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SAFTINet Cardiovascular
Cohort PRO: Medication
Adherence
CER Team
21 May 2012
+
Overview
 What medication adherence domains should we measure?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 What instruments should we use?
 Who would be surveyed (PEC: all patients) and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Overview
 What medication adherence domains should we measure?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 What instruments should we use?
 Who would be surveyed and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Medication Adherence Measures
 Options in SAFTINet
 self-report: simple to obtain in real time
 other real-time methods: more cumbersome and costly
 pill counts, drug levels, direct observation, etc.
 prescription fulfillment data
 in SAFTINet: only for Medicaid patients
 only tells whether they filled the prescription
Patient
(person)
Medication adherence
(behavior)
Self-efficacyBarriers
+
Medication Adherence Measures
 Feedback from PEC
 Medication adherence would be helpful to know
 most clinicians ask this already
 the simpler the better
 Barriers would be useful
 helped refine the list of domains to cover based on clinical
experience
 Self-efficacy—no clear direction yet from PEC
Patient
(person)
Medication adherence
(behavior)
Self-efficacyBarriers
+
Overview
 What medication adherence domains should we measure?
 What instruments should we use?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 Who would be surveyed and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Review of Self-Reported Medical
Adherence Measures
 Garfield S, et al. Suitability of measures of self-reported
medication adherence for routine clinical use: A systematic
review. BMC Med Res Methodol. 2011; 11: 149.
 Inclusion Criteria: Studies that report development, reliability or
validation of a retrospective self report adherence measure
against a non-questionnaire measure
 Exclusion Criteria: (excerpt)
 non-English
 no instrument available
 only relevant to single disease or medication
 med adherence questions not separable from other questions
+
Review findings
 58 measures in 76 papers
 Length: 1 to 21 questions
 Formats: face to face interview, telephone interview, self
administration and computer program
 43/58 specified a time period
 ~half had a measure of barriers too, but these were usually not
comprehensive or developed with patient feedback
 54/58 had validation data
+
Overview of studies by design
+
Overview of studies by validation
+
Narrowing down the field
 Selected studies with only 1 question: 21/58
 Selected studies with significant findings for validation study:
16/58
 Selected studies not limited to an HIV positive or Mental Health
population: 5/58
 Rationale: focus on less symptomatic population
+
Scale
[Ref #] Scale type Time period Sample size Population
Validated
against
Validity
Results
Adherence
Self Report
Questionnair
e (ASRQ)
[25-27] Likert
None
Specified 245
Patients from
GP practice
taking
antihyperten
sives MEMS
Significant
association
(p=0.0004)
216
Patients from
GP Practices
taking
antihyperten
sives MEMS
Sensitivity=
46%;
Specificity=6
6%
Gehi [41] Likert
Previous
month 1015
Outpatients
with
documented
chronic heart
disease
Develop-
ment of CV
events
Significant
association
(p=0.03)
bivariate
analysis,
0.06
multivariate
analysis)
Inui [46] Dichotomous
Previous 2
months 241
Patients with
HTN Pill count
Sensitivity =
55%;
Specificity =
88%
+
Scale
[Ref #] Scale type Time period Sample size Population
Validated
against
Validity
Results
Medical
Outcomes
Study
Adherence
question [57] Likert
Previous 4
weeks 139
Patients >18
with HTN,
DM, hyper-
cholesterole
mia, hypo-
thyroidism or
requiring
HRT
Pharmacy
refill records
Spearman
Rho=
0.261(p=0.05
)
Visual
Analogue
Scale (VAS)
six month
version [89]
Continuous
(visual
analogue)
Previous 6
months 1985
Patients >18
with DM MEMS
VAS higher
than MEMS
adherence
mean
difference
15% (p value
not reported)
+
Adherence Self Report
Questionnaire (ASRQ)
+
Gehi Question
 In the past month, how often did you take your medications as the
doctor prescribed?
 “All of the time” (100%)
 “Nearly all of the time” (90%)
 “Most of the time” (75%)
 “About half the time” (50%)
 “Less than half the time” (<50%)
+
Medical Outcomes Study
Adherence question
 How often have you taken your prescribed medication in the
past 4 weeks? (Select one)
 none of the time
 a little of the time
 some of the time
 a good bit of the time
 most of the time or all of the time
 Similar to Gehi question
+
Inui Question
 Many patients find it difficult to take their medicines
or stick to their diets as their doctors say they
should. Over the past two months since you were
last in clinic, do you think you have taken your
medicine as you should, on schedule and regularly?
