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Transcript of MPA Adherence Presentation Handout_MCrowe
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I NEVER MISS A DOSE
MEDICATION ADHERENCE FOR THE
PRACTICE OF PHARMACY
Mike Crowe, PharmD
Clinical Pharmacist
My Pharmacist Now, PLLC
Diplomat Specialty Pharmacy
LEARNING OBJECTIVES
At the end of this activity, the participant will be able to:
1. Discuss various measures of medication adherence;2. List several positive and negative factors correlating with
medication adherence;
3. Identify negative outcomes of medication non-adherence; and
4. Describe available tools for predicting and improving apatients medication adherence.
AMERICAS OTHER DRUG PROBLEM1,2
Each year $290 billion is spent onavoidable medical costs due to
medication non-adherence.
Hospitalizations (33-69%)
Preventable adverse drug events (21%)
Deaths (125,000/year)
WHYTHE HYPE?
More available literature
Established benefits for all parties
Involvement of ke stakeholders
Enhanced public awareness
Becoming a market by itself
INCREASING LITERATURE
400%
500%
600%
700%
PubMed Search Term Percent Growth Since 1990
"Adherence"
0%
100%
200%
300%"Hypertension"
"HIV"
BENEFICIALTO ALL PARTIES3,4
Hypertension $3.98
Medical Costs Reduction forEach Dollar Spent Adhering
Patients
Pharmacies
$0.00
$5.00
$10.00
Diabetes
Hyperlipidemia
$7.00
$5.10anu ac urers
Physicians
Payers
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KEY STAKEHOLDERS INVOLVED5,6
National Council on
Patient Information and
Education issues nationalaction plan, including public
education campaign onmedication adherence
National Consumer League begins researchcampaign with funds from Agency for Healthcare
Research and Quality for public education effort
Centers for Medicare and Medicaid
Services add adherence to lan ratin s
World Health Organization
states increased adherence wouldhave greater impact than any
improvement in medical treatment
2003 2007 2012
Department of Health and Human
Services issues request for information
regarding medication adherence
INTHE NEWS
Non-adherence becoming apparent to:
Patients
Entrepreneurs
A MARKET BY ITSELF4
Lucrative opportunities for:
Wholesalers
o ware an app ca on eve opers
Consultants
QUESTION
JC is prescribed simvastatin 40 mg to be taken once daily. JCtakes the prescription to his pharmacy to have it filled andreceives a 30 days supply of the medication. Thirty days laterhe is out of this medication.
A. JC is adherent
B. JC is non-adherent
C. Cannot tell if JC is adherent
DEFINING MEDICATIONADHERENCE7
The extent to which patients take medications
as prescribed by their healthcare providers.
Often reported as percentage of prescribed doses actuallytaken by the patient over a specified period
Includes proper:
Timing
Dosage
Frequency
TERMINOLOGY DISPUTE7,8
Compliance Adherence
VS.
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ADHERENCE: A COMPLEX PROCESS8
1. Keep scheduled appointment with prescriber
2. Accept a prescription for medication(s)
3. Fill the prescription at a pharmacy
4. Take the medication as prescribed
5. Refill the prescription in a timely manner
6. Return to the provider for necessary monitoring
EPIDEMIOLOGY8
Most common type of non-adherence is error of omission
White coat adherence common
Near perfect adherenceNearly all doses taken with
Missed doses occasionally
with some timing irregularity
Drug holidays 3-4 times/year
with occasional omissions
Drug holidays monthly or
more with frequent omissionsFew or no do ses taken
INTENTIONS BEHIND NON-ADHERENCE9
Intentional
Skipping doses
Taking smaller doses
Altering the dose
70.1%
Previous Six Months
