Presentation on theme: "Medication Non-Adherence: The Hidden Epidemic"— Presentation transcript:
1 Medication Non-Adherence: The Hidden Epidemic Managing Medication Adherence & A Safe Hospital Discharge
2 Incidence of Medication Noncompliance 50% of the 1.8 billion prescription medications dispensed annually in the United States are not taken correctly by patientsReference: Smith DL. The effect of patient noncompliance on health care costs. Medical Interface 1993;74-84.Intent of Slide: Increase audience awareness of the prevalence of medication noncompliance in the U.S.Expand upon the opportunities available for the pharmacist to intervene and increase medication compliance through patient counseling and follow-up.Adherence to Long-Term Therapies: Evidence for Action. WHO 2003Smith DL - Med Interface 1993; 74-84
3 U.S. Patients Do Not Take Medications as Prescribed 100%76%*88%47%*Rx prescribedRx continuedRx takenRx filled-12%-29%* 22% of U.S. patients take less of the medication than is prescribedThis is a conceptual slide, based on statistics from the American Heart Association.Here you can see nonadherence broken down by behavior and quantified. As you can see, there is a progression of nonadherence that starts with not filling the prescription (12%). Then there are those that fill the prescription, but do not take the medication (12%). Then there are those who take the medication, but do not persist with it (29%). And within the percentage of patients that take their medications, there are 22% that take less than is prescribed. So according to this information, only 25% of those who are prescribed medication actually take it like they should.How does this affect patients?American Heart Association: Statistics you need to know. Accessed July 27, 2002.
4 Impact of Medication Adherence on Hospitalization Risk The impact of medication adherence on the estimated all-cause hospitalization risk based on regression analysis.Results indicated that the outcome was significantly higher than the outcome for the % group (P<0.05)In the public debate over rising prescription drug costs the potential economic return s are often missed. These results demonstrate that a net return may be obtained for 3 chronic conditions that account for a large share of long term medication use. In this slide statistically significant different differences were seen in the hospitalization risk in patients that had a lower adherence level compared to those with adherence levels from %Other Notes: The study consisted of 137,277 patients under age 65Measures included disease related and all cause medical costs, drug costs and hospitalization risk were measured. Using regression analysis these measure were modeled at varying levels of medication adherence. Medication adherence was defined by days’ supply of maintenance medications for each condition.*P<0.05 when compared to the % groupSokol etal. Med Care 2005;43:
5 Impact of Medication Adherence on All-Cause Healthcare Costs The estimated all-cause healthcare costs based on regression analysisIn the public debate over rising prescription drug costs the potential economic returns are often missed. These results demonstrate that a net return may be obtained for 3 chronic conditions that account for a large share of long term medication use. In this slide statistically significant different differences were seen in the hospitalization risk in patients that had a lower adherence level compared to those with adherence levels from %Other Notes: The study consisted of 137,277 patients under age 65.Measures included disease related and all cause medical costs, drug costs and hospitalization risk were measured. Using regression analysis these measures were modeled at varying levels of medication adherence. Medication adherence was defined by days’ supply of maintenance medications for each condition.*P<0.05 when compared to the % group+ P<0.05 when compared to the % group in Diabetes and Hypercholesterolemia PatientsSokol etal. Med Care 2005;43:
6 Potential Barriers to Improving Adherence Poor attitudeMemory deficitsLanguageLiteracyCultural beliefsAlternative health beliefsPoor supportPrideDenialFear or embarrassmentSide effectsReligious beliefsUnable to “see” results of drug therapyLack of choicesCostSome of these barriers are more easily overcome than others. (i.e. support can be provided externally but cultural and religious beliefs are deeply ingrained and difficult to bridge).Vermiere E, et al. J Clin Pharm Ther ;26:
7 What is CMAG?Developed from concepts presented by the World Health Organization (WHO)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.
