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 The leading web portal for pharmacy resources, news, education and careers September 19, 2017
Pharmacy Choice - Medication Adherence Disease State Management - September 19, 2017

Medication Adherence Disease State Management

Review of Poor Medication Adherence
by Darrell Hulisz, RPh, PharmD

Medication adherence has been defined as the voluntary cooperation of the patient in taking medication as prescribed, including proper timing, dosage and frequency.1 Medication non-adherence is defined as taking less than 80% of prescribed doses, but can also include taking too many doses.2 The term adherence is favored over the term compliance since providers, healthcare systems, payers and patients all share responsibility for optimal medication adherence. The term adherence is less subjective than compliance, since the later implies that the blame rests solely on the patient. Thus, medication adherence is the extent to which a patient follows a given therapeutic medication regimen through the intended point of closure, as mutually agreed on in partnership with a healthcare provider.

Medication non-adherence is fairly common and costly. It represents a complex problem to which there is no unified solution. Poor medication adherence is correlated with adverse outcomes, higher costs of care, decreased quality of life, increased mortality, and increased rates of hospitalization and, readmission.2-4 The reported prevalence of medication non-adherence is 50%, and has remained fairly constant.3 Of all medication-related hospitalizations in the US, 33-69% are related to poor medication adherence, costing approximately $100 billion annually.5 An estimated 125,000 deaths per year are attributed to poor medication adherence, and total healthcare spending for patients with poor adherence are almost twice that of patients with high adherence.5,6

Reasons for Poor Adherence: The Patient's Perspective
An intriguing study was conducted by Cheng et al whereby patients (n=821) filling antihypertensive prescriptions were enrolled to identify problems with medication adherence.7 The three most common reasons cited by patients for non-adherence were forgetfulness (54.9%), belief that drugs are not necessary (13.7%), and fear of drug "dependence" (7.3%). Other studies of non-adherence with medications have cited forgetfulness as the most common patent-reported reason for poor adherence.8,9 Medication adherence appears to be a patterned behavior established through the creation of a routine and reminder mechanism for taking medication.

Reasons for Poor Adherence: Summary of Potential Barriers
A number of studies and reviews have examined the correlation between poor adherence and socioeconomic and/or demographic characteristics.10-21 A consistent finding is that similar patient factors are associated with medication non-adherence, including poor socioeconomic status, nonwhite race, poor literacy, and psychiatric disorders, such as depression. Chronic conditions that are asymptomatic, such as hypertension and hyperlipidemia, have also been associated with poor adherence. The complexity of medication regimens and perceived or actual side effects can affect adherence. Although the cost of medications is another important socioeconomic factor, medication non-adherence remains common even when patient cost is not a concern, such as in the Canadian healthcare system or the US Veterans Health Administration.3

Social determinants of poor medication adherence have been extensively reviewed.6 Examples include lack of family and social support, homelessness, cognitive impairment, unemployment, and lack of prescription coverage. Health-system or provider factors can also adversely affect medication adherence. Examples include unclear information about drug administration, lack of patient follow-up, poor provider-patient communication and a distrustful relationship, all of which may reduce the extent to which patients follow medication regimens.

Improving Medication Adherence: Summary of Successful Strategies
A Cochrane review of interventions studied to enhance medication compliance highlights some of the difficulties with interpreting study results.2 For example these studies are usually heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements. Many adherence intervention studies are subject to investigator bias. The Cochrane review is the largest, most comprehensive systematic review of interventions to improve medication adherence based on randomized controlled trials assessing both adherence and clinical outcomes. The Cochrane review includes 182 randomized controlled trials of various adherence interventions, but overall concluded that current methods of improving medication adherence for chronic health problems are mostly complex and not very effective.2 Moreover, even the most effective interventions do not lead to large improvements in adherence or clinical outcomes. Studies of interventions to improve adherence are often complex, involving face-to-face patient encounters with pharmacists, nurses or other allied health professionals. Other interventions are less complex, such as prescription refills monitoring, text messaging alerts, phone call reminders and patient diary use. Overall, there appears to be little difference between the high intensity, face-to-face interventions versus less complex interventions.2

Mobile and Smart Phone Apps to Aid Compliance
A plethora of free smart phone apps are available to assist tech savvy patients with adherence. Examples include MyMedSchedule, MyMeds, RxmindMe, Mango Health Medication Manager, and MedSimple. The reader is referred to a review and ranking of these apps.22 However, none of the apps have been rigorously compared and tested for validity. A number of review articles have supported the potential for electronic interventions, such as mobile phone messaging interventions to provide limited benefit in improving adherence.23-26 Provider feedback on adherence and accompanying counseling informed by recent objective adherence performance seems to increase improve adherence. This underscores the importance of a partnership between the patient and his/her provider. It seems logical that other stakeholders, such as pharmacists and third-party payers could improve adherence by sharing adherence data with providers, though there is limited data to support this.

