Medication Adherence
[Primary care educators may use the following slides for
their own teaching purposes]
CDC’s Noon Conference
March 27, 2013
Overview of This Educational Module
Medication adherence
Burden of non-adherence
Effective interventions to improve adherence
Measuring medication adherence
Provider’s role in improving medication adherence
Tools and resources
Case studies
DEFINITION
What is Adherence?
Cluster of behaviors
Simultaneously affected by multiple factors
The extent to which a person’ s behavior—taking
medication, following a diet, or making healthy lifestyle
changes—corresponds with agreed-upon
recommendations from a health-care provider
World Health Organization, 2003
Source: [Link]
What is Medication Adherence?
Medication Adherence: The patient’s conformance with the
provider’s recommendation with respect to timing, dosage,
and frequency of medication-taking during the prescribed
length of time
Compliance: Patient’s passive following of provider’s orders
Persistence: Duration of time patient takes
medication, from initiation to discontinuation
of therapy
Source:
[Link]
[Link]
OBJECTIVES
Objectives of This Module
Learn ways to improve medication adherence rates
Develop a summary of existing evidence-based
knowledge
Inform, raise awareness, and promote discussion
among patients, clinicians, pharmacists, payers, public
health practitioners, and decision makers about ways
to improve medication adherence
BACKGROUND
Background
Medication prescriptions never filled: 20% to 30%
Medication not continued as prescribed in about 50% of
cases
The World Health Organization estimated that by 2020,
the number of Americans affected by at least one chronic
condition requiring medication therapy will grow to 157
million
Sources: [Link] ; Osterberg 2005, NEJM; Ho 2009, Circulation
Medication Adherence in United States
Rates of medication adherence drop after first six
months
Only 51% of Americans treated for hypertension are
adherent to their long-term therapy
About 25% to 50% of patients discontinue statins within
one year of treatment initiation
Source: Choudhry 2011, N Engl J Med; Yeaw 2009, J Manag Care Pharm; Script Your Future press release, November 2, 2011;
accessed here: [Link]
BURDEN OF NON-ADHERENCE
Non-Adherence—Economic
Direct cost estimated at $100 billion to $289 billion
annually
Costs $2000 per patient in physician visits annually
Improved self-management of chronic diseases results
in an approximate cost-to-savings ratio of 1:10
Cost-related non-adherence reported by 11.4%
(~543,000 individuals) of stroke survivors, mostly
among the uninsured and younger (45 to 64 years)
Sources: Ho 2009, Circulation; Levine et al. 2013, Annals of Neurology
Non-Adherence—Clinical Outcomes
High adherence to antihypertensive medication is
associated with higher odds of blood pressure control
Each incremental 25% increase in proportion of days
covered (PDC ) for statins is associated with ~3.8 mg/dl
reduction in LDL cholesterol
Source: Ho 2009, Circulation
Non-adherence—Mortality, Hospitalizations,
ED Visits
Non-adherence causes ~30% to 50% of treatment failures and
125,000 deaths annually
Non-adherence to statins increased relative risk for mortality
(~12% to 25%)
Non-adherence to cardioprotective medications increased
risk of cardiovascular hospitalizations (10% to 40%) and
mortality (50% to 80%)
Poor adherence to heart failure medications increased the
number of cardiovascular-related emergency department
(ED) visits
Sources: Ho 2009, Circulation; Edmondson 2013, Br J of Health Psychology; George & Shalansky 2006, Br J Clin Phar
DIMENSIONS OF NON-ADHERENCE
Five Interacting Dimensions of
Non-Adherence
Health-care
system/team
factors
Social and Patient-related
economic factors
factors
Condition-related Therapy-related
factors factors
Source: [Link]
Health-care Factors
Health-care Team
Health-care System
Stress of health-care visits
Access to care
Discomfort in asking providers
Continuity of questions
care
Patient’s belief or
Patient education understanding
material not
written in plain Patient’s forgetfulness or
language carelessness
Stressful life events
Lack of immediate benefit of
therapy
Sources: [Link]
Provider Factors
Communication skills
Knowledge of health literacy issues
Lack of empathy
Lack of positive reinforcement
Number of comorbid conditions
Number of medications needed per day
Types or components of medication
Amount of prescribed medications or
duration of prescription
Source: Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane
Database Syst Rev 2008;(2):CD000011
Patient, Condition, and Therapy Factors
Patient-related Condition- and therapy-related
Physical Complexity of medication
Psychological Frequent changes in regimen
Treatment requiring mastery of
certain techniques
Unpleasant side effects
Duration of therapy
Lack of immediate benefit of therapy
Medications with social stigma
Sources: [Link]
Economic and Social Factors
Economic Social
Health insurance Limited English proficiency
Medication cost Inability to access or difficulty
accessing pharmacy
Lack of family or social support
Unstable living conditions
Source: [Link]
What May Providers Do to Overcome These
Challenges?
