Promoting Adherence to Therapy

Like leading the proverbial horse to water, physicians can write a prescription for treatment, but they have limited control over patient follow-through. This is not only frustrating for doctors and detrimental to patients, it also places an economic burden on our healthcare system. A new report conducted by the New England Healthcare Institute (NEHI) found that not taking medications as prescribed leads to poorer health, more frequent hospitalization, a higher risk of death and as much as $290 billion annually in emergency room visits and other avoidable medical expenses in the United States.¹ Non-adherence also causes 125,000 deaths annually and between 10 percent and 25 percent of hospital and nursing home admissions.² With such dire consequences, it begs the question: Why would a patient resist treatment knowing it could ultimately prolong illness or delay recovery? Unfortunately, there are no simple answers, nor is there a one-size-fits-all solution.

Understanding Non-Adherence

Studies show that when patients admit to non-adherence, the most common excuses include fear of unpleasant side effects, cost of medication, confusion about instructions, forgetfulness, language barriers and feeling “too good” to need medicine. Surprisingly, those with chronic conditions like diabetes and high blood pressure are among the groups that are least likely to follow their medication regimen. A recent report by the World Health Organization (WHO) revealed that 50 percent of patients with chronic disease do not take their medication as prescribed.³ In response, some organizations like NEHI are urging the federal government to make the issue a part of the national healthcare reform debate.

“If physicians and other care providers are reimbursed for better health outcomes, we believe that will go a long way toward driving adherence, because providers will have incentives to invest in the time and resources and counseling and technology and other tools that are really needed to educate patients and, in some cases, to change their behavior and to really move the needle on adherence,” NEHI Executive Director Valerie Fleishman told the Boston Globe in a recent interview.

Lack of coordination of care also can be a factor affecting medication adherence. Patients with coexisting conditions may take multiple medications prescribed by different physicians, creating a level of complexity the patient may not be equipped to handle, and a need for a level of case management that is typically not available. To adequately address this need, a physician would likely need to invest substantial time and effort gathering information and data and/or utilize electronic record sharing, which is currently not widely available within the U.S. And without the reimbursement incentives mentioned earlier, physicians with busy caseloads are unlikely to be motivated to spend a lot of time and effort compiling such data.

Pursuing a Multipronged Solution

Medication non-adherence can take a variety of forms, including not having a prescription filled, taking an incorrect dose, taking a medication at the wrong time, forgetting to take doses, or stopping therapy too soon. In understanding the full scope of the problem, it’s important to note that medication non-adherence is not the only form of non-adherence impacting patient outcomes. Patients can also suffer when they avoid making recommended lifestyle changes, such as dietary improvements, exercise or smoking cessation. Others may neglect nonpharmacologic interventions, such as physical therapy. Because the problem is more complex than simply convincing someone to take a pill at prescribed intervals, a successful solution will require a multipronged approach.

A look at some of the integrated healthcare delivery systems that are effectively implementing this type of approach could provide a glimpse into how other stakeholders might tackle the issue. Community Care of North Carolina (CCNC), Geisinger Health System in Pennsylvania and Group Health Cooperative in Washington state and Idaho are three organizations that are already making inroads.

CCNC, a loose affiliation of 14 physician networks serving Medicaid and uninsured patients, has launched the Pharmacy Home Project, a plan that pays participating physicians a monthly fee for coordination of care. Adherence is promoted through the use of case managers, who are embedded throughout the networks, and clinical pharmacists, who serve multiple physician practices on a rotating basis. The program also collects data on patient medications from multiple sources, including medical charts, claims records and records of prescriptions filled to provide prescribers with complete and accurate data. Under this program, CCNC has achieved a 5 percent to 7 percent increase in adherence rates.

At Geisinger, each patient’s medication preferences are gathered via electronic survey prior to their physician appointment. This simple step streamlines doctor visits and makes follow-up easier. Geisinger also has a medical homecare model that requires nurses to actively follow up with patients to monitor medication use and answer questions or concerns, giving patients one less excuse for skipping their medications. The organization also has made changes to its own employee health benefits by reducing copayments and deductibles for medications for chronic conditions. Geisinger reports that it has reduced monthly costs as much as 7 percent.

Group Health Cooperative provides an extra layer of patient-centered support, employing nurse case managers who work closely with patients to encourage medication adherence. Case managers also focus on patient education and troubleshooting that includes sourcing more affordable options for prescriptions. The Group Health Cooperative reports that the results have included annual savings — representing avoided healthcare costs — of more than $476 per participant.

All of these organizations have been successfully leveraging information technology and patient data, while focusing on customized interventions tailored to patients’ individual needs. They also offer trained follow-up care designed to improve adherence. While these models do not address all of the issues involved in non-adherence, they do offer encouragement that cost-effective strategies are available.

