WASHINGTON, D.C. 14 August 2009—A panel of more than 40 health care stakeholders with an interest in medication adherence described a flawed prescribing process that makes it difficult for patients to take their medications as directed.
Led by the National Consumers League (NCL), the Pharmaceutical Research and Manufacturers of America, GlaxoSmithKline, and the National Association of Chain Drug Stores Foundation, the stakeholders held a daylong conference July 15 in Washington, D.C., to discuss medication adherence and promote policies to improve adherence rates.
According to the sponsoring organizations, up to 80% of patients may fail to take their medications as prescribed, resulting in hundreds of billions of dollars in excess medical costs each year.
Walid Gellad, associate scientist at the RAND Corporation, presented an overview of published data on the causes of medication nonadherence. Among the 67 reports that were analyzed for the review, cost sharing by patients emerged as the biggest contributor to nonadherence, affecting patients` ability to have an initial prescription filled, purchase refills, and use the medications as directed.
Regimen complexity was the next-largest barrier, although the actual number of medications prescribed for the patient did not affect adherence. But adherence was influenced by patients` beliefs about medications, such as whether patients think a medication is actually necessary or are worried about drug-related adverse events.
Gellad said developing policies that tackle these contributors to nonadherence should be a priority for health care reform decision-makers.
Patient-centered care. Miryam Frieder, associate director at Avalere Health LLC, reviewed findings from a survey of existing medication management programs.
"What we heard a lot was that the reasons for nonadherence are patient specific," Frieder said, explaining that interventions to improve adherence need to be tailored to each patient.
Frieder, citing comments from the survey, said nonadherence ultimately stems from poor communication among health care providers, care programs, and patients.
The breakdown in communications means that prescribers "have no idea what their patients are actually taking," Frieder said.
She said adherence interventions typically start by getting a complete list of prescription, nonprescription, and herbal remedies the patient uses. Working closely with the patient, the regimen is reviewed and optimized for that person`s medical needs, lifestyle, and preferences.
She said some intervention programs that were studied rely on "the pharmacological expertise of a pharmacist to actually review the drug regimen," but others use nurses or case managers in this role.
A controversial undercurrent among some survey respondents, Frieder said, was "whether physicians have, in fact, the necessary skill or knowledge to manage a drug regimen for a complex patient" or if pharmacists may be better suited for the task.
Lawrence Brown, director of the University of Tennessee (UT) Center for Medication Therapy Management at the UT College of Pharmacy, said that improving medication adherence is part of a larger patient care issue.
"We want to improve adherence for the purpose of improving health outcomes," Brown said. "That really is the end goal."
Brown said pharmacy students who take his required course in medication therapy management (MTM) are taught to fully engage their patients in medication decisions. He said students need to understand that "the ultimate decision-maker, when it comes to medications, is the patient."
"The prescriber can write a prescription, the pharmacy can fill it, but when it`s home and in front of the patient, they`re the one that decides whether to put it in their mouth," Brown said.
Bruce Berger, head of the Department of Pharmacy Care Systems at Auburn University in Alabama, said pharmacy education has mostly ignored the reality that patients make their own decisions about their medicines.
"What we`ve done is continue to load people up in the clinical area," Berger said about pharmacists` education. "The training involved assumes that only the health care provider is an expert, and...ignores the patient as also being an expert—an expert on whether they want to do any of this stuff, an expert on how they make sense of things, an expert on how their managing this illness fits into their life."
Berger warned against making assumptions about therapy without conferring directly with patients. For example, he said, a health care provider may decide that replacing a patient`s two-drug regimen with a combination product will simplify treatment and improve adherence. But if the old drugs were generics and the combination is a brand-name product, the patient`s copayment could increase enough to make the regimen unworkable.
Berger has long been a proponent of motivational interviewing as a way for health care providers to connect with their patients and help them reach their health goals. He and two colleagues developed the Motivational Interviewing Training Institute, which offers intensive training in ways to help patients set and meet treatment goals.
"There`s a lot of literature now on motivational interviewing and health behavior change that shows that it produces better outcomes [and] lower health care costs [than] the biomedical model we`ve been stuck in for years," Berger said.
The road ahead. The stakeholders considered five preliminary policy recommendations, one of which was to include pharmacists on medical home and care coordination teams.
Another idea discussed was to require health plans and health care providers to provide person-to-person MTM using consistent MTM program elements. The stakeholders also talked about requiring medical home and care coordinators to provide medication-use reviews, including, but not limited to, reviews during care transitions. Medication adherence activities should be included in all new transitional care programs, the group decided.
The final suggestion was to include adherence components in standards for electronic health records.
Rebecca Burkholder, director of health policy at NCL, said the organization is working with the federal Agency for Healthcare Research and Quality to develop a national medication adherence campaign.
"We are still in the planning stages," Burkholder said. "It is primarily a consumer education campaign, but we will also be reaching out to health care providers as well [and] targeting chronic conditions."
She said the campaign will probably be publicly launched in mid-2010.
[Corrections made to paragraphs 1–3 in the section "The road ahead."]
