MEDICATION ADHERENCE:CHALLENGES AND STRATEGIES

Hanna Phan, PharmD, BCPSClinical Assistant Professor, College of PharmacyAssistant Professor, College of MedicineResidency Program Director, Pediatric PGY2 PharmDUA Pediatric Pulmonary CenterFebruary 14, 2012

CONFLICTS OF INTEREST

• Nothing to disclose

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OBJECTIVES

• Define medication adherence and describe its affect on various disease states

• Describe the health belief theories and their affect on medication adherence

• Identify common reasons for poor adherence based on patient-specific factors such as socioeconomic status, health beliefs, etc.

• Discuss possible strategies in improving medication adherence in children and adolescents

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WISDOM TO PONDER…

“Drugs don’t work in patients who don’t take them.”

-C. Everett Koop, MD

4Osterberg L, Blaschke T. NEJM. 2005; 353:487-97

MEDICATION ADHERENCE

• A.K.A. medication “compliance”

• “...the extent to which patients take medication as prescribed by their health care providers.”

• Why is it important?– Compromises efficacy of treatment regimens, leading

to a failure to achieve a desired treatment goal

5Osterberg L, Blaschke T. NEJM. 2005; 353:487-97

MEDICATION ADHERENCE

• Adherence rates are higher in which?– Acute conditions– Chronic conditions

• What is an acceptable rate of adherence?– Some say 80%– Variability

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RATES OF ADHERENCE

• Clinical trial reported adherence for chronic conditions = 43 - 78% (all patient ages)

• Pediatric medication adherence rates = 11 – 93%

• Up to 69% of all hospital admissions are due to poor medication adherence ($100 billion+/year)

• Up to 50% of admissions associated with drug-related

7Osterberg L, Blaschke T. NEJM. 2005; 353:487-97Llorente RAA et al. J Cys Fib. 2008;7:359-67Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64

RATES OF ADHERENCE

• Asthma medications– Frequently fall below 50% (30 - 70%)– Chronic controller medication is main issue– Acute corticosteroid Rx

• 44 - 98% filled• Up to 64% finished course

– Main barriers• Access to controller medication• Health beliefs (fear of side effects)• Scheduling• Peer pressures

8Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64

RATES OF ADHERENCE

• Cystic fibrosis (CF) medications– Dependent on treatment type

• Greater with GI meds (e.g., enzymes) – up to 88%• Lower with respiratory meds - up to 30-60%• Lower with airway clearance – up to 30-40%

– Main barriers• Poor perception of efficacy (e.g., respiratory meds)• Scheduling• Peer pressures• Access to health care (e.g., cost of medications)

9Llorente RAA et al. J Cys Fib. 2008;7:359-67, Zindani GN et al. J Adoles Health. 2006;38: 13-17Bregnballe V. Pat Pref Adherence. 2011; 5:507-15, Latchford G et al. Pat Ed Counsel. 2009; 75:141-144.

MEASURING ADHERENCE

• Direct methods– Observing therapy directly– Measurement of drug or metabolite in serum

• Indirect methods– Clinical responses– Patient interviewing, questionnaires– Treatment diary– Refill rate – Pill/medication counting– Electronic monitoring

10Osterberg L, Blaschke T. NEJM. 2005; 353:487-97

LET’S CHAT

• From your own experiences as a patient at one time or another, what caused you to be non-adherent to a medication or regimen?

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BARRIERS TO ADHERENCE

• Patient specific factors– Patient age– Socioeconomic status– Access to health care – Family characteristics (including culture, health beliefs)– Patient and/or caregiver psychosocial issues– Perceived benefit (or lack there of) from treatment

• Medication specific factors– Adverse drug effects– Inconvenience in dosing, lack of palatability

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BARRIERS: INFANTS AND YOUNG CHILDREN

• Caregiver is responsible for medication administration

• Health beliefs of caregivers

• Limited language skills of infants

and young children

(e.g., PRN rescue medication)

13Osterberg L, Blaschke T. NEJM. 2005; 353:487-97Llorente RAA et al. J Cys Fib. 2008;7:359-67Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64

BARRIERS: INFANTS AND YOUNG CHILDREN

• Time consuming treatments (e.g., nebulization)

• Caregiver vs. child – battle for control

• Ease of administration– Palatability – Frequency

• Parental motivation

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BARRIERS: CHILDREN

• Lack of structured home environment– Caregiver and child’s schedules– Behavior and consequence

• Parental motivation– Forgetfulness, stress– Lack of immediate benefit from

chronic treatment– Health beliefs

15Osterberg L, Blaschke T. NEJM. 2005; 353:487-97Llorente RAA et al. J Cys Fib. 2008;7:359-67Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64

BARRIERS: CHILDREN

• Confusion with multiple medications– Multiple drugs of same route, different timing– Multiple pills/doses through out the day– Acute treatment with chronic treatment– Discharge follow-up (or lack there of)

• Perceived efficacy and side effects– Caregiver perception

16Osterberg L, Blaschke T. NEJM. 2005; 353:487-97Llorente RAA et al. J Cys Fib. 2008;7:359-67Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64

BARRIERS: ADOLESCENTS

• Increasing independence, self-administer medication

• Some of the same factors as children (e.g., home environment)– Lack of structured home environment– Confusion with multiple medications– Perceived efficacy and side effects

17Osterberg L, Blaschke T. NEJM. 2005; 353:487-97Llorente RAA et al. J Cys Fib. 2008;7:359-67Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64

BARRIERS: ADOLESCENTS

• Depression and high-risk behavior– Triad of behavior – depression, unhealthy behavior,

non-adherence

• Peer pressures, acceptance– Medication use in school, social events, etc.