 Yes
 No
+
Visual Analogue Scale (VAS) six
month version
 What percent of time over the past 6 months did you take your
prescribed diabetes medication?
 Place an “x” on a horizontal line
 anchored by 0% and100%
 demarcations provided for every 10th percentile
+
Self-Reported Medical Adherence
Measures
 Recommendations on selecting a measure quantifying
medication adherence?
 Adherence Self Report Questionnaire (ASRQ)
 6 levels, more text per level
 Gehi Question
 5 levels, brief text and percentages for each level
 Medical Outcomes Study Adherence question
 5 levels, brief text for each level
 Inui Question
 yes/no question
 Visual Analogue Scale (VAS) six month version
+
Medication Adherence from Claims
Fulfillment Data
 Medication possession ratio (MPR) = (days of medication
supplied) ÷ (# days between the first and last fills)
 Proportion of days covered (PDC): the proportion of all days
within a specified time period a patient had enough medication
 Percentage of doses taken as prescribed: the percentage of
prescribed doses taken as directed during a specified time
period
 Cumulative medication gap (CMG) = (# days in which a
medication was not available) ÷ (# days between the first and
last fills)
+
Overview
 What medication adherence domains should we measure?
 What instruments should we use?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 Who would be surveyed and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Medication Adherence Measures:
Barriers Measure
 Starting point for which barriers to ask about
 what barriers have been shown to matter in research studies
 what barriers do you encounter in your own practices (known to be
very context dependent)
 emphasize barriers that are amenable to real-world intervention
(e.g., prescribe a daily rather than twice-daily medication)
Patient
(person)
Medication adherence
(behavior)
Self-efficacyBarriers
+
Medication Adherence Measures:
Barriers Measure
 Starting point for which barriers to ask about
 what barriers have been shown to matter in research studies
 RAND Corporation systematic review of barriers found to predict
measured medication adherence
 regimen complexity
 cost-sharing (e.g., prescription copayments, formulary tiers,
coinsurance, pharmacy benefit caps or monthly prescription limits,
formulary restrictions, and reference pricing)
 depression (found effect only as comorbidity of diabetes)
 beliefs about medications (perceived risks of having a side effect
and perceived impact and need for the medication)
+
Medication Adherence Measures:
Barriers Measure
 Based on the RAND list, and eliminating depression, here is a
sample barriers measure, modified by PEC
 Which of the following things make it harder for you to take
your medication(s) as prescribed?
 I am worried about the side effects of the medication(s)
 I do not feel like I need the medication(s) for my health
 I do not feel like the medication(s) make me feel any better
 It is hard to take medication(s) more than once a day
 I have so many medications to take
 I cannot afford to pay for the medication(s)
 I sometimes forget to take my medication(s)
+
Medication Adherence Measures:
Barriers Measure
 No systematic review of barriers measures
 Per PubMed, the ASK-20 and ASK-12 are
 commonly cited
 not disease specific
 validated
 ASK-12
 contains the questions most often identified as barriers by patients
taking the ASK-20
 Three domains – Inconvenience/forgetfulness, Treatment beliefs,
Behavior – each with a subscale
+
Medication Adherence Measures:
Barriers Measure
 ASK-12 total score demonstrated adequate internal consistency
reliability with a Cronbach’s alpha of 0.75
 ASK-12 score correlates with self-report measures and objective
measures
 Morisky Adherence Survey (-0.74)
 proportion of days covered as indicated by claims (r=-0.20; P=0.059)
 Score
 range 12-60
 higher score = greater barriers
 In a clinical setting it is not necessary to score the instrument, only
review the items in the dark blue boxes
+
Medication Adherence Measures: ASK-
12
+
Medication Adherence Measures: ASK-
12
+
Overview
 What medication adherence domains should we measure?
