Pinpointing the cause of nonadherence


It’s been cited as one of the biggest health crises facing the United States and, if solved, the equivalent dollar value of a blockbuster drug. According to the latest statistics from pharmacy benefit manager Express Scripts, poor medication adherence costs the country $317 billion per year, an upgrade from the $290 billion calculated in a study released in 2009 by the New England Healthcare Institute.

Of course, solving medication nonadherence is no simple task. It’s one of those issues like alcoholism and crime, the result of a complex mix of economic, personal and societal factors that combine to create one big social problem. Everything from concerns about cost and fears of side effects and efficacy to simple forgetfulness conspire to keep people from taking their medications as prescribed.

In May, for example, CVS Caremark released results of a study showing that Food and Drug Administration warnings about drug efficacy — even those that aren’t safety-related — can adversely affect medication adherence. The study cited one high-profile FDA communication that questioned the efficacy of the cholesterol drug ezetimibe, sold by Merck under the Zetia and Vytorin (ezetimibe and simvastatin) brands, after which the monthly level of patients who stopped filling their prescriptions increased by nearly 6%, while only 16.5% of those who stopped taking the drug switched to another, clinically appropriate therapy.

But like alcoholism and crime, even if it can’t be solved overnight with some magic panacea, it and its effects can be mitigated, and recent studies released since ESI’s annual drug trend report have offered some clues as to how.

Another CVS Caremark study in May, titled “Targeting Cardiovascular Medication Adherence Interventions” and published in the May/June issue of the Journal of the American Pharmacists Association, found that more than one-third of adherence interventions targeted to nonadherent patients resulted in improved medication adherence, compared with 18% of broad interventions.

The researchers reviewed nearly 60 peer-reviewed articles about randomized controlled trials for three types of interventions to improve medication adherence for cardiovascular disease or diabetes. These interventions included broad interventions targeting all patients, focused interventions targeting nonadherent patients and dynamic interventions initially administered to all patients but then targeted to nonadherent patients based on real-time adherence information. Results found that dynamic interventions and focused interventions were more likely to show impact on adherence as compared with broad interventions.

“While medication nonadherence is widely recognized as a major public health issue that impacts patient health and contributes to rising healthcare costs, there has not been a clear consensus about how best to influence patient behavior and support appropriate medication use,” said Sarah Cutrona, a former research associate at Brigham and Women’s Hospital. “These results suggest that broad interventions, which aim to prevent nonadherence by educating and motivating all patients, were the least effective. Without the benefit of identifying patients and their specific barriers to adherence, these types of interventions may be too general to motivate individual patients to change their medication taking behavior.”

A study released by Walgreens found that patients starting cholesterol medication for the first time who participated in enhanced face-to-face counseling sessions with a community pharmacist demonstrated better medication adherence than those who did not participate in the sessions.

Nonadherence is an especially important issue for patients with high cholesterol, as the condition places them at a greater risk of complications from heart disease. The study, titled “The impact of pharmacist face-to-face counseling to improve medication adherence among patients initiating statin therapy,” was published in April in the online journal Patient Preference and Adherence.

“This study demonstrates the power of face-to-face pharmacist interactions,” said Jeff Kang, Walgreens SVP health and wellness services and solutions. “Just two sessions focused on barriers to adherence for patients taking a new medicine for high cholesterol helped them establish a routine for adhering to their treatment. As a result, these patients potentially improved their long-term health outcomes. At Walgreens, our goal is to help our patients stay well while reducing overall healthcare costs, and programs that address the significant issue of prescription medication nonadherence are a crucial element of this.”

The study followed a group of more than 2,000 patients new to statin therapy for 12 months. After inclusion and exclusion criteria were applied, the intervention group consisted of 586 patients, and the comparison group comprised 516 patients. Pharmacists trained in brief motivational interviewing conducted counseling sessions that addressed barriers to adherence for statin patients, such as perceptions of the value of the therapy, fear of side effects and simple forgetfulness or establishing a routine to take medication.

Whatever it takes to combat the problem of medication nonadherence, one thing is certain: Pharmacists are one of the most important components. The National Association for Chain Drug Stores emphasized last month in a statement sent to the U.S. Senate Health, Education, Labor and Pensions Committee the value of community pharmacies in improving patient health and lowering health costs through medication therapy management. 

“Community retail pharmacies are at the front line in the healthcare system, interacting with patients on a daily basis,” NACDS wrote. “Community pharmacists are uniquely qualified through their comprehensive education and training to significantly reduce the problem of poor medication adherence. We are convinced that [medication therapy management] is a key way to vastly improve health outcomes and reduce costs by ensuring that individuals receive the maximum health benefit from their prescription medicine.”

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