Communication is key!
Effective interventions
Measure medication adherence
Sources: Ratanawongsa 2012 Arch Intern Med ; Bramley 2006 J Manag Care Pharm 12(3):239-245; Martin 2011 Am J Health
Promot 25(6):372-378
INTERVENTIONS
SIMPLE
S— Simplify the regimen
I — Impart knowledge
M—Modify patient beliefs and behavior
P — Provide communication and trust
L — Leave the bias
E — Evaluate adherence
Source: [Link]
S—Simplify the Regimen
Adjust timing, frequency, amount, and dosage
Match regimen to patient’s activities of daily living
Recommend taking all medications at the same time of
day
Avoid prescribing medications with special requirements
Investigate customized packaging for patients
Encourage use of adherence aids
Consider changing the situation vs. changing the patient
Source: [Link]
I—Impart Knowledge
Focus on patient-provider shared decision making
Keep the team informed (physicians, nurses, and
pharmacists)
Involve patient’s family or caregiver if appropriate
Advise on how to cope with medication costs
Provide all prescription instructions clearly in writing
and verbally
Suggest additional information from Internet if patients
are interested
Reinforce all discussions often, especially
for low-literacy patients
Source: [Link]
M—Modify Patient Beliefs and Behavior
Empower patients to self-manage their condition
Ensure that patients understand their risks if they don’t
take their medications
Ask patients about the consequences of not taking their
medications
Have patients restate the positive benefits of taking their
medications
Address fears and concerns
Provide rewards for adherence
Source: [Link]
P—Provide Communication and Trust
Improve interviewing skills
Practice active listening
Provide emotional support
Use plain language
Elicit patient’s input in treatment decisions
Source: [Link]
L—Leave the Bias
Understand health literacy and how it affects outcomes
Examine self-efficacy regarding care of racial, ethnic, and
social minority populations
Develop patient-centered communication style
Acknowledge biases in medical decision making
Address dissonance of patient-provider, race-ethnicity, and
language
Sources: [Link] Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H.
Freeman; Bandura, A. (1994). Self-efficacy. In V.S. Ramachaudran (Ed.), Encyclopedia of human behavior;4. New York: Academic
Press, pp. 71-81.
E—Evaluating Adherence
Self-report
Ask about adherence behavior at every visit
Periodically review patient’s medication containers,
noting renewal dates
Use biochemical tests—measure serum or urine
medication levels as needed
Use medication adherence scales—for example:
Morisky-8 (MMAS-8)
Morisky-4 (MMAS-4, also known as the Medication Adherence
Questionnaire or MAQ)
Medication Possession Ratio (MPR)
Proportion of Days Covered (PDC)
Sources: [Link] Morisky, DE & DiMatteo, MR. Journal of Clinical Epidemiology 2011; 64:262-
263; [Link]
MEDICATION ADHERENCE SCALES
General Guide to Choosing Medication Adherence
Scales Based on Disease of Interest
Therapeutic Area Medication Adherence Scales
MAQ (shortest to administer)
SEAMS (assesses self-efficacy)
Metabolic Disorders: BMQ (diabetes only)
hypertension, dyslipidemia, diabetes Hill-Bone Compliance Scale
(hypertension in predominantly
black populations)
MARS (schizophrenia and psychosis)
Mental Health:
BMQ (depression)
schizophrenia, psychosis, depression
Abbreviations used:
BMQ = Brief Medication Questionnaire
MAQ = Medication Adherence Questionnaire (also known as the Morisky-4 or MMAS-4 scale)
MARS = Medication Adherence Rating Scale
SEAMS = Self-Efficacy for Appropriate Medication Use Scale
Source: Lavsa SM et al. J Am Pharm Assoc. 2011;51(1):90-94;
Interventions Should be Patient-Tailored
Behavior-related
Forgetfulness of patients
• Daily alerts
• 90 days medication supplies
• Automatic renewals
Clinical—Questions or concerns about medication
Pharmacist consultation
Linguistically and culturally appropriate
Cost-related
Payment assistance programs
Lower cost medication alternatives
Lower cost pharmacy option (e.g. , home delivery)
STRATEGIES TO IMPROVE
MEDICATION ADHERENCE
Effective Strategies for Improving Hypertension
Medication Adherence
Team-based care
Pharmacist-led multicomponent interventions
Education with behavioral support
Pill counting
Blister packaging
Electronic monitoring
Telecommunication systems for monitoring and counseling
Single dose vs. multiple dose prescribed
Sources: Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic
review. Medical Care 2006;44:646-57; Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to
improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern
Med 2012; 157(11):785-795.