 What instruments should we use?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 Who would be surveyed and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Medication Adherence Measures: Self-
efficacy
 Medication Adherence Self-Efficacy Scale (MASES)
 Ogedegbe et al 2003
 Validated in African-American patients with hypertension
 Please rate how sure you are that you can carry out the
following tasks ALL OF THE TIME: (all answers are on a 3
point scale: Not at all sure, somewhat sure, very sure)
 Get refills for your medications before you run out
 Make taking your medications part of your routine
 Fill your prescriptions whatever they cost
 Always remember to take your blood pressure medications
 Take your blood pressure medications for the rest of your life
+Situations come up that make it difficult for people to take their medications as prescribed by their
doctors. Below is a list of such situations. We want to know your opinion about taking your blood
pressure medication(s) under each of them. Please indicate your response by checking the box that
most closely represents your opinion. There are no right or wrong answers. For each of the
situations listed below, please rate how sure you are that you can take your blood pressure
medications ALL OF THE TIME
1. When you are busy at home
2. When you are at work
3. When there is no one to remind you
4. When you worry about taking them for the rest of your life
5. When they cause some side effects
6. When they cost a lot of money
7. When you come home late from work
8. When you do not have any symptoms
9. When you are with family members
10. When you are in a public place
11. When you are afraid of becoming dependent on them
+
Overview
 What medication adherence domains should we measure?
 What instruments should we use?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 Who would be surveyed and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Options for Med Adherence PRO
Administration
 Easier to administer to all patients than to only those with select
diagnoses
 Having just one screening question is more practical
 Administer medication adherence measure first
 then administer barriers +/- self-efficacy questions
 only administer barriers +/- self-efficacy questions to those with non-
adherence
 Administer barriers +/- self-efficacy questions first and leave the
medication adherence question for last
+
Overview
 What medication adherence domains should we measure?
 What instruments should we use?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 Who would be surveyed and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Research Utility
 Which domains would we use?
 medication adherence
 barriers measure total score
 self-efficacy total score
 How would we use these in an analytic model?
PCMH
Medication adherence
Self-efficacyBarriers
Disease control
+
Research Utility
 How would we use fulfillment data in an analytic model?
 Verify self-report data
 As an outcome or intermediate variable in the PCMH model
PCMH
Prescription fulfillment
Disease control
+
Overview
 What medication adherence domains should we measure?
 What instruments should we use?
 Medication adherence: quantified
 Barriers
 Self-efficacy
 Who would be surveyed and how?
 How would we use the findings in our research?
 How would our partners use the instruments?
+
Utility to Practices
 Which of the components of the proposed PRO would have
clinical (and other use) utility to the practices?
 What related activities are the practices already doing?
 Some clinicians are asking about medication adherence and
barriers but not documenting responses in a field
 Nurses check the list of active medications at intake, asking which
they are still taking and why they stopped those they are no longer
taking
 Meaningful use phase 2 will require goal-setting and a barriers
format might meet these criteria
 ACO activities related to identifying high-risk patients for
hospitalization (next slide)
+
Example of Medication Adherence
Question Already In Use
 How many prescription medications are you currently taking every day
(H-8)?
 None (0) (skip to Social Needs)  1-2 (0)  3 OR MORE (1)
 In a TYPICAL WEEK how often did you forget to take or decide NOT to
take one or more of your medications (H-8)?
 NEVER (0)  RARELY (0)  SOMETIMES (1)  USUALLY (1)  ALWAYS
(1)
 How sure are you that you understand the reason you are taking your
medications (H-8)?
 VERY SURE (0)  SOMEWHAT SURE (0)  NOT VERY SURE (1)
 How often do you get your medications at more than one pharmacy?
