Medication adherence has long been recognized as an important, if under addressed, barrier to patient health. It can affect both quality and length of life, and overall health care costs. Nonadherence to medications has been correlated to up to 50% of treatment failures, approximately 125,000 deaths, and nearly 25% of hospitalizations per year in the United States.1-4 This impact has been valued at approximately $100 billion annually.5 

Proportion of Days Covered (PDC) is the preferred method to measure adherence to chronic medication therapies, according to the Pharmacy Quality Alliance.6 The PDC threshold above which the medication has a reasonable likelihood of achieving the most clinical benefit is 80%. Despite this threshold, the adherence rates for many chronic disease medications are estimated at 50%-60%.2-4

It is likely that in the coronavirus disease 2019 (COVID-19) era and its aftermath, we may see worsening adherence to therapy due to known factors that affect adherence and others that are unique to what is happening currently. Pharmacists are positioned to mitigate many of these factors.

This article discusses these and how pharmacists can respond to help patients take medications effectively and prevent worsening health outcomes.

Factors worsening adherence in the COVID-19 era
Perhaps the most visible factor that affects adherence is financial resources.  According to the Kaiser Family Foundation, approximately 49% of the US population has employer-based health insurance.7

Unfortunately, the economic impact of COVID-19 is well-documented. According to the Bureau of Labor statistics, the number of unemployed persons rose to 23.1 million in April 2020.8 Given the number of people who have lost health insurance, this will impact adherence rates by shifting more cost onto patients. 

An unfortunate consequence of the COVID-19 pandemic is the avoidance of care for both acute and chronic purposes not related to the virus.9 There are multiple factors driving this, including the closing of small primary care practices, reimbursement for telemedicine lagging behind in-person reimbursement, fewer than 20% of visits occurring in person, and the number of primary care physicians dropping from 138,017 to 100,024 since March 2020. 

In provider shortage areas, this has resulted in 1 family medicine provider for more than 3500 patients. Since there is a decrease in visits overall, we are seeing fewer medications being prescribed/renewed, fewer strokes and heart attacks being reported and addressed, worsening diabetes control, and slumps in diet and exercise routines. 

Since we are seeing a decrease in routine medical care being sought out, an additional consequence of this drop in care is a decrease in routine immunization rates. According to the CDC, compared with pre-coronavirus rates, measles, mumps, and rubella shots have dropped by 50%; diphtheria and whooping cough shots by 42%; and human papillomavirus vaccines by 73%.10

The mental health impact of the current pandemic has been well documented and the links to nonadherence previously established. According to recent Kaiser Family Foundation polls, nearly half of adults (45%) reported that their mental health had been affected due to worry and stress over the virus, and that job loss is associated with increased depression/anxiety leading to higher rates of substance abuse and suicide.11 The very necessary social distancing measures can result in social isolation and loneliness.   

Medication shortages and contamination in the drug supply have impacted patients trust in their medications reducing adherence to some chronic medications. The latest medication to be affected is generic metformin ER with N-nitrosodimethylamine contamination. 

Five companies have been cited by the FDA for this contamination.12 Although the relative number of medication lots is small, the very presence of these recalls across several types of medications (ranitidine, losartan, and now metformin) can reduce patient trust in the safety of their treatment.   

The rapid rate of information changes in the era of coronavirus can be overwhelming for patients and health care professionals alike. Recently, the first randomized controlled trial of remdesevir released its preliminary report in the New England Journal of Medicine.13 The report showed that remdesevir shortened recovery time compared with placebo. Prior to this, many of the reports of improvement were case based. 

Changes in the pharmacy landscape have made providing services more difficult. Pharmacies have had to close or adjust their hours during this period on top of the 1 in 8 pharmacies that closed from 2009-2015 (9654 pharmacies). Independent pharmacies in both urban and rural areas were 3 times more likely to close than chain pharmacies.14 

Although all of this is occurring, community pharmacies on the front line are experiencing a notable increase in walk-ins and phone calls, numerous inquiries for delivery and mail services, substantial price increases for common medicines, and increasing levels of staff sickness/stress.

What can pharmacists do to improve adherence to therapy and medications
Pharmacists as the most accessible health care provider
Provide appropriate and reputable source-based information on staying safe at home and using OTC products to address symptom relief for minor health care concerns.

Administer immunizations to provide care gap closures for adult and pediatric patients based on CDC recommendations and local health department points of emphasis for community outbreaks. Assess home blood sugars and provide recommendations when patients are picking up diabetes therapy medications.

Pharmacists as a source of information
  • Perform simple triage for patients and encourage them to seek medical care as appropriate.
  • Provide information to patients about obtaining insurance while unemployed through healthcare.gov.
  • Provide information about how to safely receive medical care in the coronavirus era through telehealth and other means.
  • Assess a patient’s diet and exercise regimen and educate on ways to stay on track while sheltering at home.
  • Educate on the importance of receiving routine immunizations to prevent resurgence of other infectious diseases.
  • Provide immunization information from reputable sources in patient-friendly language such as the CDC or the World Health Organization.
  • Provide guidance on how to manage stress and/or anxiety because of coronavirus.15
  • Encourage patients to be mindful of how the consume information, follow their healthy daily routines as much as they are able, get daily exercise, practice relaxation techniques, how to meaningfully use their free time, how to stay connected safely with others, and where to find mental health resources.
  • Allay fears and provide information about drug shortages and drug supply contamination. 
  • Reach out to potentially affected patients proactively. 

