REVIEW
Medication adherence part three: Strategies for improving adherence Mary Ellen Roberts, DNP, RN, APN-C, FAANP, FAAN (Assistant Professor)1 , Kathy J. Wheeler, PhD, APRN, NP-C, FAANP (Assistant Professor)2,3 , & Mary B. Neiheisel, BSN, MSN, EDD, CNS-BC, FNP-BC, FAANP (Professor of Nursing, Family Nurse Practitioner)4 1
Seton Hall University, South Orange, New Jersey University of Louisiana at Lafayette, Lafayette, Louisiana 3 Faith House, Inc., Lafayette, Louisiana 4 University of Kentucky College of Nursing, Lexington, Kentucky 2
Keywords Medication adherence; medication nonadherence; adherence; nonadherence. Correspondence Mary Ellen Roberts, Graduate Nursing, Seton Hall University, South Orange, NJ 07079. Tel: 973-275-2497; Fax: 973-761-9607; E-mail: [email protected] Received: August 2013; accepted: September 2013 doi: 10.1002/2327-6924.12113
Abstract Purpose: This is the third of a three part series on Medication Adherence in which the authors describe the continuum of adherence to nonadherence of medication usage. Data sources: Research articles through Medline and PubMed. Conclusions: Understanding the magnitude and scope of the problem of medication nonadherence is the first step in reaching better adherence rates. The second step is to evaluate the risk factors for each patient for medication adherence/nonadherence. Steps are then taken to prevent nonadherence. Implications for practice: The implications for nurse practitioners include using time with patients to assist them in adherence, building a trusting relationship with patients, and developing protocols for assessing and preventing nonadherence.
Introduction Part one of this series (Neiheisel, Wheeler, & Roberts, 2014) described the significance and effects of medication nonadherence as well as the complexity of how the concept is defined and measured. There are diverse evidenced-based methods used to assess medication adherence and persistence that provide an estimate of patients’ actual behaviors. These include subjective reporting and objective measures, such as pharmacy or claim databases. Part two (Wheeler, Roberts, & Neiheisel, 2014) discussed the factors contributing to nonadherence. Both intentional and unintentional factors include demographic characteristics, patient psychosocial and behavioral characteristics, social factors, and disease related factors, including intentional and unintentional factors involved in the patients’ active decision or choice to not follow the prescribed regimen. Financial and other health system barriers, the patient–provider relationship, and treatment-related factors are also important issues. Part three, as presented here, builds on this knowledge and discusses interventions and strategies to improve adherence. Please refer to Part one for the definitions of terms related to adherence and nonadherence; these same definitions are used in this discussion.
Interventions to improve medication adherence Despite the complexity surrounding medication adherence and nonadherence, there are approaches providers can undertake in order to improve adherence rates. These involve investing in the patient–provider relationship as well as working on patient behavior and working to counter healthcare system barriers. What is critical to the process is tailoring the evaluation and the intervention according to patient specifics. Table 1 summarizes many of the recommendations.
Patient–provider relationship Trust between patients and their healthcare providers is essential to ensure optimal communication. A trusting relationship provides patients with opportunities to discuss their values, cultural issues, preferences, and issues related to their perspectives about their medical condition and medication nonadherence and nonpersistence, such as a disbelief in the need for the medication or concerns about the efficacy of the prescribed treatment (Teutsch, 2003). Trust between patients and their healthcare providers is fostered by healthcare providers who
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Table 1 Overview of possible solutions to improve medication adherence and persistence Barrier Polypharmacy
Forgetfulness
Lack of knowledge/understanding
Side effects or adverse events
Complexity of regimen
Denial of health condition
Cultural or religious barriers
Financial barriers
Depression
Low health literacy
Possible Solutions 1. Review and reconcile medication list at every visit 2. Educate on reason for each medication 3. Encourage use of one pharmacy 4. Beware of prescribing cascade (medication nonadherence that leads providers to increase dose or add meds when not obtaining clinical objectives) 1. Pill organizers and reminders, including electronic devices 2. Link medication regimen to daily habits 3. Pharmacy-generated written prescription information 4. Visual or audible reminder aids 5. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Pharmacist counseling emphasizing reason and benefits of medication 2. Pharmacy-generated written prescription information 3. Visual aids 4. Teach-back method during office visits 5. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Pharmacy-generated written prescription information 2. Healthcare provider or pharmacist counseling regarding possible side effects and management strategies 3. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Adherence aids such as pill boxes, calendars, and reminder calls 2. Combine medications to simplify 3. Decrease frequency of regimen when possible 4. Promote associations between patients’ routine and taking medications 5. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Explore patient readiness to accept disease condition 2. Provide education about condition 3. Explain how medication works to improve condition 4. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Use LEARN framework to explore and understand patient’s beliefs L = listen with empathy E = explore and understand patient beliefs A = acknowledge differences between patient and provider beliefs R = recommend treatment N = negotiate an agreement 2. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 3. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Prescribe generic rather than brand names 2. Explore mail-order drug discount program 3. Provide links to pharmaceutical company discount programs 4. Explore financial assistance options 1. Identify depressive symptoms 2. Assess effectiveness of psychological and/or medical treatments 3. Follow-up by phone or office visit within 1–2 weeks 1. Explain how medication works to improve condition 2. Provide interpreter for patients who do not speak or understand English 3. Use written materials prepared at third to fifth grade reading level 4. Use nontechnical language and speak slowly 5. Present information in organized manner 6. Use visual aids 7. Use teach-back method to assess comprehension
Adapted with permission from Forissier (2011).
