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Addressing the Problem of Medication Non-Adherence

Patti Higginbotham, AOCN, APRNKris Admire, BA

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Following this session we will better understand: Medication Non-Adherence Patient Adherence Challenges The Impact of Specialty Pharmacy and Patient Centered

Care Services Patient Education and Support Resources Powerful Touch Points to Engage and Empower Patients and

Caregivers

Session Objectives

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Define medication non-adherence and the challenges contributing to this growing problem

Adherence can be defined as the extent to which a patient’s behavior coincides with medical advice

LaFountain, A. (2010). Adherence: Missing the mark. Retrieved from http//pharmexec.com LaFountain, A. (2011). The forgotten illness. Media Planet, 3 (1), 8.Smith, M. (2013). America’s health care problems? The solutions exist .Managed Care. 22(1), 32-35.Haynes, R.B., Taylor, D.W., Sackett, D. L.. (1979). Compliance in health care. Baltimore, MD: The John Hopkins University Press.

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Multifaceted / Complex issue

Shifted the burden Surprisingly

ignored for a long time

Increasing health costs

Increasing use of complementary therapies

Non- Adherence as a Growing Problem

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“Increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any other improvement in specific medical treatments.”

World Health Organization

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Medication Nonadherence:A Diagnosable and Treatable

Medical Condition

JAMA, May 22/29, 2013—Vol 309, No. 20 pg. 2105

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Compliance Consistency and accuracy with

which a patient follows a regimen

Implies subordinate relationship

Too closely associated with blame

Compliance vs. Adherence

Adherence Defines the extent to which a

patient’s behavior corresponds with agreed upon recommendations

D’Amato, S. (2008). Improving patient adherence with oral chemotherapy. Oncology Issues, July/August, 42-45.

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Primary Secondary Unintentional Intentional

• Trends Web Induced Specialist – FP Lack of motivation/ fear of potential side effects

Types of Non- Adherence

Stefanacci, R., & Guerin, S. (2013). Why medication adherence matters to patients, payers, providers. Managed Care, 22(1), 37-39.

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Patient understanding connection btw adherence and continued health

Patient concluded benefits not out weighing cost

Complexity of regimen Patient factors, forgetfulness Beliefs about medications Perception of medication to have

therapeutic efficacy

Reasons For Nonadherence

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Economics

Patient Outcomes

Identify Why Non-adherence Matters in Healthcare

Stefanacci, R., & Guerin, S. (2013). Why medication adherence matters to patients, payers, providers. Managed Care, 22(1), 37-39.

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Estimated $100 billion in healthcare costs• Readmission rates• Increase in physician visits• Increase in emergency room

visits• Medication adherence is central

to CMS Quality Rating System• Cost of recurrence($11-19,000

over ten years)

Economics

D’Amato, S. (2008). Improving patient adherence with oral chemotherapy. Oncology Issues, July/August, 42-45.SEER –Medicare data 2008

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Compromised Patient Outcomes

Gangloff, J.M. (2013) Troubling trend. Cure Spring

Estimated 125,000 deaths annually in U.S.

Decreased patient satisfaction Poor patient/provider relationships Compromised disease outcomes,

decreased survival Decreased quality of life

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Studies• Demographics• Patient Outcomes

Identify Patient Adherence Challenges and Major Predictors of Poor Adherence to Medication

Ginex, P., Thom, B., Anthony, V., Russell, C., & Gromisch, C. (2012). A pilot study to identify patient factors impacting adherence to oral chemotherapy. Oncology Nursing Forum, 39 (3), E176. Hershman, D. L., Kushi, L.H., Shao, T., Buono, D., Kershenbaum, A., Tsas, W.Y., .,.,., Neugut, A.I. (2010). Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early- stage breast cancer patients. Journal of Clinical Oncology,28(27), 4120-4128.

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1996-2007, examined pharmacy records of 8,769 women

49% completed their full regimen of hormone therapy Women younger than 40, highest rate of

non-adherence • At 4.5 years, 32% had discontinued therapy

Women who had lumpectomy more likely to have discontinued therapy early

Studies: Demographics(Hershman, 2010 )

Hershman, D. L., Kushi, L.H., Shao, T., Buono, D., Kershenbaum, A., Tsas, W.Y., .,.,.,Neugut, A.I. (2010). Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early- stage breast cancer patients. Journal of Clinical Oncology, 28(27),

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Ginex (ongoing study) • Examining factors that may predict which patients are more likely to

follow an oral anticancer regimen

Predictors of Nonadherence

When the world says “Give up,” Hope whispers, “Try one more time.”