Innovative Medication Management

Implementing technology platforms for patients and providers has the potential to dramatically improve patient outcomes and adherence. A recently published study in the American Journal of Managed Care revealed that health management technology promotes medication adherence, and that electronic health records are an effective and low-cost method of ensuring that patients remember to take their prescribed medicine.⁵ Researchers from CVS Caremark and Brigham and Women’s Hospital, Harvard University, collaborated over a period of three years to review medical journal articles on the impact of technology. They examined more than 7,000 papers published between 1966 and 2010 that discussed the use of healthcare management technology on disease management efforts, particularly for patients with diabetes and cardiovascular disease. In a statement published Dec. 28, 2010, senior author William H. Shrank noted: “This review suggests that health information technology interventions are promising tools in the fight to improve medication adherence. While there have been many studies on the subject of boosting adherence, we were surprised to find so few on the topic of using health information technology to accomplish this goal.”

From cell phone apps to texting bottle caps, savvy inventions are making medication adherence easier for practitioners and the patients they treat. Electronic Medical Software, which is used to track patients’ follow-up activity, adherence and progress, also can set up clinical alerts to notify the provider about drug interactions, allergies and other concerns. A notable feature of Electronic Medical Software, ePrescriptions also can boost adherence; for one thing, the prescription is transmitted directly to the pharmacy and is ready by the time the patient arrives. With ePrescriptions, the patient also receives detailed written instructions that can eliminate the confusion that sometimes sets in between the doctor visit and the prescription pickup.

Technology is making advances in hospital settings as well. In February of this year, LodgeNet Healthcare launched a new application for the hospital room that allows nurses to assign personalized patient video education based on diagnoses and medication treatment plans. The Assigned Education application is accessed via the television in a patient’s room, and provides critical information about a patient’s illness, medication and discharge instructions.

Wireless health tools and services are becoming increasingly popular ways of helping people follow their medication regimens. The Pill Phone, a patented mobile medication reminder software that is available on many wireless phones, is the only wireless application to have FDA approval for medication management. The app acts as a comprehensive drug resource based on the best-selling guide The Pill Book, by Harold M. Silverman.

The TabSafe smart pillbox is another innovation making headlines. This gadget provides visual and auditory medication reminders and has been very popular among seniors in assisted-living facilities. To use, patients press a button to dispense the correct pills and a text message is sent to predetermined recipients — perhaps a physician or family member — to confirm the pills have been dispensed.

GlowCaps by Vitality are the smart phone equivalent for prescription meds. These caps attach to standard pill bottles and connect to a cellular network. When it’s time to take medication, they flash and play a sound. They also connect to wireless reminder light plugs and can call a phone. Additionally, they order refills when necessary and send a weekly report to the user and their doctor.

If you think smart bottle caps and texting pillboxes sound futuristic, how about “smart pills”? Sensor technology combined with intelligent medicine technology could serve as the ultimate solution to medication adherence issues in the near future. Proteus Biomedical has developed technology that actually can be embedded into pills; the company envisions a patient’s physicians and caregivers will be able to confirm the medication was taken, and even track the patient’s respiration, heart rate and body temperature from their mobile phones. Proteus expects the technology to be commercially available in the U.S. within the next three years.

For those with chronic illness, there are disease-specific adherence support tools. The FactorTrack Mobile App by Bayer HealthCare Pharmaceuticals is a customizable application for hemophilia patients that can be programmed to provide infusion reminders. The app also tracks and records infusions to provide streamlined recordkeeping. And, at NuFACTOR Specialty Pharmacy headquartered in Temecula, Calif., patients can log on to the company’s website and access a menu of helpful tools tailored to the needs of patients requiring immune globulin infusions. Downloadable tools include an IG Treatment Tracker, Health Diary, Infusion Log and Medical Emergency ID Cards.

The Role of Communication in Adherence

For physicians, understanding the doctor/patient dynamic can go a long way toward improving adherence. The reality is, patients are not always completely truthful with their physicians and may avoid admitting they’ve missed or skipped medication dosages. The psychology behind this behavior lies in the way doctors are seen as authority figures; no one likes to be viewed as a “bad patient.” To get around this hurdle, physicians might try the following communications techniques:

• Rather than asking if a patient has been taking medication as prescribed, ask how much medication they take and how frequently they take it; then compare the answer with the prescribed dosage.
• Provide clear instructions. Sometimes non-adherence stems from confusion. Speaking slowly and having the patient repeat back instructions can be helpful. Emphasizing how long a medication should be taken also is important.
• Ask if cost is an issue. Keep in mind a patient might be embarrassed to tell you that they cannot afford their medications. For patients with insurance, prescribing the first- or second-tier medications avoids large out-of-pocket expenses.
• Discuss side effects. Detail the common side effects with the patient, addressing any fears they may have. Remind patients that the risks from active disease are higher than the adverse medication reactions.
• Touch on long-term positive benefits. Cost-effectiveness studies have demonstrated that staying on medications is ultimately cheaper than active disease; in today’s economy that might be a motivating factor for some patients.

Adherence = Better Outcomes

Medication non-adherence is a pressing concern within the healthcare community, and one of the lesser-known issues impacting healthcare reform. Whether patients are tackling obesity, chronic disease or an infection requiring a course of antibiotics, encouraging adherence can produce better outcomes and literally save lives. And looking to the future, improving patient adherence to therapy will ultimately require updates in healthcare delivery models, investmentsin information technology systems and improved health plan designs focused on targeted, patient-centered care.