integrate communication strategies that involve active listening, emotional support, and the provision of clear thorough information. Shared goals and decision making as well as allowing sufficient time for patients to ask any 282
questions further promotes effective communication and fosters trust between patients and providers (Bosworth et al., 2011; Brunton, 2011; Fuertes et al., 2007; Hahn, 2009; Lareau & Yawn, 2010; Parchman, Zeber, & Palmer,
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2010; Shea, 2008). Several studies confirm that trust fostered by good communication and medical management decreases the risk of patient nonadherence and nonpersistence. Among 370 patients attending a primary care clinic, 61.0% received a prescription and 79.0% of these demonstrated initial adherence to the prescribed medication regimen at a 4-day postvisit follow-up. Patient trust in their healthcare provider was significantly associated with higher rates of initial adherence (Kerse et al., 2004). A meta-analysis of 106 correlational studies and 21 intervention studies published between 1949 and August 2008 demonstrated an overall 19% increased risk of nonadherence among patients whose providers were classified as having a poor communication style compared to those who concentrated on good communication techniques (Zolnierek & Dimatteo, 2009). Notably, a trusting relationship between patient and healthcare provider has been shown to decrease the incidence of medication nonadherence among patients with limited financial resources (Piette, Heisler, Krein, & Kerr, 2005). Recognizing that each patient will have his or her own issues regarding medication adherence and persistence, the BSMART (barriers, solutions, motivation, adherence tools, relationships, and triage) process offers communication strategies that can be used by healthcare providers to facilitate the identification of potential barriers to medication adherence or persistence that are unique to specific patients (Oyekan et al., 2009). The process emphasizes asking specific questions in an empathetic, nonjudgmental way about the number of days a patient has missed taking prescribed medications, whether the patient has ever stopped or started taking any of the prescribed medications on his or her own, whether the patient has had difficulty taking the medications as prescribed, reasons for these difficulties, factors that interfere with the patient taking medications as prescribed, and the occurrence of side effects or other problems while taking the medications (Oyekan et al., 2009). An open-ended, interrogative communication style is more effective than using closeended statements to accurately assess patients’ adherence to treatment and identify any barriers to adherence and persistence (Bokhour, Berlowitz, Long, & Kressin, 2006; Hahn, 2009; Teutsch, 2003). The Adherence Estimator is a 3-item Likert-scale survey developed to be given to patients shortly after starting a new prescription to assess risk of nonadherence. The questions assess patients’ perceptions about (a) the importance of a new prescription, (b) worry that the prescription may cause more harm than good, and (c) financial concerns (McHorney, 2009). Use of such a tool can facilitate healthcare providers’ efforts to identify patients at risk for nonadherence when starting a new prescription while reassessment at periodic intervals can help
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determine medication persistence rates. This information can form the basis for discussions between patients and their caregivers about patients’ beliefs about their health condition and treatment plan and can help identify areas that may need to be addressed and collaboratively solved (Bosworth et al., 2011; Brunton, 2011). Tamblyn et al. (2010) conducted a population-based study of 13,205 patients with hypertension. All patients had been prescribed antihypertensive medications. Follow-up at 6 months following initiation of treatment revealed that 22.2% of all patients had discontinued their medication entirely. However, the risk of nonpersistence was significantly lower for patients who were treated by physicians considered to have better medical management skills (OR, 0.74; 95% CI, 0.63–0.87) and more effective communication skills (OR, 0.88; 95% CI, 0.78– 1.00). More frequent follow-up visits also were associated with a lower risk of medication discontinuation (Tamblyn et al., 2010). Furthermore, collaborative relationships between patients and their healthcare provider have also been shown to foster improved adherence to treatment regimens for both chronic and acute health conditions (Arbuthnott & Sharpe, 2009; Bokhour et al., 2006; Hawthorne, Rubin, & Ghosh, 2008). Brunton and others suggest the following strategies when providing patients with educational information about their health condition, treatment plan, and prescribed medications (Brunton, 2011; Lareau & Yawn, 2010; Shea, 2008).
1. Present information in manner that is appropriate for patients’ level of health literacy, including written information that patients can take home with them. 2. Use the teach-back method that asks patients to explain how they will take the medication or explain how the medication will be helpful. 3. Provide information in multiple formats, including written, pictorial, and verbal instructions. 4. Limit the amount of new information given to two or three issues per visit in order to increase the likelihood of retention. 5. Assess potential barriers to adherence, such as fears, beliefs, financial, social, cultural, and practical issues. 6. Encourage patients to initiate telephone or e-mail contact between visits and rely on medical assistants and nursing staff as well as the primary healthcare provider for information and clarification if questions arise. 7. Review and reinforce information and provide encouragement at follow-up office visits. 283
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Use of nontechnical, lay language further promotes discussion of diverse issues including adherence. Among patients with low levels of health literacy, use of materials, and a communication style tailored to a third to fifth grade reading level will be most effective. A multicultural intervention using standardized methods of teaching and large print, written (third grade reading level) and pictorial materials with verbal instructions improved adherence with medications for osteoporosis among black and Hispanic women at the 12-month follow-up evaluation (Robbins, Rausch, Garcia, & Prestwood, 2004).
