Medication Adherence Crucial to Management of Chronic Disease

Atlanta—Positive clinical outcomes are strongly associated with patient adherence to prescribed drug regimens, particularly for the treatment of chronic diseases. According to the World Health Organization, nearly 50% of Americans do not take medication as prescribed and many discontinue the therapy completely. Approximately 25% of original prescriptions are never filled by patients with chronic conditions such as diabetes and coronary artery disease. Annual costs associated with nonadherence have been estimated by the New England Healthcare Institute as high as $290 billion; the costs arise from increased hospital and long-term care facility admissions and utilization of other medical care for the avoidable complications of uncontrolled disease. At a Contemporary Issues session at the AMCP meeting titled Removing Barriers to Medication Adherence, William Shrank, MD, MSHS, director of Rapid-Cycle Evaluation Group, Center for Medicare & Medicaid Innovation (CMMI), Centers for Medicare & Medicaid Services, presented research from the CVS Caremark Harvard Partnership for Improving Medication Adherence, a multidisciplinary initiative aimed at improving patient adherence rates. Dr. Shrank titled his presentation “Developing Evidence-Based Approaches and Fostering Innovation to Improve Medication Adherence.” Dr. Shrank opened his presentation with a quote from C. Everett Kopp, former surgeon general of the United States: “Drugs do not work in patients who do not use them.” He continued by listing some of the barriers to adherence. At the patient level, barriers include lack of understanding about proper use of the medication, affordability of the medication, side effects, family support, and cognitive limitations. At the physician level, barriers arise from lack of knowledge and communication about drug costs, ensuring patients understand appropriate and safe use of medications, and awareness of patient adherence. At the system level, issues that may lead to nonadherence include access/coverage for the medication, the complexity of formularies, administrative barriers, need for prior authorization, the physician/patient relationship, and health information technology (HIT). Dr. Shrank continued by noting that the increased use of e-prescribing allows measurement of the rates of prescriptions that are written but never filled. This measurement found little variation in fill rates by therapeutic category in a recent study; the overall primary nonadherence rate was 22.1%. Therapeutic complexity has been shown to adversely affect adherence, Dr. Shrank said. The average statin user, for example, takes 11 medications, including 9 maintenance medications, and makes 5 pharmacy visits to fill or refill prescriptions, with half of the refills synchronized; 10% of statin users take ≥23 medications and make ≥11 visits to ≥2 pharmacies, with only 10% of refills synchronized. He said that “simplifying therapy can improve adherence” and that adherence is “greater when patients synchronize refills and fill all their prescriptions at a single pharmacy.” The presentation continued with a discussion of the 4 components of research to help explain patient behavior, with an eye toward developing evidence-based approaches to improving adherence rates: (1) aligning financial incentives, (2) the role of generics, (3) HIT solutions, and (4) social support. One possible scenario of financial incentive is providing secondary prevention medications for free following a myocardial infarction (MI). It is estimated that providing 3 years of full coverage for combination pharmacotherapy to currently insured post-MI patients will, on average, cost an additional $1149 per beneficiary in drug costs while saving $5096 per beneficiary in event-related costs; it would also save 1.1 lives and prevent 13 nonfatal reinfarctions per 100 patients. There are controlled trials planned to test other approaches to financial incentives to improve adherence, Dr. Shrank added. The role of generics has not been fully evaluated; however, it has been shown that using generic drugs can improve adherence to medications for chronic diseases. In a 2006 study, adherence rates for a nonpreferred brand were 52%, compared with 57% for a preferred brand and 59% for a generic drug. However, patient and physician perceptions may affect use of generics, leading to a need for policy changes to increase their use, according to Dr. Shrank. Possible options include tiered benefits with increased copayments for expensive brands, dispense-as-written penalties, and rewarding physicians for cost-effective prescribing. Using HIT solutions such as text reminders and encouragement to refill prescriptions, improved data collection to identify nonadherence, and data feedback loops to providers (giving physicians real-time data when patients do not fill initial prescriptions). Social support includes encouraging the involvement of the family and caregivers in helping patients adhere to their medication regimen. Dr. Shrank concluded his presentation with an overview of CMMI. The purpose of the center is “to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP [Children’s Health Insurance Program]…while preserving or enhancing the quality of care furnished.” He added that chronic medication therapy will be central to any model developed by CMMI and the “opportunities to collaborate have never been greater,” but cautioned that “all the improved chronic disease management in the world will not make a difference if patients go home and do not take their medications.”