Medication non-adherence is a common, complex and costly problem to which there is no unified solution. Patients often cite forgetfulness as the primary reason for poor adherence. Clinicians should ask patients to describe a routine or ritual for taking medications. Socioeconomic factors, such as poverty, low literacy, lack of family or social support, homelessness, unemployment, and lack of prescription coverage are associated with poor adherence. Poor medication adherence is common (40-50%) even when medications are available at no cost to the patient. Current methods of improving medication adherence for chronic health problems are mostly complex and not that effective. Even the most effective interventions do not lead to large improvements in adherence or clinical outcomes. A wide variety of smart phone apps are available to assist patients with medication adherence, are typically available free, and should theoretically improve medication adherence over the long term.
  1. Albrecht S. The pharmacist's role in medication adherence. US Pharm. 2011;36(5):45-48.
  2. Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, Agoritsas T, Mistry N, Iorio A, Jack S, Sivaramalingam B, Iserman E, Mustafa RA, Jedraszewski D, Cotoi C, Haynes RB. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2014 Nov 20;11:CD000
  3. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009 Jun 16;119(23):3028-35.
  4. Hincapie AL, Taylor AM, Boesen KP, Warholak T. Understanding reasons for nonadherence to medications in a Medicare Part D beneficiary sample. J Manag Care Spec Pharm. 2015;21(5):391-99.
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  7. Cheng JW, Kalis MM, Feifer S. Patient-reported adherence to guidelines of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Pharmacotherapy. 2001 Jul;21(7):828-41.
  8. Kitney L, Turner J, Spady D, et al. Predictors of medication adherence in pediatric inflammatory bowel disease patients at the Stollery Children's Hospital. Canadian Journal of Gastroenterology. 2009;23(12):811-815.
  9. Nair KV, Belletti DA, Doyle JJ, Allen RR, McQueen RB, Saseen JJ, Vande Griend J, Patel JV, McQueen A, Jan S. Understanding barriers to medication adherence in the hypertensive population by evaluating responses to a telephone survey. Patient Prefer Adherence. 2011 Apr 29;5:195-206.
  10. Davis EM, Packard KA, Jackevicius CA. The pharmacist role in predicting and improving medication adherence in heart failure patients. J Manag Care Spec Pharm. 2014 Jul;20(7):741-55.
  11. Osterberg L. Blaschke T. Adherence to medication. N Engl J Med 2005; 353:487-97.
  12. Maddigan SL. Farrls KB. Keating N. Wlens CA. Johnson JA. Predictors of older adults' capacity for medication management in a self-medication program. J Aging Health. 2003:15:332-5.
  13. Kalichman S, Ramachandran B. Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999:14:267-73.
  14. DeWalt DA. Pignone MP. Reading is fundamental: the relationship between literacy and health. Arch Intern Med. 2005:165:1943-4.
  15. Abel WM, Efird JT. The association between trust in health care providers and medication adherence among black women with hypertension. Frontiers in Public Health. 2013;1:66.
  16. Greenley RN, Kunz JH, Walter J, Hommel KA. Practical strategies for enhancing adherence to treatment regimen in inflammatory bowel disease. Inflamm Bowel Dis. 2013 Jun;19(7):1534-45.
  17. Gatwood J, Bailey JE. Improving medication adherence in hypercholesterolemia: challenges and solutions. Vascular Health and Risk Management. 2014;10:615-625.
  18. Dreer LE, Girkin C, Mansberger SL. Determinants of medication adherence to topical glaucoma therapy. J Glaucoma. 2012 Apr-May;21(4):234-40.
  19. Hyre AD, Krousel-Wood MA, Muntner P, Kawasaki L, DeSalvo KB. Prevalence and predictors of poor antihypertensive medication adherence in an urban healthclinic setting. J Clin Hypertens. 2007 Mar;9(3):179-86.
  20. Celano MP, Linzer JF, Demi A, Bakeman R, Smith CO, Croft S, Kobrynski LJ. Treatment adherence among low-income, African American children with persistent asthma. J Asthma. 2010 Apr;47(3):317-22.
  21. Vrijens B, Antoniou S, Burnier M, de la Sierra A, Volpe M. Current situation of medication adherence in hypertension. Front Pharmacol. 2017 Mar 1;8:100.
  22. Dayer L, Heldenbrand S, Anderson P, Gubbins PO, Martin BC. Smartphone medication adherence apps: Potential benefits to patients and providers. Journal of the American Pharmacists Association: JAPhA. 2013;53(2):172-181.
  23. Demonceau J, Ruppar T, Kristanto P, Hughes DA, Fargher E, Kardas P, De Geest S, Dobbels F, Lewek P, Urquhart J, Vrijens B; ABC project team. Identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: a systematic literature review and meta-analysis. Drugs. 2013 May;73(6):545-62.
  24. Langebeek N, Nieuwkerk P. Electronic medication monitoring-informed counseling to improve adherence to combination anti-retroviral therapy and virologic treatment outcomes: a meta-analysis. Front Public Health. 2015 May 19;3:139.
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  26. de Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Database Syst Rev. 2012 Dec 12;12:CD007459.

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