Helping patients improve medication adherence

Prescribing a medication for a patient is not the end for physicians-it’s the beginning. Ensuring that the patient uses the medication correctly is a continuing challenge for many primary care physicians (PCPs).  Nearly three out of four Americans report not taking their medications as directed, sometimes leading to hospitalization or death, and adding as much as $290 billion in avoidable healthcare costs.

Making sure patients are taking the right medications at the right times for the right reasons continues to be a big challenge for physicians-one with real impacts on patients and the nation’s healthcare system.

“We are trying to do good, but medications can do harm, they can have bad interactions, and they can be expensive,” says Reid Blackwelder, MD, FAAFP, president of the American Academy of Family Physicians (AAFP).

Data show that patient adherence is a major problem, one that increases the risk for adverse events and adds unnecessary costs to the healthcare system. According to the Centers for Disease Control and Prevention, as many as 30% of all prescriptions are never filled, and that medication use drops off despite physician direction in about half of all cases, especially after the first six months.

The problem could worsen as more Americans require intensive medication therapy. By 2020, the number of Americans expected to need medication therapy to treat at least one chronic condition is expected to grow to 157 million, according to estimates from the World Health Organization.

Cost may be a major factor for many patients. One-third of Americans suffering from a chronic illness  said they had trouble affording medications, food, or both, the New York Times reported this month.

The challenge for older patients

Medication errors can be particularly problematic for older patients, Blackwelder adds.“They can be on many medications, especially since they can have several chronic medical conditions that increase in complexity over time,” he says. “A scary fact is that by the time they are on four, five, or certainly six medications, they almost assuredly have at least one side effect from a drug/drug interaction. In our current culture, we often treat those symptoms with yet another drug.”

The Department of Health and Human Services’ Office of Inspector General estimates that more than 1.9 million adverse drug events occur among Medicare enrollees each year, with more than 180,000 of them being life-threatening or fatal. It states that more than 25% of all adverse drug events are preventable, a rate that grows to 50% for life-threatening or fatal events.

Blackwelder says that the AAFP strongly encourages the use of team-based care to improve all aspects of healthcare, and taking steps to prevent medication errors is a big part of that. “With team-based care, it doesn’t even have to be the physician who reconciles the meds. It can be someone else’s job, perhaps a nurse when she checks the patient in,” he says.

Next: Having a pharmacist on the team

Having a pharmacist on the team

A study published in April in Health Services Research demonstrates the value of involving a pharmacist in monitoring medication use by patients who are in home healthcare.

Lead author Alan J. Zillich, PharmD, associate professor at Purdue University College of Pharmacy, says patients in the study were low-risk Medicare patients who had been admitted to home healthcare from a hospital or a community setting.

Some patients were randomly assigned to have a pharmacist call them as soon as possible following admission to home healthcare, and then again seven days later. After that, pharmacists could call patients as often as they felt was necessary in the next 30 days to discuss any medication problems the patient was having.

“The patients who received the phone calls were three times less likely to be hospitalized within the next two months,” Zillich says.

The pharmacists grouped the medication-related problems they found into four categories: indications, effectiveness, safety, and adherence. Safety-related problems were the most common, occurring in about 45% of patients. “These were drug/drug interactions or dosages not being where they needed to be,” Zillich says.

The next phase of the study involved pharmacists working with the patients and/or caregivers to try to resolve the problems.

“Of 460 medical problems identified, 90% were resolved at the end of the study,” he says. About 5% were not resolved because the prescriber did not accept the pharmacist’s recommendations and the other 5% were due to patient resistance.

“While this didn’t work out for the entire cohort of patients, there was a specific group that this intervention kept out of the hospital,” Zillich says. “If you keep even one patient out of the hospital, you save an awful lot of money, regardless of who is paying for that care.”

The study points to which patients are most likely to be helped by intervention from a pharmacist.

“We thought everyone would benefit, but we found out it was only the least sick of a very sick population that benefitted from the telephone intervention,” Zillich says.

A key message PCPs can take from this study is the importance of working in synergy as a healthcare team, he says. “That may mean working in tandem with people who are not necessarily in your practice or in your hospital system. The more we can work together as a healthcare team, between physicians, nurses, pharmacists, other allied health practitioners, we can improve patient outcomes.

“To the extent PCPs can involve other medical professionals in the care of their patients, the better the outcomes will be.”

Physicians can forge partnerships with community pharmacists so they will let physicians know if a patient does not fill, or refill, a prescription, or if a patient declines a prescription due to lack of money. That kind of teamwork is needed to help patients,” Zillich says.

The benefit of interviewing

Blackwelder says that another key aspect of helping patients take their medications correctly is that PCPs need to learn how to ask the right questions. Just asking if the patient takes his or her medications as prescribed doesn’t always yield fully honest answers.

“People want to please physicians,” he says. “My first question often is, ‘tell me what medicine you are taking and why.’ It takes longer to approach it that way but then I know for sure what they know.”

At almost every visit, Blackwelder learns something interesting. “I will learn if someone doesn’t know why they are taking something or will learn they have been put on another drug by a specialist or learn about an over-the-counter medication they are taking,” he says.

Blackwelder also asks patients to bring their prescription bottles to every visit. He often detects problems, such as that a patient may have two bottles that contain the same medication (perhaps one is a brand name drug and one is a generic) and is taking both. Sometimes he learns they are not taking something that he thinks they are. “Increasing the dose of something they are not taking won’t help them,” he says.

Blackwelder uses these conversations to educate patients and, when appropriate, suggests actions the patient can take that do not require medications, such as following a specific diet or exercising to manage the condition.

Sarah L. Cutrona, MD, MPH, assistant professor of medicine with the division of general medicine and primary care and the Meyers Primary Care Institute at the University of Massachusetts medical school, has written about medication adherence, and suggests that collecting information before the physician comes in can help facilitate conversations.

“Routine written questionnaires in the waiting room and verbal screens for medication confusion or nonadherence (which can be done by medical assistants performing initial intake) can help alert providers of potential problems,” she says.

Cutrona also says that phrasing questions in a manner that normalizes nonadherence can be effective. For example: “Many people have trouble taking their medications every day. Is this true for you?”

Following up

While Blackwelder acknowledges that PCPs do not have time to call all patients after every visit to check on drug adherence, he does think it could be a good practice when putting a patient on a new prescription. Having a staff member call or email a patient to check in can be sufficient.

“This is when we learn they forgot to fill it or they heard something bad about it and decided it wasn’t the right drug for them, or couldn’t afford it,” he says.
He hopes any pharmacist would call him if there is a less expensive option available for his patient or even if he or she is unsure about why he prescribed something. With some electronic health records, he notes, it might not even have to be a phone call. It could be an electronic query that the physician can answer when he or she has time.