Rebecca L. Nelson, PharmD, RPh

Non-adherence to medications is one of the country's largest and most expensive disease categories. Specialty pharmacists play a vital role in improving adherence.

Nearly 75% of Americans report that they do not always take their medication as directed by a health care professional— a problem that causes more than one-third of medicine-related hospitalizations and nearly 125,000 deaths in the United States annually.

 “Poor medication adherence is costing Americans their good health, and is costing our nation an estimated $290 billion each year in avoidable healthcare costs,”

 said Stephen C. Anderson, IOM, CAE, chairman of the board of the National Association of Chain Drug Stores Foundation. “Improved adherence will contribute to lower overall health care costs and increased quality of life.”

Adherence is defined as the extent to which patients will follow the directions they are given for prescribed treatments. Non-adherence includes failing to fill prescriptions, delaying prescription fills, reducing the strength of the dose taken, and reducing the frequency of administration. It can also include the failure to keep appointments or to follow recommended lifestyle or dietary changes. Studies have shown that in the United States, non-adherence to medications accounts for 10% to 25% of hospital and nursing home admissions. 

 This makes non-adherence to medications one of the largest and most expensive disease categories

It is important to understand why non-adherence occurs if we want to try to improve it. Demographics, social and psychological factors, medical system barriers, as well as financial and treatment-related factors can all be considered as having an effect on patient adherence. Demographic factors such as ethnic minority, low socioeconomic status, and low levels of education have been associated with lower regimen adherence and greater morbidity.

Appropriate health beliefs, such as perceived seriousness of the condition, vulnerability to complications, and the efficacy of treatment, can predict better adherence.

 Patients have a higher adherence rate when they understand the regimen; when it seems to be effective; when they believe the benefits of taking the medication exceed the costs; when they feel they are able to succeed; and when their environment supports regimen-related behaviors. Studies have shown that low levels of conflict, high levels of cohesion and organization, and good communication patterns are associated with better regimen adherence. 

 Family relationships also play an important role in disease management. Greater levels of social support, for example, from spouses and other family members, are typically associated with better regimen adherence.

Physicians, pharmacists, and nurses all play a vital role in assisting patients’ healthy behavior and lifestyle changes. Atreja et al completed a narrative review of the current literature to help health care professionals become familiar with proven interventions that can enhance patient adherence. The interventions were then grouped into categories that can be easily remembered by the mnemonic “SIMPLE”

The goal of this framework was not only to help design scientifically proven interventions, but also to reduce the time and cost involved with implementing these strategies in a health care setting.4 Often health care providers will use the term “compliance” instead of “adherence” to describe a patient’s ability to use a medication as prescribed. Compliance has been defined as “the extent to which a person’s behavior coincides with medical advice.”8 Noncompliance basically means that patients disobey the advice of their health care providers and can be attributed to personal qualities of the patients, such as memory issues, a lack of willpower, or a low level of education.

The concept of noncompliance assumes a negative attitude toward patients, but also places patients in a passive, unequal role in relationship to their care providers. Adherence has been defined as the “active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result.”

 Adherence allows for the patient andprescriber to work together to set goals, plan treatment, and start the regimen.

Patients reflect on treatment recommendations and then either adhere to these internal guidelines—or not.

The National Consumers League and partners have developed a campaign to raise awareness about the importance of medication adherence called 

 In addition to raising awareness, some techniques to increase adherence include the use of pill boxes, pill counts, pharmacy records, a medication log/diary, refill reminder calls, reminder post cards, and phone calls about upcoming patient appointments. To evaluate adherence, the patient can be directly asked (self-reporting) if they take their medications as directed and asked open-ended questions to ensure that the patient understands the therapy plan and goals. The patient answers will be most honest when they have open communication lines with their prescriber and don’t feel that they will be scolded for not taking the medication as prescribed.

The quality of the patient-doctor relationship is vital for the patient’s regimen adherence. Research has demonstrated that both patient satisfaction and patient adherence are enhanced by patients’ involvement and participation in their care.

