased risk of cardiovascular hospitalizations (10% to 40%) and mortality (50% to 80%)  Poor adherence to heart failure medications increased the number of cardiovascular-related emergency department (ED) visits Sources: Ho 2009, Circulation; Edmondson 2013, Br J of Health Psychology; George & Shalansky 2006, Br J Clin Phar
  • 16. Five Interacting Dimensions of Non-Adherence Health-care system/team factors Source: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf Patient-related factors Therapy-related factors Condition-related factors Social and economic factors
  • 17. Health-care Factors Health-care Team  Stress of health-care visits  Discomfort in asking providers questions  Patient’s belief or understanding  Patient’s forgetfulness or carelessness  Stressful life events  Lack of immediate benefit of therapy Health-care System  Access to care  Continuity of care  Patient education material not written in plain language Sources: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
  • 18. Provider Factors  Communication skills  Knowledge of health literacy issues  Lack of empathy  Lack of positive reinforcement  Number of comorbid conditions  Number of medications needed per day  Types or components of medication  Amount of prescribed medications or duration of prescription Source: Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2008;(2):CD000011
  • 19. Patient, Condition, and Therapy Factors Condition- and therapy-related  Complexity of medication  Frequent changes in regimen  Treatment requiring mastery of certain techniques  Unpleasant side effects  Duration of therapy  Lack of immediate benefit of therapy  Medications with social stigma Patient-related  Physical  Psychological Sources: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
  • 20. Economic and Social Factors Social  Limited English proficiency  Inability to access or difficulty accessing pharmacy  Lack of family or social support  Unstable living conditions Economic  Health insurance  Medication cost Source: http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf
  • 21. What May Providers Do to Overcome These Challenges?  Communication is key!  Effective interventions  Measure medication adherence Sources: Ratanawongsa 2012 Arch Intern Med ; Bramley 2006 J Manag Care Pharm 12(3):239-245; Martin 2011 Am J Health Promot 25(6):372-378
  • 23. SIMPLE  S— Simplify the regimen  I — Impart knowledge  M—Modify patient beliefs and behavior  P —Provide communication and trust  L —Leave the bias  E —Evaluate adherence Source: http://www.acpm.org/?MedAdherTT_ClinRef
  • 24. S—Simplify the Regimen  Adjust timing, frequency, amount, and dosage  Match regimen to patient’s activities of daily living  Recommend taking all medications at the same time of day  Avoid prescribing medications with special requirements  Investigate customized packaging for patients  Encourage use of adherence aids  Consider changing the situation vs. changing the patient Source: http://www.acpm.org/?MedAdherTT_ClinRef
  • 25. I—Impart Knowledge  Focus on patient-provider shared decision making  Keep the team informed (physicians, nurses, and pharmacists)  Involve patient’s family or caregiver if appropriate  Advise on how to cope with medication costs  Provide all prescription instructions clearly in writing and verbally  Suggest additional information from Internet if patients are interested  Reinforce all discussions often, especially for low-literacy patients Source: http://www.acpm.org/?MedAdherTT_ClinRef
  • 26. M—Modify Patient Beliefs and Behavior  Empower patients to self-manage their condition  Ensure that patients understand their risks if they don’t take their medications  Ask patients about the consequences of not taking their medications  Have patients restate the positive benefits of taking their medications  Address fears and concerns  Provide rewards for adherence Source: http://www.acpm.org/?MedAdherTT_ClinRef
  • 27. P—Provide Communication and Trust  Improve interviewing skills  Practice active listening  Provide emotional support  Use plain language  Elicit patient’s input in treatment decisions Source: http://www.acpm.org/?MedAdherTT_ClinRef
  • 28. L—Leave the Bias  Understand health literacy and how it affects outcomes  Examine self-efficacy regarding care of racial, ethnic, and social minority populations  Develop patient-centered communication style  Acknowledge biases in medical decision making  Address dissonance of patient-provider, race-ethnicity, and language Sources: http://www.acpm.org/?MedAdherTT_ClinRef; Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman; Bandura, A. (1994). Self-efficacy. In V.S. Ramachaudran (Ed.), Encyclopedia of human behavior;4. New York: Academic Press, pp. 71-81.
