In part 1 of this series, we discussed what medication non-adherence is and the costs to both patients and the healthcare system. In part 2, we will discuss possible solutions to medication non-adherence.Being that medication non-adherence is a complex problem, lasting solutions are multi-faceted. Not all solutions work for everyone. In this blog, we look at two areas that can have a big impact on improving medication non-adherence, the role of the physician and pharmacist.

The Physician’s Role

Often, the first clues to medication non-adherence from patients may present as a worsening disease state.Patient non-adherence should be considered as a possible cause of the worsening disease state.Increasing a medication dose or adding another medication will not result in better outcomes if the patient is not adherent to the therapy being prescribed.Some possible solutions to increasing patient adherence and improving outcomes are discussed below.

Motivational Interviewing

Motivational interviewing was first used by psychologist William R. Miller, PhD in counseling patients with alcohol problems.It is a counseling approach to help patients change their behavior that is being caused by ambivalence. In this case, the behavior is non-adherence to the medication. This type of interaction with patients goes beyond yes or no questions and relies on open-ended questions.It is a way for physicians toexpress empathy while also encouraging patients to move forward in their behavior change, or in this case, medication adherence.

Some key aspects of motivational interviewing are found below:

  • Be empathic: Physicians should use reflective statements to convey an understanding of the patient’s ambivalence.Reflective statements such as, “I hear your frustration about the cost of the medication” or “It must difficult when the medication does not seem to be working right away” show the patient that you are listening and understand what the patient is going through.
  • Resolve patient disparity: Patients may not realize that their current behavior is inconsistent with their long-term health goals.Physicians can help patients develop self-efficacy by helping patients see past successes and their personal strengths.
  • Be a conflict manager: For some patients, their first defense mechanism may be to become confrontational.Physicians should assist patients with these feelings by using empathy and help patients develop self-efficacy as mentioned above.

Motivational interviewing can be a tool for helping patients achieve better medication adherence. The American College of Physicians offers a practice advisor module for more information.

Therapy Considerations

As covered in part 1 of this series, patients may have several reasons for not adhering to their medication.Some of these reasons may include the cost of the medication, forgetting to fill a prescription, too many medications or complex treatment plans.Addressing as many of these issues when deciding on therapy can help improve patient adherence rates.

  • Medication Dosing: Patient adherence is known to decrease as the frequency of dosing increases.Prescribing extended release or longer half-life drugs can improve patient adherence.
  • Drug Cost: Increasing the patient cost-sharing of medication has been shown to decrease patient medication adherence.Physicians have the opportunity to help patients by prescribing generics, asking about formulary issues such as drug tiers and avoiding polypharmacy, prescribing of multiple medications for many disease states, as much as possible.
  • Electronic Prescribing: 20% to 30% of first-time prescriptions are never filled. One study found after adopting e-prescribing there was a 10% increase in patient medication adherence.Many pharmacies perform reminder calls for prescriptions not picked up.When the task of dropping off the prescription at the pharmacy is removed, medication adherence improves.

The ongoing relationship the physician has with his or her patient is an important one.Using tools like motivational interviewing can help determine some detriments to patient adherence and allow for better therapy options.

The Pharmacist’s Role

Pharmacists are in the unique position to a have significant impact on improving patient medication non-adherence.From the ability to offer in-depth counseling on drugs to the fact that patients have face-to-face contact with pharmacists more often than other healthcare providers.Below, we take a look at three ways pharmacists can help improve medication non-adherence statistics.

Medication Therapy Management (MTM)

Medication therapy management (MTM) is a comprehensive drug therapy review and consultation meant to ensure that the drug therapy of patients has optimized therapeutic outcomes with reduced adverse events.Studies have consistently shown that MTM improves health outcomes.A studyon the impact such MTM services had on patients with type 2 diabetes found improvements in both hospitalization rates and patient medication adherence rates.

  • Medication adherence increased from 9.2% of patients being adherent (>80%) at the beginning to 61% after six months of MTM
  • The MTM group had 52.1% fewer hospitalizations after six months of MTM

While MTM can be time-consuming with consultations generally taking between 45 to 60 minutes, the impact on health outcomes cannot be ignored.

Appointment-based Medication Synchronization (ABMS)

The goal of appointment-based medication synchronization (ABMS) is to increase pharmacist contact with the patient on a monthly basis by refilling all medications on the same day and scheduling an appointment for the patients with the pharmacist. ABMS improves patient medication adherence by:

  • Allowing all medications to be filled on the same day
  • Gives patients the opportunity to express concerns about drug therapy
  • Patients are sent reminders for appointments

A study looked at the impact an ABMS program had on medication non-adherence.In every class of drug studied, patient medication adherence was improved for patients enrolled in the ABMS versus patients not enrolled.This resulted in a 2.57 times greater likelihood of ABMS patients being adherent to medication than those patients not enrolled.

The Pennsylvania Project

The Pennsylvania Project is a community pharmacy study that looked at the impact of pharmacist intervention on medication non-adherence in five medication classes: calcium channel blockers, oral diabetes medications, beta-blockers, statins, renin-angiotensin system antagonists. There are a couple of interesting points to this study.First, patients were screened for adherence estimation when filling new prescriptions and patient well-being when refilling a prescription.Based on these results, patients were then identified as needing a brief pharmacist intervention.Another interesting component of this study is the training pharmacists received.They were trained on reporting thresholds, how to use the data and how to provide brief, but effective pharmacist interventions for patients that needed one.

Medication adherence rates for all five drug classes were improved during the intervention study period. Unlike MTM or ABMS, the Pennsylvania Project did not require a time-consuming pharmacist intervention.The study suggests this model is something that community pharmacist can implement without great burden on the pharmacy workflow or staff, while still obtaining improvements in patient medication adherence rates. 

Conclusion

Physicians and pharmacists can play an important role in helping to improve patient medication adherence statistics.When physicians utilize a tool like motivational interviewing, they may be able to assist patients with their ambivalence and develop better therapy plans.For pharmacists, using models like medication therapy management and appointment-based medication synchronization have proven to improve the rates of medication non-adherence.Solutions from many areas of healthcare are needed to continue seeing patient improvement in medication adherence rates.