SAFTINet Teleconference Slideset guiding discussion of selection and development of a medication adherence instrument. 2 July 2012.

1. +
SAFTINet Cardiovascular
Cohort PRO: Medication
Adherence
CER Team
2 July 2012

2. +
Overview
 PEC preference regarding the medication adherence measure
 Instrument
 Pilot test
 Feedback on the instrument
 Feedback on the pilot
 How would we use the findings in our research?

3. +
Overview
 PEC preference regarding the medication adherence measure
 Instrument
 Pilot test
 Feedback on the instrument
 Feedback on the pilot
 How would we use the findings in our research?

4. +
Proposed Med Adherence Instrument
and Pilot Test
 A single medication adherence question (derived from the Gehi
question) and a single checklist of barriers
 Pilot test by 1-2 providers in each organization for a few weeks

5. +
Proposed Med Adherence Instrument:
Adherence Question
 Patient Instructions:
 It can be difficult to take all of our medications as the doctor has told
us to. Please tell us how often taking your medications is difficult for
you.
 In the past month, how often did you take your medications as the
doctor or provider prescribed?1 Please check one (1) answer.
 “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%)
 “None of the time” (0%)

6. +
Proposed Med Adherence Instrument:
Barriers Checklist
 In the past month, why have you not taken your medicine as
your doctor prescribed? Check all that apply.
 My medicine makes me feel bad (I have “side effects”). Please
describe: ________________
 I don’t feel like my medicine is working
 I feel like taking my medicine will not improve my health
 There are too many doses of medicine to take each day
 I cannot afford my medicine
 I forget to take my medicine

7. +
Proposed Med Adherence
Instrument: Barriers Checklist
 Domains for Barriers:
 Side effects
 No improvement in symptoms
 Belief medication won’t change outcomes
 Complexity of regimen
 Financial cost
 Forgetting
 Some options for wording on next slides

8. +
Proposed Med Adherence
Instrument: Barriers Checklist
 Domain for Barriers: Side effects
 Options
 proposed: My medicine makes me feel bad (I have “side effects”).
Please describe: ________________
 ASK-12: Have you skipped or stopped taking a medicine because it
made you feel bad?
 Morisky-8: Have you ever cut back or stopped taking your medicine
without telling your doctor because you felt worse when you took it?
 Morisky-4: At times, if you feel worse if you take your medicines, do
you stop taking them?

9. +
Proposed Med Adherence
Instrument: Barriers Checklist
 Domain for Barriers: No improvement in symptoms
 Options
 proposed: I don’t feel like my medicine is working
 ASK-12:
 I feel confident that each one of my medicines will help me
 Have you skipped or stopped taking a medicine because you did
not think it was working?

10. +
Proposed Med Adherence
Instrument: Barriers Checklist
 Domain for Barriers: Belief medication won’t change outcomes
 Options
 proposed: I feel like taking my medicine will not improve my health
 ASK-12:
 I feel confident that each one of my medicines will help me
 Have you skipped or stopped taking a medicine because you did
not think it was working?

11. +
Proposed Med Adherence Instrument:
Barriers Checklist
 Domain for Barriers: Complexity of regimen
 Options
 proposed: There are too many doses of medicine to take each day
 ASK-12: Taking medicines more than once a day is inconvenient

12. +
Proposed Med Adherence Instrument:
Barriers Checklist
 Domain for Barriers: Financial cost
 Options
 proposed: I cannot afford my medicine
 ASK-12:
 I feel confident that each one of my medicines will help me
 Have you skipped, stopped, not refilled, or taken less medicine
because of the cost?

13. +
Proposed Med Adherence Instrument:
Barriers Checklist
 Domain for Barriers: Forgetting
 Options
 proposed: I forget to take my medicine
 ASK-12:
 I just forget to take my medicines some of the time
 I run out of my medicine because I don’t get refills on time
 Morisky-8:
 Do you sometimes forget to take your pills?
 How often do you have difficulty remembering to take all your
medications?
 When you travel or leave home do you sometimes forget to bring
your medicine?
 Morisky-4: Have you ever forgotten to take your medicine?

14. +
Med Adherence Instrument: Provider
Guidance, 1st slide
 Provider Instructions: Please review the patient’s responses and
considering adjusting the treatment plan if patients exhibit difficulty
taking their medications. Encouraging adherence to medications is
one of the best ways to improve outcomes! Some ideas for helping
patients take their medications include:
 Side effects: Switch medications, adjust the dose, or recommend
other mitigation strategies (e.g., taking the medication with food,
reducing salt intake)
 Feeling as though the medication does not or will not improve their
health: indicate a range of time before seeing results, encourage
logging or home monitoring (e.g., blood pressure) so patients can
see change

15. +
Med Adherence Instrument: Provider
Guidance, 2nd slide
 Complex regimens: Consider reducing medications, use
combination therapies, design a treatment plan that is easier to
follow (e.g., all medications should be taken in the morning),
use organizing systems (pillboxes)
 Cost: Switch to lower cost medications, facilitate sign-up for
prescription assistance plans
 Forgetting: Encourage routines, pairing medications with other
daily activities, use of memory aids (alarms, pillboxes,
calendars), use health IT tools to remind patients to proactively
refill prescriptions

16. +
Pilot Timeline
 July 10, 2012: Feedback from PEC partners on summary of the
instrument
 July 20, 2102: Spanish translation of instrument completed
 July 20, 2012: Partners’ providers for Pilot Test identified
 Aug 1, 2012: PEC and providers participating in Pilot meet at
regularly scheduled PEC meeting
 Aug 1, 2012: Feedback questionnaires provided to PEC
partners
 Aug 13, 2012: Feedback questionnaires returned to SAFTINet
research team

17. +
Pilot Survey, 1st slide
 Is the information in the survey useful to you as a clinical
provider? Are there questions that are not useful? Are there
questions that would be really useful to you that are missing?
 Do the respondents feel comfortable answering the questions?
 Is the wording of the survey clear? Are there questions that
respondents consistently misunderstand? Is there some
wording that needs to be changed? Do you have suggestions
for better wording?
 How long does this survey take to administer?

18. +
Pilot Survey, 2nd slide
 Is the survey too long? If so, what question(s) do you suggest we
drop? Is there a question we are missing?
 Are the “provider instructions” about how to adjust the treatment
plan helpful to you? Are they too common-sense? Are they too
context-dependent (would be different at different practice sites)?
 Did it make sense to administer this survey at the patient’s visit to
the clinic? Would it be better administered by phone or by other
strategies? If so, how do you suggest we administer it?
 Do you prefer to administer the survey to all patients? To only
patients with hyperlipidemia or hypertension?

19. +
Overview
 PEC preference regarding the medication adherence measure
 Instrument
 Pilot test
 Feedback on the instrument
 Feedback on the pilot
 How would we use the findings in our research?

20. +
Overview
 PEC preference regarding the medication adherence measure
 Instrument
 Pilot test
 Feedback on the instrument
 Feedback on the pilot
 How would we use the findings in our research?

21. +
Research Utility
 Which domains would we use?
 medication adherence scale
 barriers measure total count, or focus on specific barrier(s)
 How would we use these in an analytic model?
PCMH
Medication adherence
Barriers
Disease control