  • 29. E—Evaluating Adherence  Self-report  Ask about adherence behavior at every visit  Periodically review patient’s medication containers, noting renewal dates  Use biochemical tests—measure serum or urine medication levels as needed  Use medication adherence scales—for example:  Morisky-8 (MMAS-8)  Morisky-4 (MMAS-4, also known as the Medication Adherence Questionnaire or MAQ)  Medication Possession Ratio (MPR)  Proportion of Days Covered (PDC) Sources: http://www.acpm.org/?MedAdherTT_ClinRef; Morisky, DE & DiMatteo, MR. Journal of Clinical Epidemiology 2011; 64:262- 263; https://www.urac.org/MedicationAdherence/includes/Nau_Presentation.pdf
  • 31. General Guide to Choosing Medication Adherence Scales Based on Disease of Interest Therapeutic Area Medication Adherence Scales Metabolic Disorders: hypertension, dyslipidemia, diabetes MAQ (shortest to administer) SEAMS (assesses self-efficacy) BMQ (diabetes only) Hill-Bone Compliance Scale (hypertension in predominantly black populations) Mental Health: schizophrenia, psychosis, depression MARS (schizophrenia and psychosis) BMQ (depression) Abbreviations used: BMQ = Brief Medication Questionnaire MAQ = Medication Adherence Questionnaire (also known as the Morisky-4 or MMAS-4 scale) MARS = Medication Adherence Rating Scale SEAMS = Self-Efficacy for Appropriate Medication Use Scale Source: Lavsa SM et al. J Am Pharm Assoc. 2011;51(1):90-94;
  • 32. Interventions Should be Patient-Tailored  Behavior-related  Forgetfulness of patients • Daily alerts • 90 days medication supplies • Automatic renewals  Clinical—Questions or concerns about medication  Pharmacist consultation  Linguistically and culturally appropriate  Cost-related  Payment assistance programs  Lower cost medication alternatives  Lower cost pharmacy option (e.g. , home delivery)
  • 33. STRATEGIES TO IMPROVE MEDICATION ADHERENCE
  • 34. Effective Strategies for Improving Hypertension Medication Adherence  Team-based care  Pharmacist-led multicomponent interventions  Education with behavioral support  Pill counting  Blister packaging  Electronic monitoring  Telecommunication systems for monitoring and counseling  Single dose vs. multiple dose prescribed Sources: Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic review. Medical Care 2006;44:646-57; Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med 2012; 157(11):785-795.
  • 35. How to Overcome Challenges or Barriers by System Change  Introduce team-based care  Collaborate with pharmacists and/or nurses  Educate patients on how to take medications  Monitor by pill box  Improve access and communication  Offer patients the opportunity to contact the provider’s office with any questions  Use telemedicine, particularly in rural areas  Use technologies and analytical services that facilitate measuring and improved adherence
  • 36. Script Your Future  National multiyear campaign to raise awareness about medication adherence  This campaign brings together stakeholders in health care, business, and government in six regional target markets  For health-care professionals, the campaign offers guidance on how to improve communication with patients  For patients, the campaign offers practical tools to improve medication adherence Sources: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf
  • 37. US Surgeon General Regina Benjamin, MD “Doctors, nurses, pharmacists and other health care professionals can help prevent many serious health complications by initiating conversations with their patients about the importance of taking medication as directed. This is especially important for people with chronic health conditions such as diabetes, asthma and high blood pressure, who may have a number of medicines to take each day.” Source: http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf
  • 38. Take-Home Messages for Providers  Display patience and empathy when interacting with patients  Be mindful of the number of medications prescribed and their frequency and dosages  Prescribe lower-cost medications and/or provide manufacturer coupons to help lower costs  Explain the consequences of non-adherence and suggest ways to improve adherence  Introduce team-based care to improve medication adherence  Identify roles and responsibilities in team-based care to deliver improved patient-centered health care
  • 39. Tools  American Heart Association  Medicine Management Tool  American College of Cardiology  CardioSmart Med Reminder (mobile app)  National Heart, Lung, and Blood Institute, National Institutes of Health  Tips to Help You Remember to Take Your Blood Pressure Drugs  American Society of Consultant Pharmacists Foundation  Adult Meducation: Improving Medication Adherence in Older Adults  Script Your Future  Wallet card for patients  Tools for providers Sources: URLs added to notes section of this slide
  • 40. CDC Resources  Educational Materials for Professionals. Division for Heart Disease and Stroke Prevention.  Fact Sheets, Data and Statistics, Maps, Reports, Guidelines and Recommendations. Available at http://www.cdc.gov/dhdsp/materials_for_professionals.htm  Million Hearts: Prevention at Work.  Achieve excellence in the "ABCS" (A=Aspirin for people at risk, B=Blood pressure control, C=Cholesterol management, S=Smoking cessation). Available at • http://www.cdc.gov/24-7/prevention/MillionHearts/ • http://millionhearts.hhs.gov/index.html
  • 41. CDC Resources—(cont.)  Team Up. Pressure Down.  Providers may inform patients with high blood pressure to team up with their pharmacist to better understand their condition and any medications they are taking. Available at  http://www.cdc.gov/features/tupd/  http://millionhearts.hhs.gov/resources/teamuppressuredown.html# Partners  A Program Guide for Public Health Partnering with Pharmacists in the Prevention and Control of Chronic Diseases. Division for Heart Disease and Stroke Prevention and Division of Diabetes Translation.  This guide focuses on medication therapy management services provided by pharmacists to improve medication adherence. Available at http://www.cdc.gov/dhdsp/programs/nhdsp_program/docs/Pharma cist_Guide.pdf
  • 42. Health Literacy Resources  American Medical Association Health Literacy Video  http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/ our-programs/public-health/health-literacy-program/ health-literacy-video.page  http://www.youtube.com/watch?v=cGtTZ_vxjyA  AHRQ’s Health Literacy Universal Precautions Toolkit  http://www.innovations.ahrq.gov/content.aspx?id=2684  http://www.rihlp.org/pubs/Complete_toolkit_224pgs.pdf  American College of Physician Foundation Health Literacy Programs and Resources on Medication Labeling  http://www.acpfoundation.org/health-literacy-programs/ medication-labeling-2/
  • 43. References 1. Casula M, Tragni E, Catapano AL. Adherence to lipid-lowering treatment: the patient perspective. Patient Prefer Adherence 2012; 6:805-814. 2. Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al. Full coverage for preventive medications after myocardial infarction. N Engl J Med 2011;365(22), 2088-2097. 3. Edmondson D, Horowitz CR, Goldfinger JZ, Fei K, Kronish IM. Concerns about medications mediate the association of posttraumatic stress disorder with adherence to medication in stroke survivors. Br J Health Psychol 2013 Jan 7; doi: 10.1111/bjhp.12022. [Epub ahead of print]. 4. Elliott RA, Barber N, Horne R. Cost-effectiveness of adherence-enhancing interventions: a quality assessment of the evidence. Ann Pharmacother 2005; 39(3):508-515. 5. Fongwa MN, Evangelista LS, Hays RD, Martins DS, Elashoff D, Cowan MJ, et al. Adherence treatment factors in hypertensive African American women. Vasc Health Risk Manag 2008; 4(1):157-166. 6. Fretheim A, Aaserud M, Oxman AD. Rational prescribing in primary care (RaPP): economic evaluation of an intervention to improve professional practice. PLoS Med 2006; 3(6):e216. 7. George J, Shalansky SJ. Predictors of refill non-adherence in patients with heart failure. Br J Clin Pharmacol 2007; 63(4):488-493.
