Medication_NonAdherenceX
- 1. Medication Non-Adherence: The Hidden Epidemic Managing Medication Adherence and Patient Safety David R Donohue, M.A., Qualitative Technologies, Inc. Milwaukee, WI Dr. Tom Muscarello, Ph D, DePaul University, Chicago, IL
- 2. Henry J Kaiser Family Foundation, 2010 Incidence of Medication Noncompliance 50%50% of the 3.9 billion prescription medications dispensed annually in the United States are not taken correctly by patients
- 3. U.S. Patients Do Not Take Medications as Prescribed 100% 76%* 88% 47%* Rx prescribed Rx continuedRx takenRx filled -12% -12% -29% * 22% of U.S. patients take less of the medication than is prescribed American Heart Association: Statistics you need to know. http://216.185.102.50/CAP/pro/prof_statistics2.html. Accessed July 27, 2009.
- 4. Impact of Medication Adherence on Hospitalization Risk 0 10 20 30 40 50 60 1-19* 20- 39* 40- 59* 60- 79* 80- 100 Medicat ion Possession Rat io Diabetes Hypertension Hypercholesterolemia *P<0.05 when compared to the 80-100% group HospitalizationRisk Sokol etal. Med Care 2005;43: 521-530
- 5. Impact of Medication Adherence on All- Cause Healthcare Costs 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000HealthcareCost 1-19* 20-39* 40-59* 60-79+ 80-100 Diabetes Hypertension Hypercholesterolemia *P<0.05 when compared to the 80-100% group + P<0.05 when compared to the 80-100% group in Diabetes and Hypercholesterolemia Patients
- 6. Potential Barriers to Improving Adherence Poor attitude Memory deficits Language Poor Literacy Cultural beliefs Alternative health beliefs Poor support Pride Denial Fear or embarrassment Side effects Religious beliefs Unable to “see” results of drug therapy Lack of choices Rising Cost Vermiere E, et al. J Clin Pharm Ther. 2007;26:331-342.
- 7. What is CMAG? Developed from concepts presented by the World Health Organization (WHO) 2005. Case Management Adherence Guidelines or CMAG provides an interaction and management algorithm to assess and improve the patient's knowledge and his/her motivation to take medications as they are prescribed. The guidelines provide great flexibility in that individual patient needs can be taken into account.
- 8. WHO White Paper on Adherence The World Health Organization has made a strong case that medication adherence is based on three pillars: patient information, motivation, and behavioral skill requirements. Adherence to Long-Term Therapies: Evidence for Action. WHO 2006
- 9. Case Management Adherence Guidelines. Copyright© 2005. CMSA CMAG Algorithm
- 10. CMAG Assessment Tools Tools to assess patient knowledge Health Literacy Test – Realm R, NVS Q-Method Survey Medication Knowledge Survey Modified Morisky Scale
- 11. Health Literacy Health literacy is defined as the ability to read, understand, and act on health information. Poor health literacy results in medication errors, impaired ability to remember and follow treatment recommendations, and reduced ability to navigate within the healthcare system. The Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), a brief eight-item Health Literacy screening test
- 12. Bass Pf, Wilson JF, Griffith, CH. J Gen Intern Med.2003;18:1036-1038.
- 13. Medication Knowledge Survey Assesses knowledge of various medications to be taken, their dosing schedule, benefits and storage Useful as part of the knowledge assessment for CMAG to determine if the patient is in the high or low knowledge domain
- 15. CMAG Assessment Tools Tools to assess patient motivation Readiness Ruler Duke-UNC Functional Social Support Questionnaire
- 16. Readiness Ruler Assess willingness to change behavior Zimmerman GL, Olsen CG, Bosworth MF. Am Fam Physician.2000:61;1409-1416
- 17. Social Support Family or social support is a significant predictor of adherence to long-term medical therapy Duke-UNC Functional Social Support Questionnaire Eight-item, self-administered, multidimensional instrument Broadhead WE, et al. Med Care.2006:27;221-223.
- 19. Modified Morisky Scale Patients on existing therapy Morisky 4 item validated adherence predictor scale Two new items to recognize patient understanding of medication benefits as well as refill behavior Allows patients to be categorized as either High or Low on Knowledge and Motivation domains Morisky DE, Green LW, Levine DM. Med Care. 1986;24:67-74.
- 21. New to CMAG Revision Recognize unique needs of those working successfully with inpatients Hospital Discharge
- 22. The Hospitalized Patient Acknowledges patients higher level of acuity Case managers are used with only a small percent of inpatients Case managers & Nurses have a decreased period of time to interact and plan positive interventions with their patients
- 23. Successful Discharge Collaboration with other healthcare providers both within and outside the inpatient setting is extremely important to ensure a Successful Discharge and long term health outcomes.
- 24. Steps to Ensure a Successful Discharge Educate the patient and ensure patient understanding on their diabetes disease and other chronic disease process and factors that can influence their medical condition Ensure patients have the resources to manage their diabetes and other chronic diseases after discharge from the hospital Make certain that the discharge will be “safe” for the individual patient Ensure that the patient understands the plan for transition of care into the post discharge setting Make certain that the patient has access to the follow up care and therapy
- 25. Information for Patients to Ensure a Successful Discharge Patients that are educated regarding their diabetes and other chronic disease treatments are more likely to remain adherent to treatment recommendations Patients discharged from the hospital with new medications must be monitored for compliance followup
- 26. Information for Patients to Ensure a Successful Discharge Medications that are prescribed during hospitalization need to be reconciled with other medications. Patients need to know how to monitor their diabetes and other chronic diseases and treatments in an outpatient setting.