8 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
10 Tools to assess patient knowledge CMAG Assessment ToolsTools to assess patient knowledgeHealth Literacy – RealmRMedication Knowledge SurveyModified Morisky Scale
11 Health LiteracyHealth 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 screening test
12 Bass Pf, Wilson JF, Griffith, CH. J Gen Intern Med.2003;18:1036-1038.
13 Medication Knowledge Survey Assesses knowledge of various medications to be taken, their dosing schedule, benefits and storageUseful as part of the knowledge assessment for CMAG to determine if the patient is in the high or low knowledge domain
15 Tools to assess patient motivation CMAG Assessment ToolsTools to assess patient motivationReadiness RulerDuke-UNC Functional Social Support Questionnaire
16 Readiness Ruler Assess willingness to change behavior Zimmerman GL, Olsen CG, Bosworth MF. Am Fam Physician.2000:61;
17 Social SupportFamily or social support is a significant predictor of adherence to long-term medical therapyDuke-UNC Functional Social Support QuestionnaireEight-item, self-administered, multidimensional instrumentBroadhead WE, et al. Med Care.1989:27;
19 Modified Morisky Scale Patients on existing therapyMorisky 4 item validated adherence predictor scaleTwo new items to recognize patient understanding of medication benefits as well as refill behaviorAllows patients to be categorized as either High or Low on Knowledge and Motivation domainsMorisky DE, Green LW, Levine DM. Med Care. 1986;24:67-74.
21 New to CMAG Revision Recognize unique needs of those working with inpatients Hospital Discharge
22 The Hospitalized Patient Acknowledges patients higher level of acuityCase managers may only be involved with a small percent of inpatientsCase managers & Nurses have a decreased period of time to interact and plan interventions with patientsCollaboration is important to ensure that the appropriate patients are referred to case management. Therefore, case managers need to work closely with other healthcare professional to ensure appropriate referral.
23 Successful DischargeCollaboration with other healthcare providers both within and outside the inpatient setting is extremely important to ensure a Successful Discharge
24 Steps to Ensure a Successful Discharge Educate the patient and ensure patient understanding on their diabetes disease process and factors that can influence their conditionEnsure the patient has the resources to manage their diabetes after discharge from the hospitalMake certain that the discharge will be “safe” for the individual patientEnsure that the patient understands the plan for transition of care into the post discharge settingMake certain that the patient has access to the follow up care and therapyCMAG 2 has coined the term Successful Discharge for patients receiving appropriate Discharge Planning services.Patients that receive the appropriate steps that lead to a Successful Discharge will be more likely to manage their disease outside the hospital. This will decrease the chances of the person needing to be readmitted to the hospital for acute exacerbations of chronic conditions and complications related to procedures. Since hospitalization is frequently the most expensive part of the treatment, this should help control overall healthcare expenditures.
25 Information for Patients to Ensure a Successful Discharge Patients that are educated regarding their diabetes and treatments are more likely to remain adherent to treatment recommendationsMany patients discharged from the hospital will leave on new medications or different routes of administration
26 Information for Patients to Ensure a Successful Discharge Medications that are newly started during hospitalization need to be reconciled with other medicationsPatients need to know how to monitor their diabetes and treatment in an outpatient setting.
27 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?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?
28 Why discharge counseling and adherence messaging are important for the hospital? Maintain AccreditationJCAHO, NCQA, CMSSuccessfully compete with other hospitals in the communityPatient satisfactionPublicly available quality rankingsFinancialPrevent readmissionsPromote timely patient discharges
29 Competitive Advantage for Hospital Discharge Planning Hospitals seek to be viewed as providing an outstanding level of careHospitals work to maintain a high level of patient satisfactionDischarge counseling is one of the last points of contact with the patientPatients and payers can now easily compare quality indicators on hospitals in their community
30 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< 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 knowledgeKing, 1998; Makaryus, 2005
31 Key Elements of Successful Discharge Planning Recruit a championBuild a multidisciplinary hospital teamReview baseline dataDevelop protocols and order sets that include appropriate evidence-based therapiesConduct hospital staff conferences to introduce process and gain buy inContinue data analysis and report results back to hospital staff on a regular basisEvaluate data and look for opportunities for improvementCreate an adherence programAHA, Get with the Guidelines
32 Coordination of Care and Transition of Care Outside the Hospital There are many individuals that may be involved in the discharge planning process. These individuals can be divided into lay individuals that provide support for the patients and those that are involved with the provision of healthcare services.
33 Transition of Care to the Outpatient Setting Involve family and caregivers in patient educationEnsure that patient has a plan for outpatient follow upFacilitate referral for outpatient services and healthcare providersAssist patients with resolving issues relating to the cost of outpatient services and treatmentsEvaluate Adherence Intention prior to discharge using CMAG toolsInvolvement of family and friends especially important for interventions involving lifestyle modifications.