-- Author Unknown

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“Nearly one quarter of all people with cancer now use oral medications as part of their

overall cancer treatment.”

“Important Issues in Medication Adherence” Overview Patient Resource Cancer Guide - Medication Adherence 2012 pp. 1Website: www.patientresource.com/medication_adherence_overview

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Specialty Pharmacy: Maximizing Outcomes

Patient Education and Resources: Engaging and Empowering

Support and Communication: Powerful touch points between patients and the extended healthcare team

Bridges to Improve Medication Non- Adherence

2020

“There has been a seismic shift in the way we treat cancer over the last several years & medication adherence has become a serious issue.” (CURE PG 4)

“As oral oncology medications are more widely used, patient adherence issues increase.” (CURE PG4)

“Non-adherence is a growing problem. Now there are many oral oncology medications and the responsibility is completely on the patient to take them or not.” (CURE PG12)

The Landscape in Cancer Care

CURE Supplement to CURE Magazine: “Special Report on Medication Adherence” (2012) Pp.. 4-12

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Roughly 125,000 people die each year in the United States because they do not take their medication properly

33-63% of medication related hospital admissions are related to non-adherence and account for $8.5 Billion annually

14-21% of patients never fill their original prescriptions 30-50% of all patients do not properly follow

prescribed medication instructions 12-20% of patients take other people’s medication Prescription drugs represent the fastest growing cost

component for health plans today

Troubling Trends & StatisticsImpacting Medication Adherence

Enhancing Prescription Medication Adherence: A National Action Plan, Bethesda, MD. USA Aug. 2007

The Medication Non-Adherence Epidemic:

A BILLION-DOLLAR HEALTHCARE CRISIS

Three Most Common Factors Forgetfulness Understanding Medication Costs

Dispensing Excellence, Issue 1 -Spring 2013 pp. 1

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Non- Adherent Behavior (Study of 1,020 Adults [40+] taking Prescribed Rx for a Chronic Medical Condition)

% Reporting Behavior

Forget to take Medication 42%

Run out of Medication 34%

Away from Home 27%

Attempt to Save Money 22%

Unpleasant Side Effects 21%

Too Busy 17%

Believed Medication was not needed 16%

Dislike taking Medication 12%

Patient Reported Reasons for Non-Adherence to Medication

Scott, G.N. (2013) Adherence Report Card: Is Patient Tutoring Needed? Medscape. Jul 19,2013

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Pharmacists are Key Partners in the

Future of Healthcare

On a national level, medication

non-adherence costs nearly

$290 Billion annually …

A significant source of waste in

our healthcare system

Anderson, S. (2011). Pharmacists: Reducing Costs, Saving Lives. Media Planet, 3(1), 9-10.

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Specialty Pharmacy Defined*

Often High Cost

Special Handling, Distribution and/or

Administration Requirements

Limited Access

FDA-mandated Risk Evaluation Mitigation

Strategy (REMS) Program

*Adapted from Blaser DA, et.al How to Define Specialty Pharmaceuticals – A Systematic Review. Am J Pharm Benefits. 2010;2(6).371-380.

Specialty Medication

Characteristics

Targets Chronic or Complex Conditions

Specialized Pharmacy Services

Prior Authorization

Patient Copay Assistance

Physician Contact

Proactive Patient Counseling & Education

Side Effect Management

Data / Reporting

Insurance Verification and Coordination of Benefits

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Dedicated Patient Care Team

©2012 Amber Enterprises, Inc., d.b.a. Amber Pharmacy

Nursing Services

In-home injection training Same nurse each time

BillingCoordinator

Insurance review Multiple payer processing

Clinical Oncology Pharmacist

24/7 availability Counseling, side effect

management

Care Coordinator Specialist

Refill reminders & scheduling; delivery follow-up

EnrollmentSpecialist

Coordination of benefits Prior authorization assistance Detailed review out-of-pocket

patient costs Patient assistance programs;

grants and foundations

Patients ALWAYS speak with a

member of their team

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Demonstrating Value to Healthcare Providers

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Medication Adherence Effects Quality in Cancer Care

“Quality care is the right diagnosis

and the right treatment in the right environment.”