Pharmacists as the medication expert
  • Actively work to improve the affordability of a patient’s medication regimen through formulary review, use of generics, and referral to manufacturer-based discount programs.
  • Optimize medication regimens, including deprescribing where appropriate, decreasing the complexity of regimens (number of medications, times to be taken throughout the day, etc).
  • Make special note of adherence for your patients around medications related to mental health. Ensure patients are not going without these medications.
  • Implement processes that improve adherence including 90-day fills, delivery and mail options, alerts that inform when medications are overdue, and med sync.
  • Perhaps most important during this pandemic is to stay healthy and well as a frontline health care provider.  Utilize the National Alliance on Mental Illness resources for yourself.15
  • Follow CDC guidance on how to maintain safe workplaces for yourself, your staff, and your patients.16,17 

Thank you to frontline pharmacists for all that you are doing now and always for your patients.

About the Author
Amy Kennedy, PharmD, BCACP, is an associate professor in Pharmacy Practice and Science at the University of Arizona College of Pharmacy (UACOP). Dr. Kennedy earned her Doctor of Pharmacy (PharmD) degree from the University of Wisconsin-Madison and completed a community practice residency and community-based participatory research fellowship at Virginia Commonwealth University School of Pharmacy. She is Board Certified in Ambulatory Care. 

As a Clinical Pharmacist, Dr. Kennedy provides care to her patients at El Rio Health in a patient centered medical home model specializing in chronic disease care and pain treatment.  She also serves as the Residency Program Director for the Post-Graduate Year 1 (PGY-1) Pharmacy Residency and PGY-1 Community-Based Pharmacy Residency at El Rio Health. She was recently awarded Clinical Educator of the Year at UACOP and the Arizona Pharmacy Association (AzPA) Excellence in Innovative Practice Award.

Dr. Kennedy is passionate about policy and has served as a member on the following APhA policy committees: APPM policy standing committee, House of Delegates Policy Reference and House Rules Review committees. She has also served on the APhA New Practitioner Advisory Council, the APhA Community Pharmacy Residency Advisory Council, as a New Practitioner mentor to her ASP chapter, and, most recently, on the Board of Directors for her state association. Her current teaching and research interests include preventive health, harm reduction, outpatient pain management, pharmacists’ professionalism and well-being, and the pharmacist’s role in caring for the underserved.   


References
  1. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86(4):304-314.
  2. Sabaté E. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization. 2003. www.who.int/chp/knowledge/publications/adherence_report/en/. Accessed May 21, 2020.
  3. DiMatteo MR, Giordani PJ, Lepper HS, et al. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794-811.
  4. Wu JR, Moser DK. Medication adherence mediates the relationship between heart failure symptoms and cardiac event-free survival in patients with heart failure. J Cardiovasc Nurs. 2018 Jan-Feb;33(1):40–6. doi: 10.1097/jcn.0000000000000427. 
  5. T. Adherence to medication. N Engl J Med. 2005 Aug 4;353(5):487–97. doi: 10.1056/nejmra050100. 
  6. Pharmacy Quality Alliance.  PQA Adherence measures.  https://www.pqaalliance.org/adherence-measures.  Accessed May 21, 2020
  7. Kaiser family foundation.  Rates of employer-based health insurance.  https://www.ehealthinsurance.com/resources/small-business/how-many-americans-get-health-insurance-from-their-employer.  Accessed May 21, 2020.
  8. Bureau of Labor Statistics.  Unemployment Data from April 2020.  https://www.dol.gov/newsroom/economicdata/empsit_05082020.pdf. Accessed May 21, 2020.
  9. HealthLandscape.  Coronavirus Pandemic-Related Potential Family Medicine Office Closures and Economic Impact.  https://healthlandscape.org/covid19/. Accessed May 21, 2020.
  10. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report.  Effects of the COVID-19 Pandemic on routine Pediatric Vaccine Ordering and Administration. https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e2.htm.  Accessed May 21, 2020.
  11. Kaiser Family Foundation.  The Implications of COVID-19 for Mental Health and Substance Use.  https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/. Accessed May 21, 2020.
  12. U.S Food and Drug Administration.  FDA alerts patients and Health Care Professionals to Nitrosamine Impurity Findings in Certain Metformin Extended-Release Products. https://www.fda.gov/news-events/press-announcements/fda-alerts-patients-and-health-care-professionals-nitrosamine-impurity-findings-certain-metformin. Accessed May 28, 2020.
  13. Beigel et al.  Remdesivir for the Treatment of COVID-19-Preliminary Report. NEJM. https://www.nejm.org/doi/full/10.1056/NEJMoa2007764.  Accessed May 22, 2020.
  14. Jenny S. Guadamuz, G. Caleb Alexander, Shannon N. Zenk, Dima M. Qato. Assessment of Pharmacy Closures in the United States From 2009 Through 2015. JAMA Internal Medicine, 2019; 1 DOI: 10.1001/jamainternmed.2019.4588
  15. National Alliance on Mental Illness.  COVID-19 Resource and Information Guide. https://www.nami.org/Support-Education/NAMI-HelpLine/COVID-19-Information-and-Resources/COVID-19-Resource-and-Information-Guide. Accessed May 22, 2020.
  16. Centers for Disease Control and Prevention.  Guidance for Pharmacists and Pharmacy Technicians in Community Pharmacies during the COVID-19 response. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pharmacies.html?fbclid=IwAR3iN830jGJl9nL4ZC_3-6oYqtfBb_uJGkaQK1bzupq-sMnFluKJnIkTACI. Accessed May 22, 2020.
  17. Centers for Disease Control and Prevention.  Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care during the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/framework-non-COVID-care.html. Accessed May 28, 2020.