Behavioral interventions Patients with complex medication regimens or other barriers to adherence, such as psychiatric disorders, cognitive impairments, or functional limitations that interfere with their ability to self-administer medications, may benefit from behavioral interventions to help them adopt and integrate medication taking into their daily lives (Bosworth et al., 2011; Brunton, 2011; Ingersoll & Cohen, 2008). What are some of the barriers that our patient population is facing? Forgetfulness is very common in the elderly population and often times in the adult population where their everyday lives become so busy that they forget to take their medication. Such strategies include modified or simplified dosing (e.g., fixed dose combination pills, extended release formulations) to minimize the frequency of medication taking (Arlt, Lindner, Rosler, & von Renteln-Kruse, 2008; Lareau & Yawn, 2010). A systematic review of 15 trials evaluated the effect of fixed dose combination pills and unit-of-use packaging on adherence rates with medications for infectious diseases, hypertension, diabetes mellitus as well as polypharmacy in elderly patients and vitamin supplementation. Twelve of the 15 trials demonstrated trends toward improved adherence or clinical outcomes with 7 of 13 trials reporting statistically significant improvements in adherence, although the clinical significance and short duration of some of the trials diminished the impact of these findings (Connor, Rafter, & Rodgers, 2004). Medication organizers, such as pillboxes, calendar packs, dose dispensing units of medication, unit-of-use packaging/blister packaging, and customized loading devices with or without calendars, also appear to have a favorable impact on medication adherence and persistence (Arlt et al., 2008; Bosworth et al., 2011; Conn et al., 2009; Ryan-Wooley & Rees, 2005). Inability to open prescription bottles for older patients is another deterrent to adherence; use of newer designs of easy-to-open prescription bottles will prevent some of these problems. In addition, use of suggestions by the Arthritis Foundation in opening difficult bottles will encourage adherence 284
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in this population. A meta-analysis of 33 published and unpublished randomized controlled trials evaluated the effectiveness of diverse interventions to improve medication adherence in older adults. Special medication packaging and dose modifications were both associated with significant improvements in medication adherence (Conn et al., 2009). However, it is important to objectively confirm that patients can use devices associated with medication organizers, including the ability to properly fill the device as prescribed (Arlt et al., 2008). Other behavioral interventions include provision of cues that link medication taking with a daily habit, such as brushing teeth. Tools such as alarms or beeper systems, medication charts, large print instruction materials, and large font prescription labels have been shown to increase rates of medication adherence and persistence (Brunton, 2011). Tools are particularly effective for patients with cognitive impairments, those taking multiple medications at variable times of the day, and patients on long-term therapies. Other automated reminder systems, such as automatic refills by the pharmacy, may increase adherence and persistence but may also be associated with the risk of patients taking medications that have been discontinued. Telephone, postcard, e-mail, and text messages to prompt medication taking as well as refills have demonstrated modest efficacy for the improvement of medication adherence (Haynes, Ackloo, Sahota, McDonald, & Yao, 2008). Maintaining a daily medication diary can be useful for some patients as a way to track each dose of medication taken and identify any missed doses. These records can be reviewed by telephone or at follow-up appointments with healthcare providers and may reveal specific barriers to adherence such as a pattern of missed doses that may be attributable to scheduling issues or competing priorities (Bosworth et al., 2011). Many individuals lack knowledge and understanding as to the benefits of taking the medications and of the disease state for which they are taking the medication. To eliminate this lack of knowledge, teach-back methods during office visits can be employed, visual aids as well as counseling emphasizing the reason and benefits of the medication. Patients often worry about side effects and adverse reactions. To minimize this fear, the provider can team with the pharmacist to counsel the patient on management strategies, provide written prescription information, and follow-up visits at 1- to 2-week intervals following the initial prescription. Complexity is another barrier to medication adherence. Patients on multiple medications with varying and multiple administration times can lead to frustration on the patient’s part, therefore leading to nonadherence. Helpful strategies include simplifying the regimen and
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combining medications (taking one pill instead of two decreases anxiety and increases adherence in most patients) whenever possible. As discussed previously, pill boxes, calendars, and prompting of association of the patients’ routine will enhance adherence. Denial of the health condition is another reason for nonadherence. Many patients are not ready to accept the reality of the disease condition. Exploration of readiness, education about the disease and how medication can improve the condition and quality of life are important strategies to acceptance and adherence. When experiencing barriers of cultural or religious barriers, the LEARN framework (Forrisier, 2011) will enhance the providers understanding and exploration of the patient’s beliefs. LEARN means: 1. L = listen with empathy; 2. E = explore and understand patient beliefs; 3. A = acknowledge differences between patient and provider beliefs; 4. R = recommend treatment; and 5. N = negotiate agreement. Exploring the LEARN framework follow-up visit within 1–2 weeks following the initial prescription will encourage adherence. Additional behavioral strategies to increase adherence and persistence include interventions to promote selfmanagement. For example, teaching patients to selfmonitor their health condition by taking their blood pressure, testing blood glucose levels, monitoring pain, and assessing symptom relief have been shown to improve adherence and persistence (Brunton, 2011; Haynes et al., 2008; Lareau & Yawn, 2010; Oyekan et al., 2009). Setting mutually agreeable goals with each patient, including smaller, interim goals, can help sustain motivation and adherence to long-term pharmacologic regimens. Patients can keep regular records of their progress toward goal achievement and these can be reviewed at appointments with appropriate feedback and support given to reinforce patients’ progress toward achievement of longterm goals (Bosworth et al., 2011; Brunton, 2011). This approach is consistent with the ACE-ME model for medication adherence, which include activities related to assessment, collaboration, education, monitoring, and evaluation and the B-SMART model described above (Gould & Mitty, 2010; Oyekan et al., 2009). Other problems in older individuals are the automated system used by many pharmacies to renew medications. Many older adults will either put off getting their medications or they will wait until they feel well enough to stand in line. Solutions to this problem include active pharmacist involvement. As nurse practitioners collaborate with the pharmacist to have a method to keep track
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as to when a prescription is due for renewal and either deliver the medication, or call the patient to advise that the medication is due and ask about ways to assist with delivery. There is software that pharmacy can use that has reminders of renewals that can be utilized to help correct this problem.