 NEVER (0)  RARELY (0)  SOMETIMES (1)  USUALLY (1)  ALWAYS
(1)

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Med adherence and self efficacy

  • 1. + SAFTINet Cardiovascular Cohort PRO: Medication Adherence CER Team 21 May 2012
  • 2. + Overview  What medication adherence domains should we measure?  Medication adherence: quantified  Barriers  Self-efficacy  What instruments should we use?  Who would be surveyed (PEC: all patients) and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 3. + Overview  What medication adherence domains should we measure?  Medication adherence: quantified  Barriers  Self-efficacy  What instruments should we use?  Who would be surveyed and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 4. + Medication Adherence Measures  Options in SAFTINet  self-report: simple to obtain in real time  other real-time methods: more cumbersome and costly  pill counts, drug levels, direct observation, etc.  prescription fulfillment data  in SAFTINet: only for Medicaid patients  only tells whether they filled the prescription Patient (person) Medication adherence (behavior) Self-efficacyBarriers
  • 5. + Medication Adherence Measures  Feedback from PEC  Medication adherence would be helpful to know  most clinicians ask this already  the simpler the better  Barriers would be useful  helped refine the list of domains to cover based on clinical experience  Self-efficacy—no clear direction yet from PEC Patient (person) Medication adherence (behavior) Self-efficacyBarriers
  • 6. + Overview  What medication adherence domains should we measure?  What instruments should we use?  Medication adherence: quantified  Barriers  Self-efficacy  Who would be surveyed and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 7. + Review of Self-Reported Medical Adherence Measures  Garfield S, et al. Suitability of measures of self-reported medication adherence for routine clinical use: A systematic review. BMC Med Res Methodol. 2011; 11: 149.  Inclusion Criteria: Studies that report development, reliability or validation of a retrospective self report adherence measure against a non-questionnaire measure  Exclusion Criteria: (excerpt)  non-English  no instrument available  only relevant to single disease or medication  med adherence questions not separable from other questions
  • 8. + Review findings  58 measures in 76 papers  Length: 1 to 21 questions  Formats: face to face interview, telephone interview, self administration and computer program  43/58 specified a time period  ~half had a measure of barriers too, but these were usually not comprehensive or developed with patient feedback  54/58 had validation data
  • 10. + Overview of studies by validation
  • 11. + Narrowing down the field  Selected studies with only 1 question: 21/58  Selected studies with significant findings for validation study: 16/58  Selected studies not limited to an HIV positive or Mental Health population: 5/58  Rationale: focus on less symptomatic population
  • 12. + Scale [Ref #] Scale type Time period Sample size Population Validated against Validity Results Adherence Self Report Questionnair e (ASRQ) [25-27] Likert None Specified 245 Patients from GP practice taking antihyperten sives MEMS Significant association (p=0.0004) 216 Patients from GP Practices taking antihyperten sives MEMS Sensitivity= 46%; Specificity=6 6% Gehi [41] Likert Previous month 1015 Outpatients with documented chronic heart disease Develop- ment of CV events Significant association (p=0.03) bivariate analysis, 0.06 multivariate analysis) Inui [46] Dichotomous Previous 2 months 241 Patients with HTN Pill count Sensitivity = 55%; Specificity = 88%
  • 13. + Scale [Ref #] Scale type Time period Sample size Population Validated against Validity Results Medical Outcomes Study Adherence question [57] Likert Previous 4 weeks 139 Patients >18 with HTN, DM, hyper- cholesterole mia, hypo- thyroidism or requiring HRT Pharmacy refill records Spearman Rho= 0.261(p=0.05 ) Visual Analogue Scale (VAS) six month version [89] Continuous (visual analogue) Previous 6 months 1985 Patients >18 with DM MEMS VAS higher than MEMS adherence mean difference 15% (p value not reported)
  • 15. + Gehi Question  In the past month, how often did you take your medications as the doctor prescribed?  “All of the time” (100%)  “Nearly all of the time” (90%)  “Most of the time” (75%)  “About half the time” (50%)  “Less than half the time” (<50%)
  • 16. + Medical Outcomes Study Adherence question  How often have you taken your prescribed medication in the past 4 weeks? (Select one)  none of the time  a little of the time  some of the time  a good bit of the time  most of the time or all of the time  Similar to Gehi question
  • 17. + Inui Question  Many patients find it difficult to take their medicines or stick to their diets as their doctors say they should. Over the past two months since you were last in clinic, do you think you have taken your medicine as you should, on schedule and regularly?  Yes  No
  • 18. + Visual Analogue Scale (VAS) six month version  What percent of time over the past 6 months did you take your prescribed diabetes medication?  Place an “x” on a horizontal line  anchored by 0% and100%  demarcations provided for every 10th percentile