  • 44. References (cont.) 8. Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood pressure control among United States adults with hypertension: the National Health and Nutrition Examination Survey, 2001 to 2010. Circulation 2012; 126(17):2105- 2114. 9. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation 2009; 119(23):3028-3035. 10. Ito K, Shrank WH, Avorn J, Patrick AR, Brennan TA, Antman, EM et al. Comparative cost-effectiveness of interventions to improve medication adherence after myocardial infarction. Health Serv Res 2012; 47(6):2097-2117. 11. Kronish IM, Edmondson D, Goldfinger JZ, Fei K, Horowitz CR. Posttraumatic stress disorder and adherence to medications in survivors of strokes and transient ischemic attacks. Stroke 2012; 43(8):2192-2197. 12. Levine DA, Morgenstern LB, Langa KM, Piette JD, Rogers MA, Karve SJ. Recent trends in cost‐related medication nonadherence among US stroke survivors. Annals of Neurology 2013 Feb 22; doi: 10.1002/ana.23823. [Epub ahead of print]. 13. Lyles CR, Karter AJ, Young BA, Spigner C, Grembowski D, Schillinger D, et al. Patient-reported racial/ethnic healthcare provider discrimination and medication intensification in the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med 2011; 26(10):1138-1144. 14. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008; 10(5):348-354.
  • 45. References (cont.) 15. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: response to authors. J Clin Epidemiol 2011; 64(3):255-257. 16. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353(5):487-497. 17. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA 2007;297:177–186. 18. Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, Moffet HH, et al. Communication and medication refill adherence: the Diabetes Study of Northern California. Arch Intern Med 2012 Dec 31;1-9. 19. Steiner JF, Ho PM, Beaty BL, Dickinson LM, Hanratty R, Zeng C, et al. Sociodemographic and clinical characteristics are not clinically useful predictors of refill adherence in patients with hypertension. Circ Cardiovasc Qual Outcomes 2009; 2(5):451-457. 20. Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med 2012; 157(11):785-795. 21. Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic review. Medical Care 2006;44:646-57. 22. Yeaw J, Benner JS, Walt JG, Sian S, Smith DB. Comparing adherence and persistence across 6 chronic medication classes. J Manag Care Pharm 2009; 15(9), 728-740.
  • 46. Acknowledgements Farah M. Chowdhury, MBBS, MPH Deesha Patel, MPH Mary G. George, MD, MSPH, FACS David Callahan, MD, FAAFP For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention (DHDSP) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)

Editor's Notes

  1. Health-care system and team dimensions for medication non-adherence have multiple domains. Some related to health-care delivery are Access to care—If patients are uninsured or underinsured, and thus have no access or poor access to care, they may not have the opportunity to treat their conditions and continue medication adherence. Continuity of care—Continuity of care is important for controlling chronic conditions and continuation of long-term therapy. Patient education materials may not be written in plain language. Consequently, patients may not be able to adequately understand instructions for their medication regimen. In general, the health-care team is made up of both providers and patients. Some factors for medication non-adherence are related to the health-care team; these are factors related to both patient and providers or providers or patients only. For example: Patients may consider health-care visits stressful. Patients may feel discomfort in posing questions to providers. Patients’ beliefs or understanding of the disease may differ from their providers’. Patients may be forgetful or careless. Stressful life events—for providers or patients—may play a role. A lack of immediate benefit of therapy, resulting in an uncontrolled condition, may also play a role. For example, uncontrolled blood pressure at a follow-up visit is a potential risk factor for medication non-adherence.