Healthcare system and financial interventions In a progressively more complex healthcare system moving toward greater and greater use of electronic health records, and with patients living longer and having more chronic illnesses that require multiple medications, an essential step toward medication adherence involves creating a patient-centered healthcare system with an institutional process directed at improving medication adherence. Administration, providers, and all staff involved in patient care need to be involved in dialogue and system design toward this end. Starr and Sacks (2010) and colleagues of the Medication Adherence Project recommend emphasizing team care, with workflow and office system redesign as needed. Specific steps need to be built into each patient visit so either the provider, pharmacist, or nurse assesses medication adherence, updates the medication list, and prints the list for the patient. A policy of having the patient bring in all medication bottles for each visit and this reconciliation process is recommended, disposing of any discontinued medications. An additional recommendation of this initiative includes paying particular attention to the medication list within the EHR, specifically integrating the list within the record so that it can be updated easily, can be printed, includes space for documentation of adherence issues, and links to patient education materials. Patients with regular access to care and continuity of their relationship with their healthcare providers including pharmacists are more likely to adhere to prescribed medication regimens (Gellad, Grenard, & Marcum, 2011). A retrospective cohort study of patients who initiated treatment for concomitant hypertension and dyslipidemia revealed that a higher number of outpatient visits with their healthcare provider was associated with significantly higher rates of adherence (adjusted OR, 1.26 for four to six visits in past year compared with zero to one visit; p < .0027; Chapman, Petrilla, Benner, Schwartz, & Tang, 2008). A randomized controlled trial of hospitalized patients with coronary heart disease who were discharged on aspirin, a beta-blocker, and a statin compared usual follow-up care with an intervention that emphasized continuity of care. Patients randomized to usual care received standard discharge instructions and a letter to take to their community physician. Those randomized to the continuity of care intervention 285
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received intensive inpatient counseling, communication between hospitalists and community pharmacists and physicians about discharge medications, and ongoing assessment of adherence by community pharmacists. There was an overall trend for improved adherence with all three medications among patients who received the intervention versus usual care (p = .11), while adherence was significantly higher for beta-blockers (71.0% and 49.0% for the intervention and usual care groups, respectively; p = .03; Calvert, 2012). Similarly, regular followup by pharmacists for patients taking four or more medications revealed an increase in adherence rates of 61.2% at baseline to 96.9% at the 6-month follow-up evaluation (p < .001; Lee, Grace, & Taylor, 2012). These results suggest that continuity of care involving both the primary healthcare provider and ancillary providers such as pharmacists will produce significant improvements in adherence and persistence. Similar findings were evident in a randomized controlled trial that compared usual care with an intervention for patients with heart failure. The intervention arm involved pharmacists providing patient education at the time medications were dispensed as well as regular communication between pharmacists and healthcare providers about medication use, dispensing rates, and healthcare encounters. Medication adherence rates at the 9-month follow-up were 67.9% in the usual care group compared with 78.8% for patients randomized to the intervention group. Discontinuation of the intervention resulted in declines in adherence to 70.6% for the intervention group with little change in the usual care group (66.7%), suggesting that the benefit of integrated care required continuation of the intervention (Murray et al., 2007). That said, such continuity of care might be difficult to achieve in this era of healthcare reform and major changes in systems for reimbursement of healthcare services. Efforts to promote medication adherence and persistence must also address cost barriers through the use of generic prescribing, mail-order discount programs, medical financial assistance, or pharmaceutical company programs (Bosworth et al., 2011; Brunton, 2011; WHO, 2003). Control of out-of-pocket costs is relevant for all patients but especially important for those with limited incomes, limited or no health insurance coverage, and patients with multiple chronic conditions who require multiple medications (O’Connor, 2006). Reduced out-of-pocket costs may encourage many patients to continue using those medications with the greatest benefit. Payers may also accrue financial benefits because adherence to medications by patients at high risk of serious medical conditions, such as cancer, cardiovascular disease, diabetes mellitus, and other chronic conditions, may result in overall improved health, prevention of disease
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progression or worsening, and overall decreased health expenditures (O’Connor, 2006).
Conclusions Medication nonadherence and nonpersistence are associated with alarming outcomes, including increased morbidity and mortality rates, higher utilization of medical resources, increased direct and indirect medical costs, decreased productivity, and diminished quality of life. Rates of nonadherence and nonpersistence are variable between patient populations and disease states with some of this variability attributed to methods of definition and assessment. However, many factors have been identified that are associated with variations in medication adherence, including patient demographic characteristics, patient psychosocial and behavioral characteristics, social factors, disease-related factors, financial and other health system barriers, the patient-provider relationship, and treatment-related factors. The effort to sustain medication adherence and persistence among diverse patients with acute and chronic physical and mental health conditions is challenging for all healthcare providers. The first step toward improving adherence and persistence with medication regimens is the identification of patient-specific barriers. Interventions to overcome or circumvent those barriers can then be tailored to the unique needs of individual patients. Importantly, most patients will require multifaceted interventions consistently delivered over time to significantly improve medication adherence and persistence. Essential elements of such a multifaceted approach will include (a) positive ongoing relationships with healthcare providers, (b) ongoing reinforcement and support, (c) simplification of treatment regimens, (d) shared decision making between patients and their caregivers, (e) education about the medication regimen that is tailored to patients’ health literacy and educational levels, (f) consistent follow-up and reminders, (g) reinforcement for achieving treatment goals, (h) social support from healthcare providers, other members of the care giving team, and patients’ extended social network, (i) promotion of self-management, and (j) interventions to promote continuity of care (Bosworth et al., 2011; Brunton, 2011; Haynes et al., 2008; Oyekan et al., 2009).
Acknowledgments The assistance of Dr. Mary Jo Goolsby, Former Director of Research and Education of AANP, for her role in development of the project and Carole Alison Chrvala, PhD, of Health Matters, Inc. of Hillsborough, NC 27278, and
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Pfizer for an unrestricted educational grant is gratefully acknowledged. The authors did not receive any compensation for the development and writing of these articles.
