MEDICATION ADHERENCE:

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MEDICATION ADHERENCE CHALLENGES AND
STRATEGIES Hanna Phan, PharmD, BCPS Clinical
Assistant Professor, College of
Pharmacy Assistant Professor, College of
MedicineResidency Program Director, Pediatric
PGY2 PharmD UA Pediatric Pulmonary
Center February 14, 2012
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Conflicts of interest

• Nothing to disclose

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OBJECTIVES

• Define medication adherence and describe its
  affect on various disease states
• Describe the health belief theories and their
  affect on medication adherence
• Identify common reasons for poor adherence based
  on patient-specific factors such as socioeconomic
  status, health beliefs, etc.
• Discuss possible strategies in improving
  medication adherence in children and adolescents

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Wisdom to ponder

• Drugs dont work in patients who dont take
  them.
• -C. Everett Koop, MD

Osterberg L, Blaschke T. NEJM. 2005 353487-97
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Medication adherence

• A.K.A. medication compliance
• ...the extent to which patients take medication
  as prescribed by their health care providers.
• Why is it important?
• Compromises efficacy of treatment regimens,
  leading to a failure to achieve a desired
  treatment goal

Osterberg L, Blaschke T. NEJM. 2005 353487-97
6
Medication adherence

• Adherence rates are higher in which?
• Acute conditions
• Chronic conditions
• What is an acceptable rate of adherence?
• Some say 80
• Variability

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Rates of Adherence

• Clinical trial reported adherence for chronic
  conditions 43 - 78 (all patient ages)
• Pediatric medication adherence rates 11 93
• Up to 69 of all hospital admissions are due to
  poor medication adherence (100 billion/year)
• Up to 50 of admissions associated with
  drug-related

Osterberg L, Blaschke T. NEJM. 2005
353487-97 Llorente RAA et al. J Cys Fib.
20087359-67 Desai M , Oppenheimer JJ. Curr
Allergy Asthma Rep. 2011 11454-64
8
Rates of adherence

• Asthma medications
• Frequently fall below 50 (30 - 70)
• Chronic controller medication is main issue
• Acute corticosteroid Rx
• 44 - 98 filled
• Up to 64 finished course
• Main barriers
• Access to controller medication
• Health beliefs (fear of side effects)
• Scheduling
• Peer pressures

Desai M , Oppenheimer JJ. Curr Allergy Asthma
Rep. 2011 11454-64
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Rates of adherence

• Cystic fibrosis (CF) medications
• Dependent on treatment type
• Greater with GI meds (e.g., enzymes) up to 88
• Lower with respiratory meds - up to 30-60
• Lower with airway clearance up to 30-40
• Main barriers
• Poor perception of efficacy (e.g., respiratory
  meds)
• Scheduling
• Peer pressures
• Access to health care (e.g., cost of medications)

Llorente RAA et al. J Cys Fib. 20087359-67,
Zindani GN et al. J Adoles Health. 200638
13-17 Bregnballe V. Pat Pref Adherence. 2011
5507-15, Latchford G et al. Pat Ed Counsel.
2009 75141-144.
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Measuring adherence

• Direct methods
• Observing therapy directly
• Measurement of drug or metabolite in serum
• Indirect methods
• Clinical responses
• Patient interviewing, questionnaires
• Treatment diary
• Refill rate
• Pill/medication counting
• Electronic monitoring

Osterberg L, Blaschke T. NEJM. 2005 353487-97
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Lets chat

• From your own experiences as a patient at one
  time or another, what caused you to be
  non-adherent to a medication or regimen?

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Barriers to adherence

• Patient specific factors
• Patient age
• Socioeconomic status
• Access to health care
• Family characteristics (including culture, health
  beliefs)
• Patient and/or caregiver psychosocial issues
• Perceived benefit (or lack there of) from
  treatment
• Medication specific factors
• Adverse drug effects
• Inconvenience in dosing, lack of palatability

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barriers Infants and young children

• Caregiver is responsible for medication
  administration
• Health beliefs of caregivers
• Limited language skills of infants
• and young children
• (e.g., PRN rescue medication)

Osterberg L, Blaschke T. NEJM. 2005
353487-97 Llorente RAA et al. J Cys Fib.
20087359-67 Desai M , Oppenheimer JJ. Curr
Allergy Asthma Rep. 2011 11454-64
14
barriers Infants and young children

• Time consuming treatments (e.g., nebulization)
• Caregiver vs. child battle for control
• Ease of administration
• Palatability
• Frequency
• Parental motivation

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Barriers Children

• Lack of structured home environment
• Caregiver and childs schedules
• Behavior and consequence
• Parental motivation
• Forgetfulness, stress
• Lack of immediate benefit from
• chronic treatment
• Health beliefs

Osterberg L, Blaschke T. NEJM. 2005
353487-97 Llorente RAA et al. J Cys Fib.
20087359-67 Desai M , Oppenheimer JJ. Curr
Allergy Asthma Rep. 2011 11454-64
16
Barriers Children

• Confusion with multiple medications
• Multiple drugs of same route, different timing
• Multiple pills/doses through out the day
• Acute treatment with chronic treatment
• Discharge follow-up (or lack there of)
• Perceived efficacy and side effects
• Caregiver perception

