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Patient Non-Compliance With Medications 3 rd Year Research Project Class of 2007.

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Presentation on theme: "Patient Non-Compliance With Medications 3 rd Year Research Project Class of 2007."— Presentation transcript:

1 Patient Non-Compliance With Medications 3 rd Year Research Project Class of 2007

2 Introduction Medication non-compliance …..the world’s “other drug problem” 4

3 Medication Non-Compliance As dangerous and costly as many illnesses Increases the cost of healthcare as a result of adverse outcomes 4 (i.e. hospitalizations, development of additional illnesses/complications, exacerbation of the disease or disease progression, premature disability, or death)

4 Medication Non-Compliance In the United States, 50-70% of patients do not properly take their medications 5 Costs of patient non-compliance are estimated at over $100 billion annually 5

5 Definition Compliance, simply defined as “agreement.” With regard to medicine, compliance means agreeing to take medicine(s) as directed, and then following through with that agreement…..accepting the responsibility of taking medicine(s) as agreed 8

6 Definition Adherence is defined as the extent to which a patient’s health behavior coincides with their physician’s recommendations, whether taking medications or following advice for some type of behavioral change

7 Adherence vs. Compliance Adherence is a more accurate term than compliance Compliance suggests a process in which dutiful patients passively follow the advice of their physicians Adherence, in contrast, better fits how most patients actively participate in their care and decide for themselves when and whether to follow their doctor’s advice

8 Background Research Multiple studies done looking at adherence to medication and recommended interventions to improve compliance Typical adherence rates for prescribed medications are about 50% with a range from 0% to 100% 1 Adherence greater during first 6 months of follow up and drops thereafter 1 Chronic and asymptomatic disease have lower adherence rates than acute ones 1

9 Recent Studies Primary Medication Adherence in a Rural Population: The Role of the Patient-Physician Relationship and Satisfaction with Care (Thomas H. Wroth, MD, MPH and Donald E. Pathman, MD, MPH ) – Prescription primary non-adherence is prevalent in the rural South. Adherence may be improved by remedying patient dissatisfaction and lack of confidence in their physicians as well as addressing transportation barriers

10 Recent Studies Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure, and Low-Density Lipoprotein Cholesterol – A pharmacy care program led to increases in medication adherence, medication persistence, and clinically meaningful reductions in BP, whereas discontinuation of the program was associated with decreased medication adherence and persistence

11 Background Research Although correlates of overall medication adherence have been studied, little is known about primary medication non-adherence and whether it relates to how patients view their physician, satisfaction with their care, and how easy or difficult it is for them to travel for care

12 Hypothesis Patient non-adherence with medications can be attributed to 4 key reasons: –Language Barrier –Low Education Level –Poor doctor-patient interaction –System related obstacles

13 Objectives 1.To evaluate if language barriers interfere with patient adherence with medications 2.To discover if low literacy has an impact on patient adherence 3.To assess if doctor-patient interaction has an effect on patient adherence 4.To find if there are system-based factors that interfere with patient adherence

14 Purpose Of Our Study To identify the factors that contribute to patient non-adherence with medications in an effort to optimize patient care and reduce morbidity and mortality

15 Methods 3-page survey constructed with questions written at 8 th grade level in both English and Spanish Questionnaires written in Spanish were reviewed by certified interpreters to check for accuracy Each Resident was assigned with the task of completing a minimum of 30 surveys

16 Methods Questionnaires were given to “eligible” patients upon registration for a clinic visit Some Residents surveyed their assigned patients once they entered the patient’s room Eligibility determined by inclusion and exclusion criteria*

17 Inclusion/Exclusion Criteria Inclusion Both genders All Ethnicities Age  18 years old Taking  1 prescription medication not under the exclusion criteria* Registered as FCC patient for > 1 year Last visit to FCC w/in 6 months *special inclusion for ASA for cardiovascular risk prevention and calcium with vitamin D for postmenopausal women not on HRT Exclusion Age < 18 years old Pts. with dementia or cognitive impairment requiring assistance or special needs FCC patient for < 1 yr. Last visit to FCC > 6 m. Any medication(s) not taken on a scheduled basis OTC meds NSAIDs Narcotics