18Osterberg L, Blaschke T. NEJM. 2005; 353:487-97Llorente RAA et al. J Cys Fib. 2008;7:359-67Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64

LET’S CHAT…

• Of the discussed barriers for medication adherence, which have you noticed in your experiences at the clinic?

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HEALTH BELIEF THEORIES

• Application in chronic conditions such as asthma, CF, attention deficit hyperactivity disorder

• Health Belief Model– Focus on patient’s and caregiver’s assessment of:

• Seriousness of disease • Perceived benefit from treatment

• Planned Behavior Model– Address subjective norm (e.g., peer pressure)– Move towards accepting treatment

US Department of Health and Human Services, National Institutes of Health. Theory at a Glance: Application to Health Promotion and Health Behavior. Second Edition, 2005. Available at: www.cancer.gov/cancertopics/cancerlibrary/theory.pdf. Accessed May 1, 2011.

PREDICTORS OF POOR ADHERENCE

• Presence of psychological problems, particularly depression

• Presence of cognitive impairment• Treatment of asymptomatic disease• Inadequate follow-up or discharge planning• Side effects of medication

21Osterberg L, Blaschke T. NEJM. 2005; 353:487-97

PREDICTORS OF POOR ADHERENCE - CONTINUED

• Patient/caregiver lack of belief in benefit• Patient/caregiver lack of insight into illness• Poor provider-patient relationship• Presence of barriers to care or medications• Missed appointments• Complexity of treatment• Cost of treatment

22Osterberg L, Blaschke T. NEJM. 2005; 353:487-97

INTERACTIONS & ADHERENCE

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ADHERENCE IS GOOD!

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STUDIED STRATEGIES - ASTHMA

• Electronic monitoring and feedback (MDILogII™)– Monitors MDI inhalers, provided feedback to parents

bimonthly

• School-based supervised asthma therapy– School official observes student self-administer

controller medication

• Home based education + adherence feedback– 5 home visits with asthma educators +/- feedback

25Spaulding SA et al. J Pediatr Psychol. 2012;31:64-74Gerald LB et al. Pediatrics. 2009; 123:466-74Otsuki MO et al. Pediatrics. 2009; 124:1513-21

STUDIED STRATEGIES - CF

• Adaptive aerosol delivery (AAD)– Nebulizer device w/ electronic capabilities to monitor

when it is used, for how long, and if full dose taken

• Automated medication dose reminder– Customized pagers, text messages

• Cell Phone Intervention (CFFONE™)– Web-enabled cell phone – Reminders with CF information and support

26McNamara PS et al. J Cys Fib. 2009; 8:258-263Johnson KB et al. J Telemed Telecare. 2011; 17:387-391Marciel KK et al. Pediatr Pulmolol. 2010;45:157-64

LET’S CHAT…

• Of the discussed studied strategies, which of them do you think are/are not practically feasible for real-world application? Why?

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PRACTICAL STRATEGIES

• Patient and family education– Formalized sessions or part of clinic visits

• Medication reminders– Medication list– Cell phone reminders– Alarms

• Simplifying medication regimen• Appropriate drug selection (e.g., ease,

palatability)• Pharmacy reminders for refills

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TOOLS FOR ADHERENCE

• Reminders– Medication Event Monitoring System (MEMS)– Blister packs– Alert watch

• Online resources– MyMedSchedule.com– Smart phone apps

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EXAMPLE OF ADHERENCE TOOL

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WHAT WE ARE DOING…

• Adherence assessment with each clinic visit– Patient “quizzing”– “What, how, when, why” about medications

• Patient and family education as part of clinic visit– “Homework” for older children and adolescents– Empower patient to taken ownership of health and

treatments

• Encouraged use of medication lists– Hard copy, electronic, mobile

• Simplifying medication schedules

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PATIENT MEDICATION LIST

32http://kidsmeds.info/attachments/wysiwyg/1/My_Medication_Information_Sheet.pdf

SUMMARY

• Medication adherence – Rate is worse in chronic illnesses, affects patient

outcomes and health resources

• Depends on various factors– Age, psychosocial, health beliefs, etc.

• It’s not a lone venture– Patient, Caregiver, Health care provider, Support

• There are tools available, studied strategies to help improve adherence– Patient preference, team effort to improvement

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QUESTIONS?

• hphan@pharmacy.arizona.edu

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