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Medication adherence part three: Strategies for improving adherence Mary Ellen Roberts, DNP, RN, APN-C, FAANP, FAAN (Assistant Professor)1 , Kathy J. Wheeler, PhD, APRN, NP-C, FAANP (Assistant Professor)2,3 , & Mary B. Neiheisel, BSN, MSN, EDD, CNS-BC, FNP-BC, FAANP (Professor of Nursing, Family Nurse Practitioner)4 1
Seton Hall University, South Orange, New Jersey University of Louisiana at Lafayette, Lafayette, Louisiana 3 Faith House, Inc., Lafayette, Louisiana 4 University of Kentucky College of Nursing, Lexington, Kentucky 2
Keywords Medication adherence; medication nonadherence; adherence; nonadherence. Correspondence Mary Ellen Roberts, Graduate Nursing, Seton Hall University, South Orange, NJ 07079. Tel: 973-275-2497; Fax: 973-761-9607; E-mail: [email protected] Received: August 2013; accepted: September 2013 doi: 10.1002/2327-6924.12113
Abstract Purpose: This is the third of a three part series on Medication Adherence in which the authors describe the continuum of adherence to nonadherence of medication usage. Data sources: Research articles through Medline and PubMed. Conclusions: Understanding the magnitude and scope of the problem of medication nonadherence is the first step in reaching better adherence rates. The second step is to evaluate the risk factors for each patient for medication adherence/nonadherence. Steps are then taken to prevent nonadherence. Implications for practice: The implications for nurse practitioners include using time with patients to assist them in adherence, building a trusting relationship with patients, and developing protocols for assessing and preventing nonadherence.
Introduction Part one of this series (Neiheisel, Wheeler, & Roberts, 2014) described the significance and effects of medication nonadherence as well as the complexity of how the concept is defined and measured. There are diverse evidenced-based methods used to assess medication adherence and persistence that provide an estimate of patients’ actual behaviors. These include subjective reporting and objective measures, such as pharmacy or claim databases. Part two (Wheeler, Roberts, & Neiheisel, 2014) discussed the factors contributing to nonadherence. Both intentional and unintentional factors include demographic characteristics, patient psychosocial and behavioral characteristics, social factors, and disease related factors, including intentional and unintentional factors involved in the patients’ active decision or choice to not follow the prescribed regimen. Financial and other health system barriers, the patient–provider relationship, and treatment-related factors are also important issues. Part three, as presented here, builds on this knowledge and discusses interventions and strategies to improve adherence. Please refer to Part one for the definitions of terms related to adherence and nonadherence; these same definitions are used in this discussion.
Interventions to improve medication adherence Despite the complexity surrounding medication adherence and nonadherence, there are approaches providers can undertake in order to improve adherence rates. These involve investing in the patient–provider relationship as well as working on patient behavior and working to counter healthcare system barriers. What is critical to the process is tailoring the evaluation and the intervention according to patient specifics. Table 1 summarizes many of the recommendations.
Patient–provider relationship Trust between patients and their healthcare providers is essential to ensure optimal communication. A trusting relationship provides patients with opportunities to discuss their values, cultural issues, preferences, and issues related to their perspectives about their medical condition and medication nonadherence and nonpersistence, such as a disbelief in the need for the medication or concerns about the efficacy of the prescribed treatment (Teutsch, 2003). Trust between patients and their healthcare providers is fostered by healthcare providers who
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Table 1 Overview of possible solutions to improve medication adherence and persistence Barrier Polypharmacy
Forgetfulness
Lack of knowledge/understanding
Side effects or adverse events
Complexity of regimen
Denial of health condition
Cultural or religious barriers
Financial barriers
Depression
Low health literacy
Possible Solutions 1. Review and reconcile medication list at every visit 2. Educate on reason for each medication 3. Encourage use of one pharmacy 4. Beware of prescribing cascade (medication nonadherence that leads providers to increase dose or add meds when not obtaining clinical objectives) 1. Pill organizers and reminders, including electronic devices 2. Link medication regimen to daily habits 3. Pharmacy-generated written prescription information 4. Visual or audible reminder aids 5. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Pharmacist counseling emphasizing reason and benefits of medication 2. Pharmacy-generated written prescription information 3. Visual aids 4. Teach-back method during office visits 5. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Pharmacy-generated written prescription information 2. Healthcare provider or pharmacist counseling regarding possible side effects and management strategies 3. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Adherence aids such as pill boxes, calendars, and reminder calls 2. Combine medications to simplify 3. Decrease frequency of regimen when possible 4. Promote associations between patients’ routine and taking medications 5. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Explore patient readiness to accept disease condition 2. Provide education about condition 3. Explain how medication works to improve condition 4. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Use LEARN framework to explore and understand patient’s beliefs L = listen with empathy E = explore and understand patient beliefs A = acknowledge differences between patient and provider beliefs R = recommend treatment N = negotiate an agreement 2. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 3. Follow-up by phone or office visit within 1–2 weeks following initial prescription or renewal 1. Prescribe generic rather than brand names 2. Explore mail-order drug discount program 3. Provide links to pharmaceutical company discount programs 4. Explore financial assistance options 1. Identify depressive symptoms 2. Assess effectiveness of psychological and/or medical treatments 3. Follow-up by phone or office visit within 1–2 weeks 1. Explain how medication works to improve condition 2. Provide interpreter for patients who do not speak or understand English 3. Use written materials prepared at third to fifth grade reading level 4. Use nontechnical language and speak slowly 5. Present information in organized manner 6. Use visual aids 7. Use teach-back method to assess comprehension
Adapted with permission from Forissier (2011).
