1. Improving Medication Compliance Among College Students Presented to the American College Health Association May 31, 2012 by Benjamin F. Banahan III, Ph.D., Director

2. Conflict of interest disclosure I have NO actual or potential conflict of interest in relation to this educational activity or presentation. Improving Medication Compliance Among College Students2

3. Educational objectives Describe the medication compliance problem. Identify major factors contributing to poor compliance. Identify special situations for college health pharmacies. Discuss strategies and tools for improving compliance. Powers et al 2008. Complex chronic care: patient, provider and organizational issues. J of Management and Marketing in Healthcare, 1(2): 179-190 Improving Medication Compliance Among College Students3

4. In order for prescription medications to be effective at treating illnesses, patients must: Fill the prescription given to them by the physician Routinely take the medication as directed by the physician: Quantity of medication to be taken Number of times per day medication is to be taken Time(s) of day medication is to be taken Refill the medication as needed in order to take the medication as long as recommended by the physician. If a patient fails to do any of these – medication adherence is less than perfect. Medication adherence = How well patients manage their medications Improving Medication Compliance Among College Students4

5. Adherence: Medication adherence includes two related components 30 days supply 30 days to refill 35 days to refill45 days to refill Medication compliance refers to the act of conforming to the recommendations made by the provider with respect to timing, dosage, and frequency of medication taking. Medication persistency = 140 days Medication Possession Ratio (MPR) = 120 days supply / 140 days covered = 86% Medication persistence is defined as the duration of time from initiation to discontinuation of therapy. Improving Medication Compliance Among College Students5

6. Adherence: What is acceptable? 30 days supply 30 days to refill 35 days to refill45 days to refill Medication compliance is often considered appropriate if MPR is >= 80%. Some medications such as HIV meds, antisiezure meds, antipsychotics may need higher MPR to be clinically successful. Medication persistence is considered to be acceptable if medication is taken as “long as needed” Antibiotic taken for 5 days with 10 day course of therapy can be a problem. Stopping medication against or without advice of physician can be problem. Improving Medication Compliance Among College Students6

7. Background: Why is adherence getting so much attention? Increased availability of chronic medications that can manage symptoms or prevent progression of serious illnesses. Poor adherence can increase total health care costs. Poor adherence can make a potentially effective medication a useless health care expenditure. Improving Medication Compliance Among College Students7

8. Background: Chronic diseases are managed with “maintenance medications” Maintenance medications are prescription medications taken regularly to help prevent or manage chronic diseases. Most patients with chronic diseases will need to take maintenance medications the rest of their life. Most patients with complex chronic conditions require multiple daily medications for adequate control. Many patients struggle with self-management of their maintenance medications. Improving Medication Compliance Among College Students8

9. Background: Health care increasingly is focused on managing chronic diseases 82% of adults 65 years old and older have at least 1 chronic condition. 24% of older adults have four or more chronic conditions. Even among the non-elderly, managing chronic diseases is increasingly the largest use of pharmaceutical products. Powers et al 2008. Complex chronic care: patient, provider and organizational issues. J of Management and Marketing in Healthcare, 1(2): 179-190 Improving Medication Compliance Among College Students9

10. Adherence: Adherence is the # 1 problem in treating chronic conditions today National Association of Chain Drug Stores, 2004. As many as half of all patients fail to take their medications as directed... Improving Medication Compliance Among College Students10

11. Adherence: Adherence is the # 1 problem in treating chronic conditions today National Association of Chain Drug Stores, 2004.... and that failure has very costly implications. Improving Medication Compliance Among College Students11

12. Patient attitudes, knowledge and behaviors Forgetfulness Not understanding the instructions for when/how to take the medication Lack of knowledge about disease being treated “Feeling better” and deciding to quit the medication Poor disease management Failure to appropriately manage transient side effects when starting new medications Failure to maintain effective therapeutic levels Cost factors Co-pay and co-insurance levels Transportation problems Adherence: Many factors contribute to medication non-adherence Improving Medication Compliance Among College Students12

13. Adherence: Cost issues limit access to care Kaiser Family Foundation. Economic Problems Facing Families. April, 2008. % saying they or a family member have done the following in the past year because of cost. Among those who did each: % saying their condition got worse as a result Improving Medication Compliance Among College Students13

14. Adherence: Adherence can vary by physician Source: Verispan patient data for the cholesterol market + ZS analysis. Physician Distribution Based on Average Patient Compliance Lipid Market (n = 23,812) LOWHIGH Some practices do very poorly While others do very well Improving Medication Compliance Among College Students14

