The New England Healthcare Institute estimated that medication non-adherence in the United States contributes to approximately 125,000 deaths and costs the health care system $290 billion each year. Patients skip their medications for a variety of reasons. They might forget to take their medications or elect not to take them due to side effects. Sometimes patients take their medications on time, but are not taking them correctly. Medication adherence is an important factor in decreasing morbidity and mortality and steps need to be taken to increase compliance.

Counsel upon Discharge and First Fill

A study by Makaryus et al found that less than 50 percent of patients were able to list all of their medications or describe what they were being used for. This suggests that patient education can play a role in medication adherence. Doctors and pharmacists should discuss medications and their purpose when a patient is discharged from a hospital or getting a medication for the first time. Patients that are well informed about their medications are more likely to continue taking them. This idea is supported by a study by Jackevicius CA et al that showed discharge counseling was associated with improved adherence after hospital discharge for myocardial infarction (heart attack). Counseling also provides an opportunity to improve the patient-provider relationship which is also a factor in medication adherence.

Decrease Dosage Frequency

A successful strategy to increase adherence is to reduce the number of daily doses of medications. In one study compliance decreased from 79% with once daily dosing to 65% with three times daily dosing. Four times daily dosing resulted in a 51% compliance rate. Once and twice daily dosing had similar compliance rates. This study confirms that adherence increases with less frequent daily dosing.

Motivational Interviewing

Motivational Interviewing can help increase drug adherence. Motivational interviewing is a style of counseling and psychotherapy designed to help patients commit to changing their behavior. The therapist and patient have an open discussion and the patient must decide how ready he or she is to change. The studies for this strategy have not demonstrated a significant benefit. More studies are needed to make a conclusion about its effectiveness. For more information about Motivational Interviewing click here.

Pill Boxes and Blister Packs

A proven method of increasing adherence is packing medications into special containers such as pill boxes or blister packs. These pill boxes and blister packs provide a convenient way for patients to organize their medications and remember to take them. One study observed adherence in HIV patients who used pillbox organizers. Pillbox use was estimated to improve adherence by 4.1%–4.5%.

Automated Phone Calls

Phone calls to remind patients to pick up their medications can improve adherence. Kaiser Permanente in Southern California found that automated phone and mail reminders increased the percentage of patients who picked up their prescriptions from 26 to 42 percent.

Smart Phone Apps

A more recent technological advancement in this field is smart phone apps. There are several apps for smart phone users that can help patients remember to take their medications. Some helpful features on these apps include alarms that go off when medications are due, instructions on how to take the medication, refill reminders, and a place to store doctor and pharmacy phone numbers. Patients can simply input medications as they are prescribed and the app will do the remembering for them.

Medication Therapy Management (MTM)

In order to achieve greater adherence, a multimodal course of action needs to be taken. Medication Therapy Management is collaboration among health care professionals in order to optimize medication use and improve patient outcomes. This is a method of patient-centered care that focuses on a patient’s whole medical profile rather than on a single drug.

A pharmacist’s role in MTM is to reconcile medications and look for potential medication related problems, optimize therapy, and offer solutions. Through the systematic process of medication therapy review, the pharmacist verifies that all prescribed medications are appropriate and addresses any adverse effects that the patient might be experiencing. If any error is seen in the patient’s medication profile, the pharmacist would contact the physician and make appropriate recommendations. The pharmacist would also follow-up with the patient to assess their health status. Not only does this improve the patient-pharmacist relationship, but this type of medication review can decrease drug errors, prevent medication related adverse effects, and increase adherence.

The benefits of a patient-centered care model were demonstrated in the Ashville project when two employers in Asheville, North Carolina implemented this type of service for their diabetic employees. Total health care costs decreased by 28% in the year that the program was implemented compared to the previous year. The number of days diabetic employees were absent from work decreased by 52% from the previous year. These results underline how MTM improves health status through increased adherence and reduces healthcare costs.

References:

APhA. Medication Therapy Management in Pharmacy Practice: Core elements of an MTM Service Model. Version 2.0. APhA. 2008: 1-19.

Claxton AJ, Cramer J, and Pierce C. A Systematic Review of the Associations Between Dose Regimens and Medication Compliance. Clinical Therapeutics. 2001; 23(8):1296-1310.

Cranor CW, Bunting BA, Christensen DB, et al. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003; 43(2):173-84.

Ho PM, Bryason CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119: 3028 3035.

Jackevicius CA, Li P, Tu JV. Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction. Circulation. 2008;117: 1028–1036.

Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge.Mayo Clin Proc.2005;80:991–994.

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Petersen ML,Wang Y, van der Laan MJ, et al.Pillbox Organizers are Associated with Improved Adherence to HIV Antiretroviral Therapy and Viral Suppression: a Marginal Structural Model Analysis.Clin Infect Dis.(2007)45 (7):908-915.

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