18 Methods Patients allowed as much time as needed to complete surveys, and able to use medication bottles/lists for assistance Physicians reviewed surveys upon completion to verify accuracy and make any necessary clarifications during patient interview Questionnaires valid once signed by physician

19 Methods Data compiled to see: –What percentage of patients know the medications they are taking and for what reason –What patients do when they run out of their medication –What reason(s) patients give for not taking their medication as prescribed

20 Methods Data collected used to identify the specific individual-based obstacles as well as system-based obstacles involved in medication adherence

21 Methods Identify problematic areas as defined by our patient population Implement strategies in FCC to improve medication adherence and standard of care

22 Survey 1. Circle your gender: Female Male 2. Circle your ethnicity (optional) Caucasian Hispanic Africanamerican Asian Philipino American-Indian Other 3. Circle the language or languages that you speak: English Spanish English and Spanish other 4. How old are you? (Circle the one that apply) 18-30 31-45 46-65 65 or more

23 Survey 5. How long have you been a patient in Family Care Clinic? 1-3 years 3-6 years more than 6 years 6. What is your education level? (Circle the one that applies better to you) A. Don’t know how to read B. Can read with difficulty C. Can read very well D. Finish elementary school E. Finish High school F. More than high school

24 Survey 7. What kind of insurance do you have? MISP MEDICAL MEDICARE IEHP Exclusive Care MOLINA Self Paid Pending 8. Do you know the medications you are taking? Yes No 9. Do you have the mediations with you? Yes No 10. Can you name them? Yes No 11. Do you know what the medications you are taking are for? Yes No 12. How many medications are you taking? 13. How many times a day do you have take your medicines?

25 Survey 14. Where do you get your medications? RCRMC Other Pharmacy 15.What do you do when you run out of medication? (Circle what happens most often) A. Call the pharmacy B. Call the doctor’s office C. Call the special line to refill medications D. Go to the emergency room E. Stop taking the medication

26 Survey 16.What are the reason(s) that you run out of medication? (you can choose more than one) [ If you choose more than one, please put* next to the most common reason] A. Pharmacy lost the prescription B. Language problem in communication with Pharmacy. If yes was an interpreter available Yes No C. Medications needs TAR form to be filled by the doctor D. Didn’t have the copayment to pay medications E. Pharmacy was closed when trying to get prescriptions F. Pharmacy was to slow and left without getting the prescriptions G. Didn’t have doctor’s license number in prescription when trying to get prescriptions outside the hospital H. Hard time getting transportation to pharmacy I. Finish medications earlier than the next doctor’s appointment J. Waiting for doctor’s office to refill medication

27 Survey 17. Did you know there is a special phone line to refill your prescriptions over the phone Yes No 18. If yes Have you ever use it? Yes No If yes, were you able to refill your medications through it? Yes No If Not, you couldn’t do it because: A. Didn’t understand how to use it? B. Line was too busy most of the time and couldn’t get through it C. Unable to spell the name of your medication D. Left message over the phone but didn’t get a call from the Dr. telling you that your prescriptions were ready.

28 Survey 19. Reasons why you don’t take your medications as prescribed: (Circle all the reasons that apply to you) A. Forget to take it B. Confusion as to what medication to take and when C. Fear of side effects D. Don’t know what the medications you are taking are for E. Feel depressed or sad and don’t feel like taking the medicines F. Disorganization, lose medications can’t find where are they

29 Survey 20. What motivates you the most to take your medications? (Circle all that apply) Put * next to the main reason A. The doctor during the visit B. The nurses C. Myself D. My family E. Friends F. Other 21. Please write down any suggestions to improve your own compliance with your medications


















47 Of the 84 that couldn’t refill, 5 didn’t understand how to use it




51 Conclusion Medication Non-Adherence is Multifactorial

52 Prerequisites to Adherence 6 1)Demographics 2)Psychosocial & Behavioral Characteristics 3)Medication Characteristics 4)Healthcare Delivery System Characteristics

53 Demographic Variables Age Socio-economic status of the patients –e.g. unstable living quarters, limited access to healthcare facilities, burdensome schedules, language barrier, limited level of education, lack of financial resources to pay for medications

54 Socioeconomic Factors

55 Psychosocial & Behavioral Characteristics Patients’ medication-taking behavior Patients’ beliefs about and attitudes towards their disease –More likely to be compliant if they feel threatened by their disease, or if they believe their medication will actually cure or control the disease