  2. Many provider-related factors affect medication non-adherence: Provider communication skills Lack of provider’s knowledge about health literacy and plain language. We included resources related to health literacy in the resource list; the American Medical Association offers a short video on this topic. Lack of empathy. Researchers reported that providers miss 70% to 90% of opportunities to express empathy. Researchers defined empathic opportunities as instances where patients expressed a strong negative emotion, and they developed thematic categories to describe provider response by analyzing 47 visits between patients and their providers. Researchers categorized provider’s responses into “Ignore/Change Topic,” “Dismiss,” “Elicit,” “Problem Solving,” and “Empathic Response.” [Hsu et al. Patient Educ Couns. 2012;88(3):436-442.] Lack of positive reinforcement from provider Number of comorbid conditions Number of medications needed per day Types or components of medication Amount of prescribed medications or duration of the prescription  
  3. Patient-related factors could be physical as well as psychological or behavioral. Some patient-related physical factors are Visual, hearing, or cognitive impairments Swallowing problems Lack of or severity of symptoms Chronic conditions (e.g., hypertension, diabetes mellitus) Patient-related psychological factors include Depression Confidence in ability to follow treatment regimen Fear of possible adverse effects or dependence Expectations or attitude toward prescription Some examples of condition- and therapy-related factors are Complexity of medication regimen (for example, number of daily doses or number of concurrent medications) Frequent changes in regimen Treatment requiring mastery of certain techniques (for example, injections or inhalers) Unpleasant side effects which may be actual or perceived Duration of therapy Lack of immediate benefit of therapy Medications with social stigma
  4. CDC Resources Educational Materials for Professionals. From the Division for Heart Disease and Stroke Prevention. - Fact Sheets, Data and Statistics, Maps, Reports, Guidelines and Recommendations to prevent and control cardiovascular diseases are available. Providers may share this information to patients. Available at http://www.cdc.gov/dhdsp/materials_for_professionals.htm Million Hearts: Prevention at Work. - Million Hearts™ is a national initiative to prevent one million heart attacks and strokes by 2017. Million Hearts™ brings together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners including doctors, nurses, pharmacists, and other health care professionals, private insurers, businesses, health advocacy groups, and community organizations to support Million Hearts™ through a wide range of activities. - Million Hearts™ aims to prevent heart disease and stroke by Improving access to effective care Improving the quality of care for the ABCS (Aspirin for people at risk, Blood pressure control, Cholesterol management and Smoking cessation) Focusing clinical attention on the prevention of heart attack and stroke Empowering the public to lead a heart-healthy lifestyle (preventing or quitting tobacco use and reducing sodium and transfat consumption) Improving the prescription of and adherence to appropriate medications for the ABCS. - Million Hearts™ information is available at: http://www.cdc.gov/24-7/prevention/MillionHearts/ http://millionhearts.hhs.gov/index.html
  5. CDC Resources – (con’t) Team Up. Pressure Down - Team Up. Pressure Down is a nationwide program to lower blood pressure and prevent hypertension through patient-pharmacist engagement. - Providers may inform patients to team up with their pharmacist to better understand their condition and any medications that patients are taking. - Through medication, healthy lifestyle changes, and working closely with their health care team, patients can get—and keep—their blood pressure under control. Available at http://www.cdc.gov/features/tupd/ http://millionhearts.hhs.gov/resources/teamuppressuredown.html#Partners A Program Guide for Public Health: Partnering with Pharmacists in the Prevention and Control of Chronic Diseases. From the Division for Heart Disease and Stroke Prevention and the Division of Diabetes Translation. - This guide focuses on medication therapy management services provided by pharmacists to improve medication adherence. Available at http://www.cdc.gov/dhdsp/programs/nhdsp_program/docs/Pharmacist_Guide.pdf