NCCN Oncology Policy Summit: Measuring Quality in Oncology – Challenges & Opportunities Jul. 2013

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1. The Right Drug

2. The Right Dose

3. At the Right Time

4. On the Right Schedule

5. Under the Right Conditions

6. With the Right Precautions

Key Factors for Proper Adherence

Patient Resources & Cancer Guide – Medication Adherence, Overview, 2012 pp. (1)

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Direct Methods of Measuring Adherence• Direct Observation

• Lab Values & Test Measures

Indirect Methods of Measuring Adherence• Patient Questionnaires & Assessments

• Pill Counts

• Frequency of Prescription Refills

• Patient Journals & Medication Trackers

• Advanced Technology• Smart Phone Apps & Reminders• Rx Bottle Glow Caps

Methods of Measuring AdherenceDirect & Indirect Methods

Osterberg,L.& Blaschke, T. (2005) Adherence to Medication.The New England Journal of Medicine ; 353:489

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MedCoach Medication Reminder• Medications, refill reminders, history, doctors, pharmacies, etc.

Drugs.com• Includes “My Drug List” Drugs A-Z, drugs by condition, pill identifier,

interactions checker, side effects, phonetic search, Q & A, etc. iTriage

• Search symptoms, doctors, hospitals, conditions, medications, health news, etc.

Pill Monitor• Designed to manage pills and medications, pill reminders, history of

taking medications and pill monitor data.

(Logs can be shared by email)

Smart Phone Medication Apps

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Morisky 8 – Item MedicationAdherence Questionnaire

ASK 20 – Adherence Barrier Survey

Medication Adherence Assessments

Morisky DR, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986; 24:67-74ASK-20 Hahn SR, Yu-Isenberg KS, Priest JL, Skinner EP, Weaver MB, Olson PS. A comparison of barriers to medication adherence in patients with chronic conditions. Poster presented at: Society of general Internal Medicine 29th Annual Meeting; April 26-29, 2006

“Communication is the cornerstone of medication

adherence.”

“Important Issues in Medication Adherence” OverviewPatient Resource Cancer Guide - Medication Adherence 2012 pp. 2.

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Patient Education & Resources ProgramAn exclusive program

designed to assist and

support specialty pharmacy

patients and caregivers

dealing with specialized

health conditions

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Patient Care Methods to Improve Medication Adherence

Patient Education

Monitor Dosing Schedules

Communication

Osterberg,L.& Blaschke, T. (8-4-2005) Adherence to Medication. The New England Journal of Medicine; 353:5 491

Patient EmpowermentStories of hope, courage and compassion

Amber Pharmacy - Patient & Caregiver Case Studies; Referenced Organizations & Agencies in Website Bibliography

Farah

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Ruth

Linda and mother, Ann

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Aitken, M. (2013) Avoidable Costs in US Healthcare: the $200 Billion Opportunity from Using Medicines More

Responsibly. Reported by the IMS Institute for Healthcare Infomatics. (5)

ASK-20 Hahn SR., Yu-Isenberg KS., Priest JL, Skinner EP, Weaver MB., Olson PS.

A Comparison of Barriers to Medication Adherence in Patients with Chronic Conditions

Poster presented at: Society of General Internal Medicine 29th Annual Meeting; April 26-29, 2006

CURE Supplement to CURE Magazine – “Special Report on Medication Adherence” (2012) pp. 4-12

Dispensing Excellence Issue 1- Spring 2013 pp.1

Enhancing Prescription Medication Adherence: A National Action Plan, Bethesda, MD. USA August 2007

McKethan,A., Benner, J., Brookhart,A. (2012) Seizing The Opportunity To Improve Medication Adherence”

Health Affairs Blog. August 28th, 2012

Morisky DR, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of

medication adherence. Med Care 1986; 24:67-74

NCCN Oncology Policy Summit: Measuring Quality in Oncology – Challenges & Opportunities Jul. 2013

Osterberg,L.& Blaschke, T. (8-4-2005) “Adherence to Medication”. The New England Journal of Medicine;

353:5 487

Patient Resources & Cancer Guide – Medication Adherence, Overview, 2012 pp. (1)

Scott, G.N. (2013) Adherence Report Card: Is Patient Tutoring Needed? Medscape Jul 19, 2013

Stefanacci, R., & Guerin, S. (2013). Why medication adherence matters to patients, payers, providers.

Managed Care, 22(1), 37-39

Medication Adherence - Bibliography

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Questions & Answers

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