WASHINGTON, DC 29 May 2009—Taking recommended medications in accordance with prescribers` instructions is akin to flossing one`s teeth every day—both are tasks that people know they should do but don`t always follow through on, says Cynthia Jackevicius, associate professor of pharmacy practice and administration at the Western University of Health Sciences College of Pharmacy in Pomona, California.
Jackevicius, speaking April 24 at the American Heart Association conference on outcomes research in Washington, D.C., used the flossing example to get health care providers thinking about the patient`s point of view on adhering to medication regimens.
Jackevicius, who works with cardiology patients at a Veterans Affairs health care center in Los Angeles, said the first step in improving medication adherence is simple.
"You have to ask patients if they are adherent," she said. "The asking step is very important, but it`s something we tend not to do."
One way to gauge adherence is to ask patients how often during the past month they took all of their medications, a method Jackevicius said she uses in clinical practice.
Researchers involved with the Heart and Soul Study, supported in part by the National Institutes of Health, found a significant association between medication nonadherence and the subsequent occurrence of cardiovascular events in patients with stable coronary heart disease. The 8.2% of patients who reported taking medications as the physician prescribed 75% of the time or less often had double the other patients` risk for myocardial infarction (MI), stroke, or death from coronary heart disease, according to a report in the September 10, 2007, issue of Archives of Internal Medicine.
The World Health Organization (WHO) reported in 2003 that, in developed countries, medication adherence rates average 50% for long-term therapy for the treatment of chronic conditions. Adherence rates are lower in the developing world, according to WHO.
The National Council on Patient Information and Education (NCPIE), of which ASHP is a member, released an action plan in 2007 with 10 recommendations for improving medication adherence. The document calls for raising awareness of medication adherence as a critical health care issue and mounting a coordinated, multidisciplinary campaign to improve adherence.
Jackevicius said health care providers need to understand whether their patients are nonadherent for "nonintentional" reasons, such as forgetfulness, or "intentional" reasons, such as a belief that the cost of the medication outweighs its benefits.
She described intentional nonadherence as a behavioral issue and nonintentional nonadherence as "process oriented," and she said different approaches are needed to tackle these very different reasons for not taking medications.
"If we don`t really understand the underlying theory, in terms of models [of nonadherence], it`s hard to create interventions that actually fix things," she said.
Jackevicius said at least two studies support the idea of starting medication regimens in certain patients before discharge from the hospital to increase the likelihood that they will continue the therapy.
In the case of cholesterol-lowering medications, "the thought is that if you start a medication in hospital and link it to a cardiac procedure or event, you`re really getting into the behavioral constructs," she said. "And you`re also getting the patient in the habit" of taking the drug.
Jackevicius is the lead author of a 2008 report in Circulation that examined factors associated with the initial filling of postdischarge prescriptions among adults hospitalized after an acute MI.
"We found that the vast majority of prescriptions were filled within seven days, and very few were filled after seven days," she said. Patients whose medical record documented that they had received predischarge counseling about medication indications or adverse effects were more likely to have had those prescriptions filled, and death rates a year after discharge were lower among patients who had their prescriptions filled.
Jackevicius said these findings raise the question of whether such patients should have follow-up within about a week of hospital discharge to ask whether they had their prescriptions filled and to emphasize the importance of taking the medications.
NCPIE`s report notes that poor medication adherence remains a serious public health issue despite at least 30 years of study and debate on the subject. Jackevicius said those three decades of research have produced fairly little consensus on the causes of nonadherence.
Much of this research, she said, has involved single strategies to improve adherence, and most interventions have produced only small improvements.
"It`s not really surprising, because there are so many determinants and potential causes of nonadherence. So we shouldn`t be surprised that if you only do one thing, it`s going to have a smaller effect," she said.
She said there is agreement that poly-pharmacy, poor provider–patient relationships, and patients` use of multiple health care providers contribute to adherence problems.
Health care policy barriers have also been found to contribute to medication nonadherence.
"There is solid work that if you have a copay, and increase the copay, that you decrease adherence and you worsen outcomes," Jackevicius said. But she noted that lowering copayments has not been conclusively found to improve adherence.
She urged health care providers to be aware of cost-related nonadherence.
"It is much higher in the U.S. than elsewhere, especially in uninsured Americans," Jackevicius said. "Almost a quarter of patients report in surveys that they don`t fill a prescription, or [they| miss doses or spread out pills because of cost. So unless we ask...we may not know it`s a problem."
Jackevicius said future studies are needed that look at multiple interventions and that are of sufficient duration to produce lasting improvements in patients` behavior.
"We`re still a long way away, I think, from having really good interventions for improving nonadherence," she said.