integrate communication strategies that involve active listening, emotional support, and the provision of clear thorough information. Shared goals and decision making as well as allowing sufficient time for patients to ask any 282
questions further promotes effective communication and fosters trust between patients and providers (Bosworth et al., 2011; Brunton, 2011; Fuertes et al., 2007; Hahn, 2009; Lareau & Yawn, 2010; Parchman, Zeber, & Palmer,
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2010; Shea, 2008). Several studies confirm that trust fostered by good communication and medical management decreases the risk of patient nonadherence and nonpersistence. Among 370 patients attending a primary care clinic, 61.0% received a prescription and 79.0% of these demonstrated initial adherence to the prescribed medication regimen at a 4-day postvisit follow-up. Patient trust in their healthcare provider was significantly associated with higher rates of initial adherence (Kerse et al., 2004). A meta-analysis of 106 correlational studies and 21 intervention studies published between 1949 and August 2008 demonstrated an overall 19% increased risk of nonadherence among patients whose providers were classified as having a poor communication style compared to those who concentrated on good communication techniques (Zolnierek & Dimatteo, 2009). Notably, a trusting relationship between patient and healthcare provider has been shown to decrease the incidence of medication nonadherence among patients with limited financial resources (Piette, Heisler, Krein, & Kerr, 2005). Recognizing that each patient will have his or her own issues regarding medication adherence and persistence, the BSMART (barriers, solutions, motivation, adherence tools, relationships, and triage) process offers communication strategies that can be used by healthcare providers to facilitate the identification of potential barriers to medication adherence or persistence that are unique to specific patients (Oyekan et al., 2009). The process emphasizes asking specific questions in an empathetic, nonjudgmental way about the number of days a patient has missed taking prescribed medications, whether the patient has ever stopped or started taking any of the prescribed medications on his or her own, whether the patient has had difficulty taking the medications as prescribed, reasons for these difficulties, factors that interfere with the patient taking medications as prescribed, and the occurrence of side effects or other problems while taking the medications (Oyekan et al., 2009). An open-ended, interrogative communication style is more effective than using closeended statements to accurately assess patients’ adherence to treatment and identify any barriers to adherence and persistence (Bokhour, Berlowitz, Long, & Kressin, 2006; Hahn, 2009; Teutsch, 2003). The Adherence Estimator is a 3-item Likert-scale survey developed to be given to patients shortly after starting a new prescription to assess risk of nonadherence. The questions assess patients’ perceptions about (a) the importance of a new prescription, (b) worry that the prescription may cause more harm than good, and (c) financial concerns (McHorney, 2009). Use of such a tool can facilitate healthcare providers’ efforts to identify patients at risk for nonadherence when starting a new prescription while reassessment at periodic intervals can help
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determine medication persistence rates. This information can form the basis for discussions between patients and their caregivers about patients’ beliefs about their health condition and treatment plan and can help identify areas that may need to be addressed and collaboratively solved (Bosworth et al., 2011; Brunton, 2011). Tamblyn et al. (2010) conducted a population-based study of 13,205 patients with hypertension. All patients had been prescribed antihypertensive medications. Follow-up at 6 months following initiation of treatment revealed that 22.2% of all patients had discontinued their medication entirely. However, the risk of nonpersistence was significantly lower for patients who were treated by physicians considered to have better medical management skills (OR, 0.74; 95% CI, 0.63–0.87) and more effective communication skills (OR, 0.88; 95% CI, 0.78– 1.00). More frequent follow-up visits also were associated with a lower risk of medication discontinuation (Tamblyn et al., 2010). Furthermore, collaborative relationships between patients and their healthcare provider have also been shown to foster improved adherence to treatment regimens for both chronic and acute health conditions (Arbuthnott & Sharpe, 2009; Bokhour et al., 2006; Hawthorne, Rubin, & Ghosh, 2008). Brunton and others suggest the following strategies when providing patients with educational information about their health condition, treatment plan, and prescribed medications (Brunton, 2011; Lareau & Yawn, 2010; Shea, 2008).
1. Present information in manner that is appropriate for patients’ level of health literacy, including written information that patients can take home with them. 2. Use the teach-back method that asks patients to explain how they will take the medication or explain how the medication will be helpful. 3. Provide information in multiple formats, including written, pictorial, and verbal instructions. 4. Limit the amount of new information given to two or three issues per visit in order to increase the likelihood of retention. 5. Assess potential barriers to adherence, such as fears, beliefs, financial, social, cultural, and practical issues. 6. Encourage patients to initiate telephone or e-mail contact between visits and rely on medical assistants and nursing staff as well as the primary healthcare provider for information and clarification if questions arise. 7. Review and reinforce information and provide encouragement at follow-up office visits. 283
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Use of nontechnical, lay language further promotes discussion of diverse issues including adherence. Among patients with low levels of health literacy, use of materials, and a communication style tailored to a third to fifth grade reading level will be most effective. A multicultural intervention using standardized methods of teaching and large print, written (third grade reading level) and pictorial materials with verbal instructions improved adherence with medications for osteoporosis among black and Hispanic women at the 12-month follow-up evaluation (Robbins, Rausch, Garcia, & Prestwood, 2004).
