Medication Non Adherence X
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Transcript of Medication Non Adherence X
Medication Non-Adherence:
The Hidden Epidemic
Managing Medication Adherence & A Safe Hospital Discharge
David R Donohue, M.A., Qualitative Technologies, Inc. Milwaukee, WI
Dr. Tom Muscarello, Ph D, DePaul University, Chicago, IL
Henry J Kaiser Family Foundation, 2009
Incidence of Medication Noncompliance
50%50% of the 3.6 billion prescription medications dispensed annually in the United States are not taken
correctly by patients
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 prescribedAmerican Heart Association: Statistics you need to know. http://216.185.102.50/CAP/pro/prof_statistics2.html. Accessed July 27,
2009.
Impact of Medication Adherence on Hospitalization Risk
0
10
20
30
40
50
60
1-19* 20-39*
40-59*
60-79*
80-100
Medication Possession Ratio
Diabetes Hypertension Hypercholesterolemia
*P<0.05 when compared to the 80-100% group
Hosp
italiz a
t ion
Ris
k
Sokol etal. Med Care 2005;43: 521-530
Impact of Medication Adherence on All-Cause Healthcare Costs
02,000
4,0006,0008,000
10,000
12,00014,00016,000
18,000H
ealt
hcare
Co
st
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
Sokol etal. Med Care 2005;43: 521-530
Potential Barriers to Improving Adherence
Poor attitude Memory deficits Language 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 Cost
Vermiere E, et al. J Clin Pharm Ther. 2007;26:331-342.
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.
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 2003
Case Management Adherence Guidelines. Copyright© 2005. CMSA
CMAG Algorithm
CMAG Assessment Tools
Tools to assess patient knowledgeHealth Literacy Test – Realm RMedication Knowledge SurveyModified Morisky Scale
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
Bass Pf, Wilson JF, Griffith, CH. J Gen Intern Med.2003;18:1036-1038.
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
CMAG Assessment Tools
Tools to assess patient motivationReadiness RulerDuke-UNC Functional Social
Support Questionnaire
Readiness Ruler
Assess willingness to change behavior
Zimmerman GL, Olsen CG, Bosworth MF. Am Fam Physician.2000:61;1409-1416
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.
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.
New to CMAG RevisionRecognize unique needs of those working successfully with inpatients
Hospital Discharge
The Hospitalized Patient
Acknowledges patients higher level of acuity
Case managers may only be involved with a small percent of inpatients
Case managers & Nurses have a decreased period of time to interact and plan positive interventions with patients
Successful Discharge
Collaboration with other healthcare providers both within and outside the inpatient setting is extremely important to ensure a Successful Discharge
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 condition
Ensure the patient has 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
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
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.
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?
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 Publicly available quality rankings
Financial Prevent readmissions Promote timely patient discharges
Competitive Advantage for Hospital Discharge Planning
All hospitals seek to be viewed as providing an outstanding level of 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
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, 2005
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 adherence program and measure it
AHA, Get with the Guidelines
Coordination of Care and Transition of Care Outside the Hospital
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