  • 19. + Self-Reported Medical Adherence Measures  Recommendations on selecting a measure quantifying medication adherence?  Adherence Self Report Questionnaire (ASRQ)  6 levels, more text per level  Gehi Question  5 levels, brief text and percentages for each level  Medical Outcomes Study Adherence question  5 levels, brief text for each level  Inui Question  yes/no question  Visual Analogue Scale (VAS) six month version
  • 20. + Medication Adherence from Claims Fulfillment Data  Medication possession ratio (MPR) = (days of medication supplied) ÷ (# days between the first and last fills)  Proportion of days covered (PDC): the proportion of all days within a specified time period a patient had enough medication  Percentage of doses taken as prescribed: the percentage of prescribed doses taken as directed during a specified time period  Cumulative medication gap (CMG) = (# days in which a medication was not available) ÷ (# days between the first and last fills)
  • 21. + Overview  What medication adherence domains should we measure?  What instruments should we use?  Medication adherence: quantified  Barriers  Self-efficacy  Who would be surveyed and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 22. + Medication Adherence Measures: Barriers Measure  Starting point for which barriers to ask about  what barriers have been shown to matter in research studies  what barriers do you encounter in your own practices (known to be very context dependent)  emphasize barriers that are amenable to real-world intervention (e.g., prescribe a daily rather than twice-daily medication) Patient (person) Medication adherence (behavior) Self-efficacyBarriers
  • 23. + Medication Adherence Measures: Barriers Measure  Starting point for which barriers to ask about  what barriers have been shown to matter in research studies  RAND Corporation systematic review of barriers found to predict measured medication adherence  regimen complexity  cost-sharing (e.g., prescription copayments, formulary tiers, coinsurance, pharmacy benefit caps or monthly prescription limits, formulary restrictions, and reference pricing)  depression (found effect only as comorbidity of diabetes)  beliefs about medications (perceived risks of having a side effect and perceived impact and need for the medication)
  • 24. + Medication Adherence Measures: Barriers Measure  Based on the RAND list, and eliminating depression, here is a sample barriers measure, modified by PEC  Which of the following things make it harder for you to take your medication(s) as prescribed?  I am worried about the side effects of the medication(s)  I do not feel like I need the medication(s) for my health  I do not feel like the medication(s) make me feel any better  It is hard to take medication(s) more than once a day  I have so many medications to take  I cannot afford to pay for the medication(s)  I sometimes forget to take my medication(s)
  • 25. + Medication Adherence Measures: Barriers Measure  No systematic review of barriers measures  Per PubMed, the ASK-20 and ASK-12 are  commonly cited  not disease specific  validated  ASK-12  contains the questions most often identified as barriers by patients taking the ASK-20  Three domains – Inconvenience/forgetfulness, Treatment beliefs, Behavior – each with a subscale
  • 26. + Medication Adherence Measures: Barriers Measure  ASK-12 total score demonstrated adequate internal consistency reliability with a Cronbach’s alpha of 0.75  ASK-12 score correlates with self-report measures and objective measures  Morisky Adherence Survey (-0.74)  proportion of days covered as indicated by claims (r=-0.20; P=0.059)  Score  range 12-60  higher score = greater barriers  In a clinical setting it is not necessary to score the instrument, only review the items in the dark blue boxes
  • 29. + Overview  What medication adherence domains should we measure?  What instruments should we use?  Medication adherence: quantified  Barriers  Self-efficacy  Who would be surveyed and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 30. + Medication Adherence Measures: Self- efficacy  Medication Adherence Self-Efficacy Scale (MASES)  Ogedegbe et al 2003  Validated in African-American patients with hypertension  Please rate how sure you are that you can carry out the following tasks ALL OF THE TIME: (all answers are on a 3 point scale: Not at all sure, somewhat sure, very sure)  Get refills for your medications before you run out  Make taking your medications part of your routine  Fill your prescriptions whatever they cost  Always remember to take your blood pressure medications  Take your blood pressure medications for the rest of your life