57 Medication Characteristics Complexity of the regimen Effects of the regimen

58 Characteristics Associated with Decreased Compliance 7 >4 meds More frequent daily doses Patient confusion re: med regimen Patients’ belief that they cannot follow the regimen Fear of side effects


60 Healthcare Delivery System Characteristics System-related obstacles –Pharmacy waiting time, difficulty obtaining medication refills, insurance complications Lack of knowledge and understanding of their disease state and regimen –Relationship between the patient and the healthcare provider

61 System-Related Obstacles #1 concern: Pharmacy Only 2.3% of those surveyed, claimed to have never run out of medications! … what about the other 97.7% of patients who do run out of medications?

62 System-Related Obstacles Cont’d 13% simply stop taking the medication or go to the ER 14% use the Prescription Refill Line 21% call their Doctor 44% call the Pharmacy

63 Knowledge of Prescription Refill Line YES NO 56% 44% Used It Didn’t Use 57% 43% Didn’t Know ?????? How ???? 4% 96%

64 Pharmacy Most popular method of refilling medications, and yet: –Language problems when communicating w/ Pharmacy staff –Medication Tars –Pharmacy hours too limited –Too long of a wait, patients unable to wait 36% of patients had these specific pharmacy complaints

65 Physician-Patient Relationship Nearly 70% of patients cited themselves as the motivating factor in adhering to medication regimens What does this mean? Patient education is a must! It’s our duty as physicians to explain medical conditions, treatment options, prognosis in terms that the patient can understand

66 Strengths/Weaknesses Strengths Non-Bias Willingness of Physicians Involved Good Sample Size Thoroughness Applicable to RCRMC Patient Population Weaknesses Human error Length of Survey Language Barrier Selection Bias

67 Recommendations – System Based Obstacles Medication Card Upon registration, the patient will be given a medication card at the front desk (unless the patient has an old card) Patient will first attempt to fill out the card in the waiting room Nurse will review the card and verify the medications by the bottles and note from previous visit Physician will do the final review and completion of the card

68 Recommendations – System Based Obstacles Write prescription on-line Ex. Medications can be easily reviewed, and medication list can be printed out Cost?

69 Recommendations – System Based Obstacles Extend open hours for RCRMC Pharmacy New outside county pharmacy for MISP patients Write from the list of Walmart $5 prescription or Costco special price medications

70 Recommendations – System Based Obstacles Stamp the refill line number on the appointment card Post refill line number on the door inside the room Email address for pharmacy refill Easier access of medication profile inside the hospital computer system

71 Recommendations – Language Barrier One full time Spanish interpreter for pharmacy Interpreter phone at pharmacy

72 Recommendations – Doctor-Patient Interaction Strategies for increasing adherence 3 : Provide rationale for tx. in patient’s language Collaborate on tx. plan Frequent follow-up Positive reinforcement Family counseling/therapy

73 Recommendations – Doctor-Patient Interaction Doctor to prescribe more medication refills (ex. 6 refills for chronic meds) Doctor to ask for side effect of medications at the start of the clinic visit Doctor to ask if patient needs medication refill before next appointment Doctor to remind patient at the end of every visit to take medications


75 Recommendation – Front Office-Patient Interaction When the patient is called to confirm appointment, remind the patient to bring the bottles of their medications

76 References 1.“Interventions to Enhance Patient Adherence to Medication Prescriptions”; Clinician’s Corner 2.Up-To-Date: Adherence to Pharmacologic Therapy 3.“Adherence to Pharmacologic Therapy in Patients with Type 2 Diabetes Mellitus”; American Journal of Medicine; Vol. 118, May 2005 4.Zuger, Abigail. “The ‘Other’ Drug Problem: Forgetting to Take Them,” The New York Times, June 2:Section F, Page 1, Column 2, 1998 5.Santella, T., Wertheimer, A.. “Medication Compliance Research: Still So Far to Go,” The Journal of Applied Research; Vol. 33, 2001 6.Berger, Bruce. “Improving Treatment Adherence: A Motivational Interviewing Approach,”, 2002 7.Claxton et al., “A Systematic Review of the Associations between Dose Regimens and Medication Compliance,” Clinical Therapeutics, 23 (8): 1296-1310, August 2001. 8.

77 Thank you

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