Improving Medication Adherence for Better Health, Lower Costs

San Antonio—With rising drug prices and an increase in the diagnosis of chronic conditions, patients must take their medications to improve their health and keep long-term healthcare costs down. Healthcare professionals have attempted numerous interventions to convince people to use their medications as prescribed.

Although most of the initiatives are simple, a high percentage of people do not adhere to their medications. In fact, nonadherence costs the US healthcare system $320 billion per year, according to Josh Benner, PharmD, president and chief executive officer at RxAnte, Inc., a healthcare analytics firm. He spoke at the AMCP meeting during a session titled How Can Managed Care Plans Manage Medication Adherence?.

“[Nonadherence] is one of the biggest missed opportunities in healthcare today,” Dr. Benner said.

Michael Fischer, MD, associate physician in the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital in Boston, Massachusetts, said research has consistently shown that most people do not take their medications as providers intended. The problem is consistent across all conditions, including cardiovascular disease, HIV, and gastroenterology. “[Nonadherence] is ubiquitous across all drug classes,” Dr. Fischer said.

Dr. Fischer mentioned a retrospective cohort study of 34,501 people in New Jersey who were at least 65 years of age, began treatment with statins between 1990 and 1998, and who were followed until death, disenrollment, or December 31, 1999 [JAMA. 2002;288(4):455-461]. The authors defined persistence as the duration of time the patients continued to fill their statin prescriptions. They found that 26% of patients took their treatment regimens at a high level after 5 years, much lower than indicated in previous trials that had 5-year discontinuation rates of 5% to 30%.

In addition, Dr. Fischer discussed a study in which he and his co-authors evaluated 75,589 patients who were treated by 1217 prescribers in the first year of a community-based electronic prescribing initiative [J Gen Intern Med. 2010;25(4):284-290]. They found that 78% of prescriptions were filled, including 72% of new medications. The highest rates of nonadherence were for first-time medications intended to treat hypertension, hyperlipidemia, diabetes, and other chronic conditions.

Nonadherence leads to a worsened health status and quality of life, an increase in hospitalizations and morbidity, and avoidable costs of more than $100 billion per year, according to Dr. Fischer. There are also additional indirect costs, such as lost productivity at work. “We have a really substantial problem here,” Dr. Fischer said.

Still, it is a complicated issue that is not an easy fix. Dr. Fischer said providers may misdiagnosis a condition, prescribe the wrong medications, or tell patients to take too many or too few drugs. Patients may mistrust their physicians or the medications prescribed and also may be distracted by other priorities in their life.

Dr. Fischer cited an article that noted that nonadherence arises from poor communication between providers and patients and troubles that providers and patients have interacting with the healthcare system [N Engl J Med. 2005; 353(5):487-497]. The authors noted that patients who are nonadherent to their medications may not understand the disease or the risks, benefits, and proper use of the treatments they are taking. Patients may also miss appointments, receive poor treatment from providers or other medical personnel, have trouble paying for medications, and face issues with drugs being switched on their formularies. Providers, meanwhile, may not understand the costs of the drugs they are prescribing or have knowledge of insurance coverage or formularies that may lead to patients not being able to afford or use the medications.

Some ideas that Dr. Fischer offered included providing patients with printed prescriptions and making it easier for patients to access their medications. He added that that the most effective modes of delivering adherence interventions are when a nurse or pharmacist visits the hospital, when pharmacists discuss proper use with patients when they pick up their medications, and when patients are sent reminders via text messages, email, and electronic pill bottles. However, he noted that many successful adherence interventions have not been adopted because they are costly and complex, whereas the less intensive interventions are not typically effective. “There are a large number of solutions that are simple and obvious and wrong,” Dr. Fischer said.

Dr. Benner said increasing rates of adherence is difficult because most interventions are delivered after people stop taking their medications instead of before they begin treatment. In addition, the best interventions, such as seeing a physician or pharmacist in person or having access to care managers, are also the most costly. “This is a business problem that makes improvement so hard,” Dr. Benner said.

Dr. Benner cited an article from Lisa Rosenbaum, MD, and William H. Shrank, MD, both of whom made a few suggestions on improving adherence [N Engl J Med. 2013; 369(8):694-695]. They mentioned linking adherence to accountable care delivery models, coordinating interventions between doctors, pharmacists, and pharmacy benefit managers, using predictive models to target provider efforts to the right patients, providing real-time feedback to providers with regards to electronic prescribing and claims data, and implementing risk-adjusted performance measures.

“Whether patients take their medications is ultimately up to them, but physicians’ professional responsibility entails both a willingness to help people in need and a constant effort to do better,” Dr. Rosenbaum and Dr. Shrank wrote. “When it comes to medication adherence, what we are doing now is not cutting it. Though as individuals we may feel ill-equipped to transform patients into “pill people,” as a community we face an opportunity to develop better ways of caring for patients even when they're out of our sight.”