- 27. Questions: Addressed With Patients Prior To Discharge What is wrong with me and what will this condition mean to my long-term health? What do I need to do when I get home to treat my condition successfully? Who should I contact if I have questions regarding my treatment after I am discharged? What are things that I need to watch for to know if my condition is getting worse and what should I do if these occur? How will I pay for my outpatient medical supplies or services? What resources are available to me?
- 28. Why discharge counseling and adherence messaging are important for the hospital? Maintain Accreditation JCAHO, NCQA, CMS Successfully compete with other hospitals in the community Patient satisfaction levels are increased Publicly available quality rankings Financial Prevent readmissions, and charge backs Promote timely hospital patient discharges
- 29. Competitive Advantage for Hospital Discharge Planning All hospitals seek to be viewed as providing an outstanding level of patient care Hospitals work to maintain a high level of patient satisfaction Discharge counseling is one of the last points of contact with the patient Patients and payers can now easily compare quality indicators on hospitals in their community www.hospitalcompare.hhs.gov www.jcaho.org/quality+check/home.htm
- 30. Current State of Hospital Discharge Counseling and Adherence Messaging Studies of patients recently discharged from the hospital have found that: < 50% of patients could state their diagnosis accurately < 50% of patients could list all their medications < 25% of patients could state common side effects, and what to expect from their medications Patients taking three or more medications were more likely to have problems with medication knowledge and scheduling King, 1998; Makaryus, 2007
- 31. Key Elements of Successful Discharge Planning Recruit a champion or mentor Build a multidisciplinary hospital team Review ALL baseline data Develop protocols and order sets that include appropriate evidence-based therapies Conduct hospital staff conferences to introduce process and gain buy in from all stakeholders Continue data analysis and report results back to hospital staff on a regular basis Evaluate data and look for opportunities for improvement at all levels Create an medication adherence program and measure it AHA, Get with the Guidelines
- 32. Coordination of Care and Transition of Care Outside the Hospital
- 33. Transition of Care to the Outpatient Setting Involve family and all caregivers in patient education Ensure that each patient has a plan for outpatient follow up Facilitate referral for outpatient services and healthcare providers Assist patients with resolving issues relating to the cost of outpatient services and treatments Evaluate Adherence Intention prior to discharge using CMAG tools
Editor's Notes
- #2: Power Point completed December 2010.
- #3: Reference: Henry J Kaiser Family Foundation, 2009. The effect of patient noncompliance on health care costs. Intent of Slide: Increase audience awareness of the prevalence of medication noncompliance in the U.S. Expand upon the opportunities available for the pharmacist to intervene and increase medication compliance through patient counseling and follow-up.
- #4: This is a conceptual slide, based on statistics from the American Heart Association. Here you can see non adherence broken down by behavior and quantified. As you can see, there is a progression of non adherence that starts with not filling the prescription (12%). Then there are those that fill the prescription, but do not take the medication (12%). Then there are those who take the medication, but do not persist with it (29%). And within the percentage of patients that take their medications, there are 22% that take less than is prescribed. So according to this information, only 25% of those who are prescribed medication actually take it like they should. How does this affect patients?
- #5: The impact of medication adherence on the estimated all-cause hospitalization risk based on regression analysis. Results indicated that the outcome was significantly higher than the outcome for the 80-100% group (P&lt;0.05) In the public debate over sky rocketing prescription drug costs the potential economic return s are often missed. These results demonstrate that a net return may be obtained for 3 chronic conditions that account for a large share of long term medication use. In this slide statistically significant differences were seen in the hospitalization risk in patients that had a lower adherence level compared to those with adherence levels from 80-100% Other Notes: The study consisted of 137,277 patients under age 65 Measures included disease related and all cause medical costs, drug costs and hospitalization risk were measured. Using regression analysis these measure were modeled at varying levels of medication adherence. Medication adherence was defined by days’ supply of maintenance medications for each condition.
- #6: The estimated all-cause healthcare costs based on regression analysis In the public debate over sky rocketing prescription drug costs the potential economic returns are often missed. These results demonstrate that a net return may be obtained for 3 chronic conditions that account for a large share of long term medication use. In this slide statistically significant differences were seen in the hospitalization risk in patients that had a lower adherence level compared to those with adherence levels from 80-100% Other Notes: The study consisted of 137,277 patients under age 65. Measures included disease related and all cause medical costs, drug costs and hospitalization risk were measured. Using regression analysis these measures were modeled at varying levels of medication adherence. Medication adherence was defined by days’ supply of maintenance medications for each condition.
- #7: Some of these barriers are more easily overcome than others. (i.e. support can be provided externally but cultural and religious beliefs are deeply ingrained and difficult to bridge).
- #23: Collaboration is vital at all levels to ensure that the appropriate patients are referred to case management. Therefore, case managers need to work closely with other healthcare professional to ensure appropriate referral.
- #24: Doctors, nurses, clinicians and family and friends all need to be on the long term care team of the patient.
- #25: CMAG 2 has coined the term, “Successful Discharge,” for patients receiving appropriate Discharge Planning services. Patients that receive the appropriate steps that lead to a Successful Discharge will be more likely to manage their disease outside the hospital. This will decrease the chances of the person needing to be readmitted to the hospital for acute exacerbations of chronic conditions and complications related to procedures. Since hospitalization is frequently the most expensive part of the treatment, this will help in controling overall healthcare expenditures.
- #33: There are many individuals that may be involved in the discharge planning process. These individuals can be divided into lay individuals that provide support for the patients and those that are involved with the provision of healthcare services.
- #34: Involvement of family and friends especially important for interventions involving lifestyle modifications. Thank you, David R Donohue, M.A. Qualitative Technologies, Inc. and Dr Tom Muscarello, Ph D, DePaul University, Chicago, IL