Stopping medication
Unintentional
Forgetting
Running out
Careless about takingUnintentional
Intentional
34.3%
ADHERENCE BARRIERS10
Forgetfulness,30%
Decision to omit,
Lack of
information, 9%
Emotionalresponses, 7%
No reason
provided, 27%
Other priorities,
16%
QUESTION
Direct measures of medication adherence include each of thefollowing except:
A. Observing a patient administer his/her doseB. Measuring the drug levels in a patients blood
C. Checking refill history
MEASURES OF ADHERENCE8,11
Direct methods
Patient self-reports
Pill counts
Assessment of clinical responseElectronic monitors
Physiologic markers
Prescription refill history
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DIRECT MEASURES OF ADHERENCE8,11
Measure Advantages Disadvantages
Direct observance Most accurate
Impractical Patient can hide dose
Ex ensive
Drug assay Objective Metabolic variations White coat adherence Snapshot only
Biologic markers Objective Expensive Snapshot only
SELF-REPORTED ADHERENCE8,11
Advantages
Simple and inexpensive Most useful method in clinical setting
Patient recall makes susceptible to error
Results can be distorted by patient
May create Hawthorne Effect
PILL COUNTS8,11
Advantages Objective
Quantifiable
Eas to erform
Disadvantages Easily altered by patient
No information on other aspects of adherence
Tedious process
ASSESSMENT OF CLINICAL RESPONSE8
Advantages Simple
Generally easy to perform
Factors other than adherence can affect
ELECTRONIC MONITORING DEVICES8,11
Advantages
Precise, more accurate than pill counts
Results easily quantifiable
Tracks adherence atterns
Disadvantages
Expensive
May take wrong amount
Dont always equate to ingestion
Some require downloading of data
PHYSIOLOGIC MARKERS8,11
Advantages Often easy to perform
Disadvantagesar er may e a sen or reasons
other than non-adherence
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PRESCRIPTION REFILL HISTORY8,11
Advantages
Objective Easy to obtain and relatively inexpensive
Avoids Hawthorne Effect
Disadvantages Refill does equate to ingestion or correct dose timing
Requires closed pharmacy system
Does not account for acute treatments
Inaccurate days supply will distort rates
May be overstated early on in therapy due to dose adjustments
MEDICATION POSSESSION RATIO (MPR)12
Most commonly used method for claims-based adherence
May overestimate adherenceReporting measures vary by source
( )
umma on o ays supp y v e y se per o o me
MPR =Sum of days supply for all fills in period
Number of days in periodx 100%
PROPORTION OF DAYS COVERED (PDC)12
More conservative estimate of adherence
Better suited for medication regimens vs. MPR
Endorsed by Pharmacy Quality Alliance (PQA)
Adopted by CMS for plan ratings
( )
Not a simple summation of days supply
PDC =Number of days in period covered
Number of days in periodx 100%
MPRVS. PDC12
Drug 3
Drug 2
Drug 1
Prescription Fill History and Days Supply
30 Days Supply 30 Days Supply 30 Days Supply 30 Days S
30 Days Supply 30 Days Supply 30 Days Supply
30 Days Supply30 Days Supply 30 Days Supply 30 Days Supply
0 10 20 30 40 50 60 70 80 90 100
Drug 4 30 Days Supply30 Days Supply 30 Days Supply30 Days Su
Statistic Drug 1 Drug 2 Drug 3 Drug 4 Regimen
Days Supply (S) 100 90 110 100 n/a
MPR ( S / 100 ) 1.00 0.90 1.10 1.00 1.00
Days Covered (C) 100 90 100 90 n/a
PDC ( C / 100 ) 1.00 0.90 1.00 0.90 0.80
QUESTION
What is the PDC for this patients HIV treatment regimen?
A. 100%
B. 40%
0 10 20 30 40 50 60 70 80 90 100
Drug 3
Drug 2
Drug 1
Prescription Fill History and Days Supply
30 Days Supply 30 Days Supply30 Days Supply
30 Days Supply 30 Days Supply 30 Days Supply
30 D
30 Days Supply 30 Days Supply 30 D
.