  6. Some health literacy resources are American Medical Association Health Literacy Video http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program/health-literacy-video.page http://www.youtube.com/watch?v=cGtTZ_vxjyA Rhode Island Blue Cross Blue Shield developed this literacy toolkit; it is also located under the AHRQ Healthcare Innovations Exchange.  Accessed on 03/14/13. http://www.rihlp.org/pubs/Complete_toolkit_224pgs.pdf http://www.innovations.ahrq.gov/content.aspx?id=2684  American College of Physician Foundation Health Literacy Programs and Resources on Medication Labeling http://www.acpfoundation.org/health-literacy-programs/medication-labeling-2/
  7. References: Casula M, Tragni E, Catapano AL. Adherence to lipid-lowering treatment: the patient perspective. Patient Prefer Adherence 2012; 6:805-814. Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al. Full coverage for preventive medications after myocardial infarction. N Engl J Med 2011;365(22), 2088-2097. Edmondson D, Horowitz CR, Goldfinger JZ, Fei K, Kronish IM. Concerns about medications mediate the association of posttraumatic stress disorder with adherence to medication in stroke survivors. Br J Health Psychol 2013 Jan 7; doi: 10.1111/bjhp.12022. [Epub ahead of print]. Elliott RA, Barber N, Horne R. Cost-effectiveness of adherence-enhancing interventions: a quality assessment of the evidence. Ann Pharmacother 2005; 39(3):508-515. Fongwa MN, Evangelista LS, Hays RD, Martins DS, Elashoff D, Cowan MJ, et al. Adherence treatment factors in hypertensive African American women. Vasc Health Risk Manag 2008; 4(1):157-166. Fretheim A, Aaserud M, Oxman AD. Rational prescribing in primary care (RaPP): economic evaluation of an intervention to improve professional practice. PLoS Med 2006; 3(6):e216. George J, Shalansky SJ. Predictors of refill non-adherence in patients with heart failure. Br J Clin Pharmacol 2007; 63(4):488-493.
  8. References (cont.): Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood pressure control among United States adults with hypertension: the National Health and Nutrition Examination Survey, 2001 to 2010. Circulation 2012; 126(17):2105-2114. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation 2009; 119(23):3028-3035. Ito K, Shrank WH, Avorn J, Patrick AR, Brennan TA, Antman, EM et al. Comparative cost-effectiveness of interventions to improve medication adherence after myocardial infarction. Health Serv Res 2012; 47(6):2097-2117. Kronish IM, Edmondson D, Goldfinger JZ, Fei K, Horowitz CR. Posttraumatic stress disorder and adherence to medications in survivors of strokes and transient ischemic attacks. Stroke 2012; 43(8):2192-2197. Levine DA, Morgenstern LB, Langa KM, Piette JD, Rogers MA, Karve SJ. Recent trends in cost‐related medication nonadherence among US stroke survivors. Annals of Neurology 2013 Feb 22; doi: 10.1002/ana.23823. [Epub ahead of print]. Lyles CR, Karter AJ, Young BA, Spigner C, Grembowski D, Schillinger D, et al. Patient-reported racial/ethnic healthcare provider discrimination and medication intensification in the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med 2011; 26(10):1138-1144. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008; 10(5):348-354.
  9. References (cont.): Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: response to authors. J Clin Epidemiol 2011; 64(3):255-257. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353(5):487-497. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA 2007;297:177–186. Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, Moffet HH, et al. Communication and medication refill adherence: the Diabetes Study of Northern California. Arch Intern Med 2012 Dec 31;1-9. Steiner JF, Ho PM, Beaty BL, Dickinson LM, Hanratty R, Zeng C, et al. Sociodemographic and clinical characteristics are not clinically useful predictors of refill adherence in patients with hypertension. Circ Cardiovasc Qual Outcomes 2009; 2(5):451-457. Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med 2012; 157(11):785-795. Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic review. Medical Care 2006;44:646-57. Yeaw J, Benner JS, Walt JG, Sian S, Smith DB. Comparing adherence and persistence across 6 chronic medication classes. J Manag Care Pharm 2009; 15(9), 728-740.
  10. Acknowledgements: Farah M. Chowdhury, MBBS, MPH Deesha Patel, MPH Mary G. George, MD, MSPH, FACS David Callahan, MD, FAAFP