Osterberg L, Blaschke T. NEJM. 2005
353487-97 Llorente RAA et al. J Cys Fib.
20087359-67 Desai M , Oppenheimer JJ. Curr
Allergy Asthma Rep. 2011 11454-64
17
Barriers Adolescents

• Increasing independence, self-administer
  medication
• Some of the same factors as children (e.g., home
  environment)
• Lack of structured home environment
• Confusion with multiple medications
• Perceived efficacy and side effects

Osterberg L, Blaschke T. NEJM. 2005
353487-97 Llorente RAA et al. J Cys Fib.
20087359-67 Desai M , Oppenheimer JJ. Curr
Allergy Asthma Rep. 2011 11454-64
18
Barriers Adolescents

• Depression and high-risk behavior
• Triad of behavior depression, unhealthy
  behavior, non-adherence
• Peer pressures, acceptance
• Medication use in school, social events, etc.

Osterberg L, Blaschke T. NEJM. 2005
353487-97 Llorente RAA et al. J Cys Fib.
20087359-67 Desai M , Oppenheimer JJ. Curr
Allergy Asthma Rep. 2011 11454-64
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Lets chat

• Of the discussed barriers for medication
  adherence, which have you noticed in your
  experiences at the clinic?

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Health Belief Theories

• Application in chronic conditions such as asthma,
  CF, attention deficit hyperactivity disorder
• Health Belief Model
• Focus on patients and caregivers assessment of
• Seriousness of disease
• Perceived benefit from treatment
• Planned Behavior Model
• Address subjective norm (e.g., peer pressure)
• Move towards accepting treatment

US Department of Health and Human Services,
National Institutes of Health. Theory at a
Glance Application to Health Promotion and
Health Behavior. Second Edition, 2005. Available
at www.cancer.gov/cancertopics/cancerlibrary/theo
ry.pdf. Accessed May 1, 2011.
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Predictors of Poor Adherence

• Presence of psychological problems, particularly
  depression
• Presence of cognitive impairment
• Treatment of asymptomatic disease
• Inadequate follow-up or discharge planning
• Side effects of medication

Osterberg L, Blaschke T. NEJM. 2005 353487-97
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Predictors of Poor Adherence - Continued

• Patient/caregiver lack of belief in benefit
• Patient/caregiver lack of insight into illness
• Poor provider-patient relationship
• Presence of barriers to care or medications
• Missed appointments
• Complexity of treatment
• Cost of treatment

Osterberg L, Blaschke T. NEJM. 2005 353487-97
23
Interactions adherence
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Adherence is good!
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Studied Strategies - ASthma

• Electronic monitoring and feedback (MDILogII)
• Monitors MDI inhalers, provided feedback to
  parents bimonthly
• School-based supervised asthma therapy
• School official observes student self-administer
  controller medication
• Home based education adherence feedback
• 5 home visits with asthma educators /- feedback

Spaulding SA et al. J Pediatr Psychol.
20123164-74 Gerald LB et al. Pediatrics. 2009
123466-74 Otsuki MO et al. Pediatrics. 2009
1241513-21
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Studied Strategies - CF

• Adaptive aerosol delivery (AAD)
• Nebulizer device w/ electronic capabilities to
  monitor when it is used, for how long, and if
  full dose taken
• Automated medication dose reminder
• Customized pagers, text messages
• Cell Phone Intervention (CFFONE)
• Web-enabled cell phone
• Reminders with CF information and support

McNamara PS et al. J Cys Fib. 2009
8258-263 Johnson KB et al. J Telemed Telecare.
2011 17387-391 Marciel KK et al. Pediatr
Pulmolol. 201045157-64
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Lets chat

• Of the discussed studied strategies, which of
  them do you think are/are not practically
  feasible for real-world application? Why?

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practical Strategies

• Patient and family education
• Formalized sessions or part of clinic visits
• Medication reminders
• Medication list
• Cell phone reminders
• Alarms
• Simplifying medication regimen
• Appropriate drug selection (e.g., ease,
  palatability)
• Pharmacy reminders for refills

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Tools for adherence

• Reminders
• Medication Event Monitoring System (MEMS)
• Blister packs
• Alert watch
• Online resources
• MyMedSchedule.com
• Smart phone apps

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Example of Adherence tool
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What we are doing

• Adherence assessment with each clinic visit
• Patient quizzing
• What, how, when, why about medications
• Patient and family education as part of clinic
  visit
• Homework for older children and adolescents
• Empower patient to taken ownership of health and
  treatments
• Encouraged use of medication lists
• Hard copy, electronic, mobile
• Simplifying medication schedules

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Patient Medication list
http//kidsmeds.info/attachments/wysiwyg/1/My_Medi
cation_Information_Sheet.pdf
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Summary

• Medication adherence
• Rate is worse in chronic illnesses, affects
  patient outcomes and health resources
• Depends on various factors
• Age, psychosocial, health beliefs, etc.
• Its not a lone venture
• Patient, Caregiver, Health care provider, Support
• There are tools available, studied strategies to
  help improve adherence
• Patient preference, team effort to improvement

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Questions?

• hphan_at_pharmacy.arizona.edu