 Research has generally shown that lower medication adherence can be expected when a health condition is chronic, when symptoms are not bothersome or apparent, when the treatment is more complex, and when a treatment regimen requires lifestyle changes.

 Other options for monitoring adherence include electronic tools such as metered dose inhalers, reminder alarms attached to pill boxes, or electronic recording devices attached to the vial that report back to the physician when the pill vial is opened.

Disease management programs increase and maintain patient adherence through patient education, open communication lines, and support with their health care team. Standard disease management program tools include easily accessible, supportive, and educational websites and call centers; suggestions for improving patient lifestyles and health; and options to sign up for dose and refill reminder calls, e-mails, and texts. These initiatives not only aid the patient by helping maintain motivation and adherence, but also by providing education about lifestyle choices that are vital components of treating many diseases.

Improved patient adherence translates into higher sustained sales, but also allows for better patient disease management over time, decreasing the long-term disease management costs by decreasing the number of hospitalizations. Pharmacies that provide patient services cast themselves in a favorable light with many stakeholders, including patients, physicians, caregivers, payers, and support groups. Prescribers faced with a decision between a treatment with a supportive program and one without will be more inclined to refer the patient to the pharmacy with the program, since it will drive desired outcomes.

To improve patients’ involvement, health care providers should cultivate patient-centered relationships that respect patient autonomy; have a patient-friendly atmosphere; provide continuity of care with regular telephone contacts; talk collaboratively with patients about treatment rationales and goals; brainstorm and problem-solve with their patients; gradually implement and tailor the regimen; provide written instructions; use self-monitoring, social supports and reinforcement, and behavioral contracts; and routinely refer patients to behavioral health specialists. 

		McCarthy R. The price you pay for the drug not taken. 

		Thinking outside the pillbox. New England Healthcare Institute website. www.nehi.net/news/press_releases/110/nehi_research_shows_patient_medication_nonadherence_costs_health_care_system_290_billion_annually. Accessed February 19, 2012.

		Smith DL. Compliance packaging: a patient education tool. 

		Atreja A, Bellam N, Levy SR. Strategies to enhance patient adherence: making it simple. 

		Delamater AM, Jacobson AM, Anderson BJ, et al. Psychosocial therapies in diabetes: report of the Psychosocial Therapies Working Group. 

		Brownlee-Duffeck M, Peterson L, Simonds JF, Goldstein D, Kilo C, Hoette S. The role of health beliefs in the regimen adherence and metabolic control of adolescents and adults with diabetes mellitus. 

		Delamater AM. Improving patient adherence. 

		Horwitz RI, Horwitz SM. Adherence to treatment and health outcomes. 

		Hayden Bosworth H; National Consumers League. Medication adherence: making the case for increased awareness. http://savvyconsumer.files.wordpress.com/2011/05/nclduke_briefingpaper_final.pdf

		National Consumers League (2011) Medication Adherence Campaign. www.nclnet.org/health/106-prescription-drugs/234-ncls-medication-adherence-campaign. Accessed February 19, 2012.

		Martin LR, Williams SL, Haskard KB, DiMatteo MR. The challenge of patient adherence. 

Therapeutics and Clinical Risk Management

		DiMattaeo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes; a meta-analysis. 

 is pharmacist in charge, senior clinical pharmacist at BioScrip Pharmacy Services in Columbus, Ohio. BioScrip® is a leading provider in comprehensive, cost-effective pharmaceutical and homecare solutions.  Rebecca is licensed in 17 states and is responsible for maintaining overall pharmacy compliance to all state and federal laws, management and development of clinical programs as well as being actively involved in mentoring pharmacy students. She graduated from Ohio Northern University Raabe College of Pharmacy in 2007 and currently resides in Dublin, Ohio.

Articles

Non-adherence to medications is one of the country's largest and most expensive disease categories. Specialty pharmacists play a vital role in improving adherence. 