Behavioral interventions Patients with complex medication regimens or other barriers to adherence, such as psychiatric disorders, cognitive impairments, or functional limitations that interfere with their ability to self-administer medications, may benefit from behavioral interventions to help them adopt and integrate medication taking into their daily lives (Bosworth et al., 2011; Brunton, 2011; Ingersoll & Cohen, 2008). What are some of the barriers that our patient population is facing? Forgetfulness is very common in the elderly population and often times in the adult population where their everyday lives become so busy that they forget to take their medication. Such strategies include modified or simplified dosing (e.g., fixed dose combination pills, extended release formulations) to minimize the frequency of medication taking (Arlt, Lindner, Rosler, & von Renteln-Kruse, 2008; Lareau & Yawn, 2010). A systematic review of 15 trials evaluated the effect of fixed dose combination pills and unit-of-use packaging on adherence rates with medications for infectious diseases, hypertension, diabetes mellitus as well as polypharmacy in elderly patients and vitamin supplementation. Twelve of the 15 trials demonstrated trends toward improved adherence or clinical outcomes with 7 of 13 trials reporting statistically significant improvements in adherence, although the clinical significance and short duration of some of the trials diminished the impact of these findings (Connor, Rafter, & Rodgers, 2004). Medication organizers, such as pillboxes, calendar packs, dose dispensing units of medication, unit-of-use packaging/blister packaging, and customized loading devices with or without calendars, also appear to have a favorable impact on medication adherence and persistence (Arlt et al., 2008; Bosworth et al., 2011; Conn et al., 2009; Ryan-Wooley & Rees, 2005). Inability to open prescription bottles for older patients is another deterrent to adherence; use of newer designs of easy-to-open prescription bottles will prevent some of these problems. In addition, use of suggestions by the Arthritis Foundation in opening difficult bottles will encourage adherence 284
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in this population. A meta-analysis of 33 published and unpublished randomized controlled trials evaluated the effectiveness of diverse interventions to improve medication adherence in older adults. Special medication packaging and dose modifications were both associated with significant improvements in medication adherence (Conn et al., 2009). However, it is important to objectively confirm that patients can use devices associated with medication organizers, including the ability to properly fill the device as prescribed (Arlt et al., 2008). Other behavioral interventions include provision of cues that link medication taking with a daily habit, such as brushing teeth. Tools such as alarms or beeper systems, medication charts, large print instruction materials, and large font prescription labels have been shown to increase rates of medication adherence and persistence (Brunton, 2011). Tools are particularly effective for patients with cognitive impairments, those taking multiple medications at variable times of the day, and patients on long-term therapies. Other automated reminder systems, such as automatic refills by the pharmacy, may increase adherence and persistence but may also be associated with the risk of patients taking medications that have been discontinued. Telephone, postcard, e-mail, and text messages to prompt medication taking as well as refills have demonstrated modest efficacy for the improvement of medication adherence (Haynes, Ackloo, Sahota, McDonald, & Yao, 2008). Maintaining a daily medication diary can be useful for some patients as a way to track each dose of medication taken and identify any missed doses. These records can be reviewed by telephone or at follow-up appointments with healthcare providers and may reveal specific barriers to adherence such as a pattern of missed doses that may be attributable to scheduling issues or competing priorities (Bosworth et al., 2011). Many individuals lack knowledge and understanding as to the benefits of taking the medications and of the disease state for which they are taking the medication. To eliminate this lack of knowledge, teach-back methods during office visits can be employed, visual aids as well as counseling emphasizing the reason and benefits of the medication. Patients often worry about side effects and adverse reactions. To minimize this fear, the provider can team with the pharmacist to counsel the patient on management strategies, provide written prescription information, and follow-up visits at 1- to 2-week intervals following the initial prescription. Complexity is another barrier to medication adherence. Patients on multiple medications with varying and multiple administration times can lead to frustration on the patient’s part, therefore leading to nonadherence. Helpful strategies include simplifying the regimen and
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combining medications (taking one pill instead of two decreases anxiety and increases adherence in most patients) whenever possible. As discussed previously, pill boxes, calendars, and prompting of association of the patients’ routine will enhance adherence. Denial of the health condition is another reason for nonadherence. Many patients are not ready to accept the reality of the disease condition. Exploration of readiness, education about the disease and how medication can improve the condition and quality of life are important strategies to acceptance and adherence. When experiencing barriers of cultural or religious barriers, the LEARN framework (Forrisier, 2011) will enhance the providers understanding and exploration of the patient’s beliefs. LEARN means: 1. L = listen with empathy; 2. E = explore and understand patient beliefs; 3. A = acknowledge differences between patient and provider beliefs; 4. R = recommend treatment; and 5. N = negotiate agreement. Exploring the LEARN framework follow-up visit within 1–2 weeks following the initial prescription will encourage adherence. Additional behavioral strategies to increase adherence and persistence include interventions to promote selfmanagement. For example, teaching patients to selfmonitor their health condition by taking their blood pressure, testing blood glucose levels, monitoring pain, and assessing symptom relief have been shown to improve adherence and persistence (Brunton, 2011; Haynes et al., 2008; Lareau & Yawn, 2010; Oyekan et al., 2009). Setting mutually agreeable goals with each patient, including smaller, interim goals, can help sustain motivation and adherence to long-term pharmacologic regimens. Patients can keep regular records of their progress toward goal achievement and these can be reviewed at appointments with appropriate feedback and support given to reinforce patients’ progress toward achievement of longterm goals (Bosworth et al., 2011; Brunton, 2011). This approach is consistent with the ACE-ME model for medication adherence, which include activities related to assessment, collaboration, education, monitoring, and evaluation and the B-SMART model described above (Gould & Mitty, 2010; Oyekan et al., 2009). Other problems in older individuals are the automated system used by many pharmacies to renew medications. Many older adults will either put off getting their medications or they will wait until they feel well enough to stand in line. Solutions to this problem include active pharmacist involvement. As nurse practitioners collaborate with the pharmacist to have a method to keep track
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as to when a prescription is due for renewal and either deliver the medication, or call the patient to advise that the medication is due and ask about ways to assist with delivery. There is software that pharmacy can use that has reminders of renewals that can be utilized to help correct this problem.