PERSISTENCY: PART OFADHERENCE7,11
ADHERENCE
% of doses taken as prescribed
PERSISTENCE
days taking medication w/o exceeding gap
Start Medication or
Observation
Stop Medication or
End Observation
X X X
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WHAT IS OPTIMAL?8
No consensus on optimal adherence level
80% acceptable for many disease states 95% for more serious conditions
One of two oals:
Dichotomous (yes/no to predefined level)
Continuous (0-100%)
CORRELATES TOADHERENCE8,13
Not consistently associated with adherence:
Race Sex
Socioeconomic status
Based around three Cs Commitment
Concern
Cost
COMMITMENT AND COST (+)9
Ranked Quartile
Perceptions
Non-Adherence Rate
Perceived
Need
Perceived
Affordability
1 Absent 75.5% 82.2%
2 (Low) 74.7% 72.9%
3 (Moderate) 70.7% 68.3%
4 (High) 62.0% 59.6%
REMOVAL OF COST BARRIERS (+)14
3.0%
4.0%
5.0%
Effects of a Value-Based Insurance Design
0.0%
1.0%
2.0% Over 1 Year
Over 2 Years
NEGATIVE ADHERENCE CORRELATES2
National Council of Patient Information and Education
1. Poor patient/provider communication
2. Unresolved patient concerns
3. Provider issues4. Special patient population issues
5. Regimen related barriers
6. Environmental barriers
POOR PATIENT-PROVIDER
RELATIONSHIP (-)8,15,16
Non-adherence commonly caused by misunderstandings
Providers less satisfied with job have less adherent patients
Most important components of relationship
Trust Communication
Caring
Patients must be able to
Ask questions
Voice concerns
Collaborate on plan
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PERCEIVED CONCERNS (-)9
Examples
Perceptions about the seriousness of the illnessDisagreement with the diagnosis or treatment
Ranked Quartile
Perceived ConcernsNon-Adherence Rate
1 (Absent) 61.3%
2 (Low) 70.7%
3 (Moderate) 73.6%
4 (High) 77.6%
COMPLEXITY OFTREATMENT (-)17
Regimen
Frequency
Mean
Compliance (%)
Standard
Deviation (%)Range (%)
1 dose/d (QD) 79 14 35-97
2 doses/d (BID) 69 15 38-90
3 doses/d (TID) 65 16 40-91
4 doses/d (QID) 51 20 33-81
QD versus TID, p = 0.008
QD versus QID, p < 0.001
BID versus QID, p = 0.001
QUESTION
Medication non-adherence can lead to which of the followingnegative outcomes?
A. Reduced quality of life for the patient
B. Strained patient-provider relationship
C. Both A and B
NON-ADHERENCE NEGATIVE OUTCOMES16
Patient and physician frustration
Misdiagnosis
Unnecessary treatment
Exacerbation of disease
Failure to receive quality awards for performance
HIV/AIDS5,8,18
Challenges
Side effects or fear of side effects
Co-morbidities
Fewer healthcare options
Unforgiving medications
High pill burden
Stigma
Resistance and treatment failure
Opportunistic infections
Specific improvement considerations
Establish family and friends support system
Patient education on relation between adherence and viral load
Simplifying regimen (remove food and storage restrictions)
Regularly assess and manage side effects
CARDIOVASCULAR DISEASE4,8,19
Challenges
Often asymptomatic
Multiple medications required
Poor outcomes Hospitalization
Death
Improvement considerations
Self-monitoring of blood pressure
More forgiving antihypertensives
Combination antihypertensives
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PEDIATRIC PATIENTS8,20,21
Challenges
Childs cooperation
Reliance on guardian
Lifestyle issues
Uncontrolled/uncured disease
Antibiotic resistance
Specific improvement considerations
Token reinforcement system
Use more palatable medications
Involve family members, schools, and other social supports
Provide written support materials
Pill swallowing training
Challenges
Side effects
Dosing requirements
Poor outcomes
Silent disease
Misconceptions about treatment
OSTEOPOROSIS15,22,23
-
Adherence reduced risk of hospitalization due to fracture by 20-30%
Specific improvement considerations Allowing patient to decide frequency of dose
Interventions to correct misconceptions
Providing individual treatment plan
Show patients evidence of need for treatment and positive results
DIABETES18,24,25
Challenges
Multiple comorbidities/medications (statin, antihypertensives)
Poor outcomes
Adherence < 80% linked to increased blood pressure , A1C, LDL
, , -
Adherent patients have $4,000 less annual medical costs
Specific improvement recommendations
Involve patient and family in education and treatment goals
Establish collaborative patient-provider relationship
Simplify medication regimen
GERIATRIC POPULATION1,26
Non-adherence related to 21.1% of avoidable ADEs
Geriatric patients base prescription importance on
Drug-related factors
Patient-related factors
External factors
