Long-term use of medication is fundamental in the treatment of chronic illnesses, yet relies upon patient adherence to result in positive outcomes. Adherence is the degree to which a person’s behavior corresponds with agreed prescriber recommendations as it applies to taking medications, following a diet, or executing lifestyle changes.
Unfortunately, lack of medication adherence is prevalent with a projected 50% of patients with chronic illnesses not taking medications as prescribed. This results in increased morbidity and mortality, hospitalizations and an approximate cost to the healthcare system of between $100 billion and $289 billion per year.
Frontiers in Pharmacology published a review study matching adherence interventions to patient determinants. The RxLive team has categorized the reasons for medication adherence into six major buckets — Cost, Side Effects, Skills, Understanding and Knowledge, Social and Behavioral factors, and Access to Care and Burden of Regimen.
Pharmacists are integral in improving patient medication adherence through their unique training and deep pharmacological knowledge, coupled with their position and accessibility in the healthcare chain. The RxLive technology platform provides pharmacists with additional tools and suggestions to address adherence problems they identify in the course of their practice.
The RxLive category of “skills” includes adherence issues such as patient challenges using devices, communication skills issues, lack of confidence in one’s capabilities, problems with forgetfulness, and physical difficulties.
Skills: Influence on medication adherence
Patients’ ability or proficiency expressed as skill sets affects medication adherence. Skill levels affect use of drug-delivery devices, memory retention, communication, physical capabilities and confidence.
Drug-delivery devices can add a layer of complexity to medication adherence, requiring not only a firm understanding of timing of medication dosing but the correct use of the delivery device. For example, Annals of Allergy, Asthma & Immunology published that up to 92% of asthmatic patients incorrectly use inhalers, and that correct use of epinephrine auto-injectors is as low as 22%. Accurate use of drug-delivery devices relies on many skill sets that include physical skills, memory retention and confidence. Both the skill sets and the challenges that often come with them can vary widely between individuals and patient populations. Other causes of improper device use result from lack of patient or caregiver understanding, complicated or absent instruction manuals, device usability, health literacy, and environmental unpredictability in uncontrolled home environments.
Forgetfulness and memory-retention skills are common sources of medication nonadherence. The Express Scripts ScreenRx program studying adherence among patients with hyperlipidemia, hypertension and diabetes has revealed that 69% of subjects were non-adherent due to behavioral issues and skills such as forgetfulness and procrastination.
A study in the Journal of Neuroscience demonstrates that memory formation is affected by acute stress, making learning more difficult for people experiencing stress. Additionally, the historical Ebbinghaus’ forgetting curve, recently replicated, reveals memory retention of learned knowledge decreases over time unless it’s consciously and repetitively reviewed.
Senior citizens — Memory-retention skills and metacognitive skills are an increased challenge among the elderly population. They are more prone to confusing dosing for concurrent medications with a recollection of prior medication regimens, thus interfering with adherence. They can also experience difficulty associating paired items or instructions within a regimen such as taking a medication with food in the morning.
Young adults — Unfortunately, growing research also shows low medication adherence rates in young adults. Express Scripts reported in a 2016 assessment of 1.4 million diabetic subjects that 50% of those aged 20 to 44 weren’t adherent to oral diabetic medication, mainly indicating forgetfulness as a factor. Memory-retention skills in younger adults are affected by stress, technology, media multitasking that can increase frequency of attention lapses, and a lack of awareness of the connection between immediate actions (or lack thereof) and the potential long-term consequences.
Communications skills also impact medication adherence, with a reported 40 to 60% of patients unable to accurately recall a provider’s directions for prescribed medications only 10 to 18 minutes later. The inability to accurately communicate directions affects how they relay their care instructions to other healthcare providers or caregivers, and inhibits useful question sessions which may impact the accuracy of therapy administration.
Diminished physical skills can be caused directly by patients’ diseases as well as age…diminishing physical stamina and strength; causing fatigue, pain, tremor, cognitive functioning; or altering emotional status. Lack of physical skills affects medication adherence by creating difficulties opening pill bottles, using medical devices, administering medications, and decreasing confidence in their own abilities to do so. Other physical skills impact adherence, such as difficulty swallowing capsules or self-injecting medications, vision deficits impacting focus and color recognition, and an inability to walk or drive.
Confidence-building skills that increase the perception of self-efficacy is correlated with better medication adherence across multiple disease states. Lack of a patient’s ability to correctly follow a prescribed medication regimen is worsened when patients don’t ask their providers questions due to a feeling of apprehension or intimidation.