Healthcare system and financial interventions In a progressively more complex healthcare system moving toward greater and greater use of electronic health records, and with patients living longer and having more chronic illnesses that require multiple medications, an essential step toward medication adherence involves creating a patient-centered healthcare system with an institutional process directed at improving medication adherence. Administration, providers, and all staff involved in patient care need to be involved in dialogue and system design toward this end. Starr and Sacks (2010) and colleagues of the Medication Adherence Project recommend emphasizing team care, with workflow and office system redesign as needed. Specific steps need to be built into each patient visit so either the provider, pharmacist, or nurse assesses medication adherence, updates the medication list, and prints the list for the patient. A policy of having the patient bring in all medication bottles for each visit and this reconciliation process is recommended, disposing of any discontinued medications. An additional recommendation of this initiative includes paying particular attention to the medication list within the EHR, specifically integrating the list within the record so that it can be updated easily, can be printed, includes space for documentation of adherence issues, and links to patient education materials. Patients with regular access to care and continuity of their relationship with their healthcare providers including pharmacists are more likely to adhere to prescribed medication regimens (Gellad, Grenard, & Marcum, 2011). A retrospective cohort study of patients who initiated treatment for concomitant hypertension and dyslipidemia revealed that a higher number of outpatient visits with their healthcare provider was associated with significantly higher rates of adherence (adjusted OR, 1.26 for four to six visits in past year compared with zero to one visit; p < .0027; Chapman, Petrilla, Benner, Schwartz, & Tang, 2008). A randomized controlled trial of hospitalized patients with coronary heart disease who were discharged on aspirin, a beta-blocker, and a statin compared usual follow-up care with an intervention that emphasized continuity of care. Patients randomized to usual care received standard discharge instructions and a letter to take to their community physician. Those randomized to the continuity of care intervention 285
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received intensive inpatient counseling, communication between hospitalists and community pharmacists and physicians about discharge medications, and ongoing assessment of adherence by community pharmacists. There was an overall trend for improved adherence with all three medications among patients who received the intervention versus usual care (p = .11), while adherence was significantly higher for beta-blockers (71.0% and 49.0% for the intervention and usual care groups, respectively; p = .03; Calvert, 2012). Similarly, regular followup by pharmacists for patients taking four or more medications revealed an increase in adherence rates of 61.2% at baseline to 96.9% at the 6-month follow-up evaluation (p < .001; Lee, Grace, & Taylor, 2012). These results suggest that continuity of care involving both the primary healthcare provider and ancillary providers such as pharmacists will produce significant improvements in adherence and persistence. Similar findings were evident in a randomized controlled trial that compared usual care with an intervention for patients with heart failure. The intervention arm involved pharmacists providing patient education at the time medications were dispensed as well as regular communication between pharmacists and healthcare providers about medication use, dispensing rates, and healthcare encounters. Medication adherence rates at the 9-month follow-up were 67.9% in the usual care group compared with 78.8% for patients randomized to the intervention group. Discontinuation of the intervention resulted in declines in adherence to 70.6% for the intervention group with little change in the usual care group (66.7%), suggesting that the benefit of integrated care required continuation of the intervention (Murray et al., 2007). That said, such continuity of care might be difficult to achieve in this era of healthcare reform and major changes in systems for reimbursement of healthcare services. Efforts to promote medication adherence and persistence must also address cost barriers through the use of generic prescribing, mail-order discount programs, medical financial assistance, or pharmaceutical company programs (Bosworth et al., 2011; Brunton, 2011; WHO, 2003). Control of out-of-pocket costs is relevant for all patients but especially important for those with limited incomes, limited or no health insurance coverage, and patients with multiple chronic conditions who require multiple medications (O’Connor, 2006). Reduced out-of-pocket costs may encourage many patients to continue using those medications with the greatest benefit. Payers may also accrue financial benefits because adherence to medications by patients at high risk of serious medical conditions, such as cancer, cardiovascular disease, diabetes mellitus, and other chronic conditions, may result in overall improved health, prevention of disease
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progression or worsening, and overall decreased health expenditures (O’Connor, 2006).
Conclusions Medication nonadherence and nonpersistence are associated with alarming outcomes, including increased morbidity and mortality rates, higher utilization of medical resources, increased direct and indirect medical costs, decreased productivity, and diminished quality of life. Rates of nonadherence and nonpersistence are variable between patient populations and disease states with some of this variability attributed to methods of definition and assessment. However, many factors have been identified that are associated with variations in medication adherence, including patient demographic characteristics, patient psychosocial and behavioral characteristics, social factors, disease-related factors, financial and other health system barriers, the patient-provider relationship, and treatment-related factors. The effort to sustain medication adherence and persistence among diverse patients with acute and chronic physical and mental health conditions is challenging for all healthcare providers. The first step toward improving adherence and persistence with medication regimens is the identification of patient-specific barriers. Interventions to overcome or circumvent those barriers can then be tailored to the unique needs of individual patients. Importantly, most patients will require multifaceted interventions consistently delivered over time to significantly improve medication adherence and persistence. Essential elements of such a multifaceted approach will include (a) positive ongoing relationships with healthcare providers, (b) ongoing reinforcement and support, (c) simplification of treatment regimens, (d) shared decision making between patients and their caregivers, (e) education about the medication regimen that is tailored to patients’ health literacy and educational levels, (f) consistent follow-up and reminders, (g) reinforcement for achieving treatment goals, (h) social support from healthcare providers, other members of the care giving team, and patients’ extended social network, (i) promotion of self-management, and (j) interventions to promote continuity of care (Bosworth et al., 2011; Brunton, 2011; Haynes et al., 2008; Oyekan et al., 2009).
Acknowledgments The assistance of Dr. Mary Jo Goolsby, Former Director of Research and Education of AANP, for her role in development of the project and Carole Alison Chrvala, PhD, of Health Matters, Inc. of Hillsborough, NC 27278, and
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Pfizer for an unrestricted educational grant is gratefully acknowledged. The authors did not receive any compensation for the development and writing of these articles.
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