Higher importance associated with higher worth
ADHERENCE PREDICTION TOOLS13
Over 25 adherence screening tools
Goal is to create efficiency through targeted interventions
Predictive evidence is lacking
MORISKY SCALE27
First developed and tested in 1986
Studied in many disease states
Question Answer
Do you ever forget to take your medicine? Yes/No
Are you careless at times about taking your medicine? Yes/No
When you feel better do you sometimes stop taking your medicine? Yes/No
Sometimes if you feel worse when you take the medicine, do you stop? Yes/No
Score 1 for each Yes; 0 = high; 1-2 = intermediate; 3-4 = low adherence
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ADHERENCE ESTIMATOR13
Developed by Merck in 2009
Assesses three Cs Commitment
Concern
Measure Low Risk Medium Risk High Risk
PDC (median) 0.655 0.598 0.484
MPR (median) 0.912 0.909 0.866
IMPROVEMENTTOOLS
Memory aids and devices
Applications and software for patientsRefill synchronizing programs
Forgiving medications
TECHNOLOGY25,28,29
Allows for patient-centered applications with
Medication reminders
Refill request function
Drug information access
ex message remn er su scr ers
Overall PDC improvement of 8% vs. nonusers
Online prescription management account enrollees
Overall PDC improvement of 18.74% vs. nonusers
REFILL SYNCHRONIZATION PROGRAM30
Simplify My Meds
National Community Pharmacists Association
Allows pharmacies to synchronize patient refills
Functions with iPad application, reminds staff
Check need for prior authorization
Check inventory
Check refills
Prepare refills
MOTIVATIONAL INTERVIEWING31
A directive, patient-centered counseling style for
eliciting behavior change by helping patients to
explore and resolve ambivalance.
A way of breaking down barriers
An approach shaped by understanding what triggers change
Not just a set of techniques
Validated in clinical trials to improve adherence
MEMORY AIDS/DEVICES4
Alarm devices
Automatic delivery to home
Pill boxes and multi-dose envelopes
CalendarsStrategic placement of medication
Patient diaries
Refill reminders (letters and calls)
Tokens or rewards
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FORGIVING MEDICATIONS32
For patients still struggling with adherence
Consider drug, disease, and formulation
Medications post-dose duration of beneficial action (D)
Prescribed dosing interval (I)
Forgiveness (F)
NO SINGLE APPROACH FORALL8
Provide education for patients and family members
Improve dosage schedules with pill boxes, simplifying theregimen, providing cues to remind patients of doses
Increase availability of appointments, make follow-upappon men s convenen an e cen
Improve communication between healthcare providers andpatients, including pharmacists
CONCLUSION
Medication adherence is a serious and costly problem
Non-adherence leads to many negative outcomes
Understanding how to measure adherence can help
eat care provi ers assess w en non-a erence is an issue
Using predictors of non-adherence and tools for improving
adherence, pharmacists can positively impact patient
outcomes
REFERENCES
Please refer to handout.
QUESTIONS
Please feel free to contact me with any questions.
Mike Crowe, PharmD
mcrowe m harmacistnow.com810.399.7589
POST-TEST QUESTION 1
True or False. Medication possession ratio (MPR) is morelikely to overestimate adherence than the proportion of dayscovered (PDC).
A. rue
B. False
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POST-TEST QUESTION 2
Which of the following has NOT been shown to correlatewith poor medication adherence?
A. Perceived concerns
B. Sex of the patient
C. Complexity of the regimen
D. Poor patient-provided communication
POST-TEST QUESTION 3
Which of the following is the least appropriately matchedspecial population with outcome of non-adherence?
A. Osteoporosis: increased fracture risk
B. HIV/AIDS: opportunistic infection
C. Diabetes: increased medical costs
D. Heart failure: amputation
POST-TEST QUESTION 4
Technologically-based interventions that have shown toimprove medication adherence include:
A. Text-messaging services
B. Online prescription management accounts
C. Electronic reminder devices
D. All of the above
POST-TEST QUESTION 5
Research has shown that medication non-adherence can befully corrected in all patients through which of the followinginterventions?
A. o-pay ass stance car s
B. Reducing medication dosing frequency
C. Synchronizing all medication refills
D. None of the above
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INeverMissaDose:MedicationAdherenceforthePracticeofPharmacy
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