How to Overcome Challenges or
Barriers by System Change
Introduce team-based care
Collaborate with pharmacists and/or nurses
Educate patients on how to take medications
Monitor by pill box
Improve access and communication
Offer patients the opportunity to contact the provider’s office with any
questions
Use telemedicine, particularly in rural areas
Use technologies and analytical services that facilitate measuring
and improved adherence
Script Your Future
National multiyear campaign to raise awareness about
medication adherence
This campaign brings together stakeholders in health
care, business, and government in six regional target
markets
For health-care professionals, the campaign offers
guidance on how to improve communication with
patients
For patients, the campaign offers practical tools to
improve medication adherence
Sources: [Link]
US Surgeon General Regina Benjamin, MD
“Doctors, nurses, pharmacists and other health care
professionals can help prevent many serious health
complications by initiating conversations with their patients
about the importance of taking medication as directed. This is
especially important for people with chronic health
conditions such as diabetes, asthma and high blood pressure,
who may have a number of medicines to take each day.”
Source: [Link]
Take-Home Messages for Providers
Display patience and empathy when interacting with
patients
Be mindful of the number of medications prescribed and
their frequency and dosages
Prescribe lower-cost medications and/or provide
manufacturer coupons to help lower costs
Explain the consequences of non-adherence and suggest
ways to improve adherence
Introduce team-based care to improve medication
adherence
Identify roles and responsibilities in team-based care to
deliver improved patient-centered health care
Tools
American Heart Association
Medicine Management Tool
American College of Cardiology
CardioSmart Med Reminder (mobile app)
National Heart, Lung, and Blood Institute, National
Institutes of Health
Tips to Help You Remember to Take Your Blood Pressure Drugs
American Society of Consultant Pharmacists Foundation
Adult Meducation: Improving Medication Adherence in Older Adults
Script Your Future
Wallet card for patients
Tools for providers
Sources: URLs added to notes section of this slide
CDC Resources
Educational Materials for Professionals. Division for
Heart Disease and Stroke Prevention.
Fact Sheets, Data and Statistics, Maps, Reports, Guidelines and
Recommendations. Available at
[Link]
Million Hearts: Prevention at Work.
Achieve excellence in the "ABCS" (A=Aspirin for people at risk,
B=Blood pressure control, C=Cholesterol management, S=Smoking
cessation). Available at
• [Link]
• [Link]
CDC Resources—(cont.)
Team Up. Pressure Down.
Providers may inform patients with high blood pressure to team up
with their pharmacist to better understand their condition and any
medications they are taking. Available at
[Link]
[Link]
Partners
A Program Guide for Public Health Partnering with
Pharmacists in the Prevention and Control of Chronic
Diseases. Division for Heart Disease and Stroke
Prevention and Division of Diabetes Translation.
This guide focuses on medication therapy management services
provided by pharmacists to improve medication adherence. Available
at
[Link]
cist_Guide.pdf
Health Literacy Resources
American Medical Association Health Literacy Video
[Link]
foundation/our-programs/public-health/health-literacy-
program/[Link]
[Link]
AHRQ’s Health Literacy Universal Precautions Toolkit
[Link]
[Link]
American College of Physician Foundation Health
Literacy Programs and Resources on Medication
Labeling
[Link]
programs/medication-labeling-2/
References
1. Casula M, Tragni E, Catapano AL. Adherence to lipid-lowering treatment: the patient
perspective. Patient Prefer Adherence 2012; 6:805-814.
2. Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al. Full
coverage for preventive medications after myocardial infarction. N Engl J Med
2011;365(22), 2088-2097.
3. Edmondson D, Horowitz CR, Goldfinger JZ, Fei K, Kronish IM. Concerns about
medications mediate the association of posttraumatic stress disorder with
adherence to medication in stroke survivors. Br J Health Psychol 2013 Jan 7; doi:
10.1111/bjhp.12022. [Epub ahead of print].
4. Elliott RA, Barber N, Horne R. Cost-effectiveness of adherence-enhancing
interventions: a quality assessment of the evidence. Ann Pharmacother 2005;
39(3):508-515.
5. Fongwa MN, Evangelista LS, Hays RD, Martins DS, Elashoff D, Cowan MJ, et al.
Adherence treatment factors in hypertensive African American women. Vasc Health
Risk Manag 2008; 4(1):157-166.
6. Fretheim A, Aaserud M, Oxman AD. Rational prescribing in primary care (RaPP):
economic evaluation of an intervention to improve professional practice. PLoS Med
2006; 3(6):e216.
7. George J, Shalansky SJ. Predictors of refill non-adherence in patients with heart
failure. Br J Clin Pharmacol 2007; 63(4):488-493.
References (cont.)
8. Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood
pressure control among United States adults with hypertension: the National Health
and Nutrition Examination Survey, 2001 to 2010. Circulation 2012; 126(17):2105-
2114.
9. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in
cardiovascular outcomes. Circulation 2009; 119(23):3028-3035.
10. Ito K, Shrank WH, Avorn J, Patrick AR, Brennan TA, Antman, EM et al. Comparative cost-
effectiveness of interventions to improve medication adherence after myocardial
infarction. Health Serv Res 2012; 47(6):2097-2117.
11. Kronish IM, Edmondson D, Goldfinger JZ, Fei K, Horowitz CR. Posttraumatic stress
disorder and adherence to medications in survivors of strokes and transient ischemic
attacks. Stroke 2012; 43(8):2192-2197.
12. Levine DA, Morgenstern LB, Langa KM, Piette JD, Rogers MA, Karve SJ. Recent trends in
cost‐related medication nonadherence among US stroke survivors. Annals of Neurology
2013 Feb 22; doi: 10.1002/ana.23823. [Epub ahead of print].
13. Lyles CR, Karter AJ, Young BA, Spigner C, Grembowski D, Schillinger D, et al. Patient-
reported racial/ethnic healthcare provider discrimination and medication
intensification in the Diabetes Study of Northern California (DISTANCE). J Gen Intern
Med 2011; 26(10):1138-1144.
14. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication
adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008;
10(5):348-354.
References (cont.)
15. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication
nonadherence: response to authors. J Clin Epidemiol 2011; 64(3):255-257.
16. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353(5):487-497.
17. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based
pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA
2007;297:177–186.
18. Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, Moffet HH, et al.
Communication and medication refill adherence: the Diabetes Study of Northern
California. Arch Intern Med 2012 Dec 31;1-9.
19. Steiner JF, Ho PM, Beaty BL, Dickinson LM, Hanratty R, Zeng C, et al. Sociodemographic
and clinical characteristics are not clinically useful predictors of refill adherence in
patients with hypertension. Circ Cardiovasc Qual Outcomes 2009; 2(5):451-457.
20. Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions
to improve adherence to self-administered medications for chronic diseases in the
United States: a systematic review. Ann Intern Med 2012; 157(11):785-795.
21. Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for
hypertension management: a systematic review. Medical Care 2006;44:646-57.
22. Yeaw J, Benner JS, Walt JG, Sian S, Smith DB. Comparing adherence and persistence
across 6 chronic medication classes. J Manag Care Pharm 2009; 15(9), 728-740.
Acknowledgements
Farah M. Chowdhury, MBBS, MPH
Deesha Patel, MPH
Mary G. George, MD, MSPH, FACS
David Callahan, MD, FAAFP
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@[Link] Web: [Link]
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
Division for Heart Disease and Stroke Prevention (DHDSP)
National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)