  • 31. +Situations come up that make it difficult for people to take their medications as prescribed by their doctors. Below is a list of such situations. We want to know your opinion about taking your blood pressure medication(s) under each of them. Please indicate your response by checking the box that most closely represents your opinion. There are no right or wrong answers. For each of the situations listed below, please rate how sure you are that you can take your blood pressure medications ALL OF THE TIME 1. When you are busy at home 2. When you are at work 3. When there is no one to remind you 4. When you worry about taking them for the rest of your life 5. When they cause some side effects 6. When they cost a lot of money 7. When you come home late from work 8. When you do not have any symptoms 9. When you are with family members 10. When you are in a public place 11. When you are afraid of becoming dependent on them
  • 32. + Overview  What medication adherence domains should we measure?  What instruments should we use?  Medication adherence: quantified  Barriers  Self-efficacy  Who would be surveyed and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 33. + Options for Med Adherence PRO Administration  Easier to administer to all patients than to only those with select diagnoses  Having just one screening question is more practical  Administer medication adherence measure first  then administer barriers +/- self-efficacy questions  only administer barriers +/- self-efficacy questions to those with non- adherence  Administer barriers +/- self-efficacy questions first and leave the medication adherence question for last
  • 34. + Overview  What medication adherence domains should we measure?  What instruments should we use?  Medication adherence: quantified  Barriers  Self-efficacy  Who would be surveyed and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 35. + Research Utility  Which domains would we use?  medication adherence  barriers measure total score  self-efficacy total score  How would we use these in an analytic model? PCMH Medication adherence Self-efficacyBarriers Disease control
  • 36. + Research Utility  How would we use fulfillment data in an analytic model?  Verify self-report data  As an outcome or intermediate variable in the PCMH model PCMH Prescription fulfillment Disease control
  • 37. + Overview  What medication adherence domains should we measure?  What instruments should we use?  Medication adherence: quantified  Barriers  Self-efficacy  Who would be surveyed and how?  How would we use the findings in our research?  How would our partners use the instruments?
  • 38. + Utility to Practices  Which of the components of the proposed PRO would have clinical (and other use) utility to the practices?  What related activities are the practices already doing?  Some clinicians are asking about medication adherence and barriers but not documenting responses in a field  Nurses check the list of active medications at intake, asking which they are still taking and why they stopped those they are no longer taking  Meaningful use phase 2 will require goal-setting and a barriers format might meet these criteria  ACO activities related to identifying high-risk patients for hospitalization (next slide)
  • 39. + Example of Medication Adherence Question Already In Use  How many prescription medications are you currently taking every day (H-8)?  None (0) (skip to Social Needs)  1-2 (0)  3 OR MORE (1)  In a TYPICAL WEEK how often did you forget to take or decide NOT to take one or more of your medications (H-8)?  NEVER (0)  RARELY (0)  SOMETIMES (1)  USUALLY (1)  ALWAYS (1)  How sure are you that you understand the reason you are taking your medications (H-8)?  VERY SURE (0)  SOMEWHAT SURE (0)  NOT VERY SURE (1)  How often do you get your medications at more than one pharmacy?  NEVER (0)  RARELY (0)  SOMETIMES (1)  USUALLY (1)  ALWAYS (1)

Editor's Notes

  1. Maria: Would focus on the beliefs aspect We don’t know about side effect, relief of symptoms, and beliefs Alycin: I would like to know about cost as a barrier because then I would get them on an assistance program Jeanne: One thing missing is the forgetting issue—why they forget is not clear If I hear of this I tell them about pill boxes Jena: Another barrier is I feel asymptomatic, I feel fine Collapse the insurance/formulary within the not affording to pay
  2. Parinda: I like leaving the med adherence question for last; they may be more likely to be honest if they recognize we can recognize and validate their responses to the barriers issues Jeanne: This means we would give the long questionnaire to everyone. In real world, having one screening question might be more practical—just target the people who are reporting those who are not taking the medications regularly Jena: Instead of asking how often they take their meds, ask how often you forget to take their meds Alicyn: the RN gives them the med list and have the patients cross of meds they are not taking anymore at triage Parinda: I would like to take this to our PCPs and get their input, how they address it now MCPN: Pre-appointment checklist: various questions is 2 pages long and we could add 1 more question to this—administered as the patient checks in for the visit in the waiting room. It’s the same issue with the ACT because someone has to decide that this patient needs to fill out this form until it gets back to the provider. It would be easier to ask of all patients. From a clinician’s perspective, I don’t just want to know about CV meds, so it makes more sense to ask about all of the meds.