15. Adherence: Adherence can vary by pharmacy Measure 2004 (%) MeanMin 10 th percentile 25 th percentile Median 75 th percentile 90 th percentile Max Proportion of patients 18 years and older who met PDC threshold of 80 percent per pharmacy BBs47.721.336.741.947.652.858.675.8 CCBs57.429.446.752.457.262.967.985.3 ACEI/ARBs55.820.945.951.055.861.065.679.2 Statins47.921.438.542.248.253.558.673.2 Biguanides44.320.031.438.445.150.057.164.9 Sulfonylureas49.324.239.543.848.754.462.271.4 TZDs49.821.636.243.050.456.963.872.6 Note: Patients attributed to the pharmacy that dispensed majority of the medications related to the measure. There were no major differences when modified attribution strategies were used. Improving Medication Compliance Among College Students15 Performance scores for pharmacies meeting PQA criteria by measure type – 2004 – Proportion of Days Covered

16. Co-pay Levels Also Affect Medication Use Persistence With Statin Therapy by Co-Pay Level Improving Medication Compliance Among College Students16

17. Adherence: Medication adherence rates are related to health care costs Better adherence results in: higher prescription costs. Disease-Related Health Costs at Varying Levels of Medication Adherence Disease Adherence Level Medical Cost ($) Drug Costs ($) Total Costs ($) Hospitalization Risk (%) Diabetes 1% - 19%$8,812$55$8,86730% 20% - 39%$6,959$165$7,12426% 40% - 59%$6,237$285$6,52225% 60% - 79%$5,887$404$6,29120% 80% - 100%$3,808$763$4,57013% Hypertension 1% - 19%$4,847$31$4,87828% 20% - 39%$5,973$89$6,06224% 40% - 59%$5,113$184$5,29724% 60% - 79%$4,977$285$5,26220% 80% - 100%$4,383$489$4,87119% Source: Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Medical Care 2005;43: 521-530. and lowers overall health care costs. Improving Medication Compliance Among College Students17

18. Adherence: So what can we do about this problem? Informational interventions through educational processes Written and oral education material. Disease management education. Improving Medication Compliance Among College Students18

19. Adherence: So what can we do about this problem? Therapy modification interventions Simplification of dosage regimens Switching medications to avoid adverse events Switching medications to avoid higher out-of-pocket costs Improving Medication Compliance Among College Students19

20. Adherence: So what can we do about this problem? Behavioral interventions Increased patient involvement in care Use of compliance aids (i.e., pill organizers, special packaging) Reminder systems to combat forgetfulness Refill reminder systems Improving Medication Compliance Among College Students20

21. Adherence: Collaborative care models – providers and patients working TOGETHER Collaborative care models encourage patients and providers to work more closely together in order to strengthen and support self-care in chronic illness. Collaborative care occurs when patients and care providers have: Shared goals for managing the disease A sustained working relationship Mutual understanding of roles and responsibilities The skills required for carrying out their roles Pharmacists have regular contact with patients and can develop effective collaborative care services that can improve adherence and outcomes. Von Korff et al. 1997. Collaborative Management of Chronic Illness. Annals of Internal Medicine, 127(12): 1097-1102 Improving Medication Compliance Among College Students21

22. Adherence: Pharmacy based programs have been shown to reduce costs Patient care services provided by community-based pharmacies to diabetes patients in Asheville, NC demonstrated: Improved control of the patients’ diabetes Improved compliance – resulting in increased use and expenditures for medications Lower overall health care expenditures. $4,651 $7,082 $5,210 $5,882 Cranor and Christensen. 2003. The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc, 43(2): 149-159. Improving Medication Compliance Among College Students22

23. Adherence: Pharmacy care services also reduced sick days Patient care services for the group of Asheville city employees resulted in a significant reduction in sick days used every year. Cranor and Christensen. 2003. The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc, 43(2): 149-159. The employer estimated that the value of increased productivity was $18,000 per year. Improving Medication Compliance Among College Students23

24. The RxSync Service SM is a community pharmacy practice model that improves adherence and outcomes by: Simplifying the refill process to make it easier to avoid running out of an important medication. Providing a timely reminder to the patient for refills needed each month. Monitoring medication problems that might lead to medication noncompliance or other health problems. Working with the patient and physician to appropriately address medication problems that are identified. CPMM: The RxSync™ program helps community pharmacies with adherence Improving Medication Compliance Among College Students24

25. What medications / diseases do you focus on most often in college health pharmacy? Chronic / maintenance Acute What conditions have the greatest consequences if students are not compliant / persistent? Chronic Acute What should you focus on?

26. Collaborative actions with other services or academic programs. Health center providers Health educators Health professional students Use of technology Your pharmacy management software system Computer generated voice / text / e-mail messages What can you do to improve adherence?

27. Contact Information: Benjamin F. Banahan III, PhD Center for Pharmaceutical Marketing and Management (phone) 662-915-5352 (e-mail) benb3@olemiss.edu