The ‘troublemaker’ label — Researchers at Beth Israel Deaconess Medical Center revealed that 50% to 70% of surveyed patients hesitated raising concerns to their care provider about their care or therapy, commonly admitting that they didn’t want to be perceived as a “troublemaker.” According to the most recent Gallup’s annual survey, pharmacists ranked among the top professionals for honesty and ethics, indicating their potential impact on creating and sustaining trusting patient relationships can lead to optimal medication adherence by building patient confidence.
Overconfidence — Contrastingly, overconfidence can lead to medication nonadherence as reported in studies examining overconfidence in memory skills and personal ability. Overconfidence in memory skills includes those patients who overestimate their future memory or are unaware of their risk for forgetting, making them less likely to review information. Self-confidence in a patient’s ability or perception of expertise can lead to medication nonadherence, noted in a study published in Ergonomics. In the study, patients deviated from prescribed medication regimens, self-adjusting their doses in special circumstances such as consuming a high-salt meal or based on how they perceived their bodies were functioning at a given time.
How pharmacists can identify lack of skills that impact medication adherence
Pharmacists can rely on patient observation during counseling sessions to identify lack of skills. Physical skills, communication skills, forgetfulness, and understanding of devices can be assessed during the teach-back method while observing the patient as they repeat or demonstrate the medication regimen. Pharmacists can identify low confidence by asking questions about their level of comfort using the medication, or noticing if the patient appears anxious or says negative things about themselves during the teach-back method.
Identification of nonadherence due to skills can also be identified through patient self-reporting when prompted by open-ended pharmacist or staff questions during pharmacy visits. Identifying a non-adherence risk enables pharmacists to drill down to determine if it’s due to a lack of one or more skills.
How pharmacists can improve adherence to overcome skill issues
Patient self-reporting through pharmacy prompts
Self-reporting is a simple, low-cost and fast method to identify nonadherence at several different points in the context of pharmacy care. Self-reporting can occur through patient questioning or record review at the time of prescription drop-off, refill or new script counseling.
- Patient questions or questionnaires should be phrased in an open-ended, non-judgmental manner. However, limitations exist due to inaccurate patient recall or overestimation of adherence for social desirability. Scales for self-efficacy assessment include The Self-efficacy for Appropriate Medication Use Scale (SEAMS) and Brief Medication Questionnaire (BMQ).
- Once the reason for nonadherence is identified, the pharmacist can help overcome the barrier through repetition with the teach-back method and by offering written reference materials, practice exercises and technological resources such as instruction videos and websites.
- If diminished physical skills are impacting adherence, medications can be packaged in different ways, provided in different dosage forms, or caregivers can be trained to administer meds correctly.
- Forgetfulness can be addressed from both the patient and pharmacy perspective. Pharmacies can implement prescription refill apps, text reminders, phone call services, and systematically run prescription refill-due software reports to identify those needing refills. Pharmacists can recommend to their patients to use medication schedule charts, alarms, pill organizers, patient medication diaries, and organization techniques to store their current medications for ease of accessibility and use.
Scheduled patient follow-up appointments and medication review
- Establishing routine, scheduled touchpoints with pharmacists for patients identified as having skill barriers is a method for increasing medication adherence by combating the forgetting curve. Adherence is in jeopardy without reinforcement and practice as exampled by the forgetting curve, illuminating the importance of repeat patient-pharmacist interactions. Subsequent visits enable the pharmacist to assess skill improvement, the need for further instruction, and any changes in medication therapy that could impact adherence.
- Repeat pharmacist interactions also instill a sense of patient security and confidence, with patients confident that they have a trusted pharmacist to turn to when questions arise, and by seeing measurable improvements in their skills resulting from the repetition and reinforcement that regular touchpoints provide. RxLive recommends scheduled patient follow-ups at 6-month intervals. For patients with significant skill barriers, timely pharmacist follow-ups help ensure instructions given through the teach-back method are remembered, patient skills are improved, and a relationship of trust between the pharmacist and patient continues to grow.
- Ongoing medication review is important as well, since the addition of other regimens can require additional patient skills or put additional stress on existing challenges that the pharmacist can help the patient overcome.
Collaboration between pharmacists and healthcare providers
- Including pharmacists on a collaborative team in a primary care setting can help effectively address skills building for medication adherence. As we do at RxLive with our care partners, pharmacists and providers can effectively collaborate to assess potential risks of therapy nonadherence, identify and address skill barriers, instruct patients on their medication therapy, and review medication regimens.
- The same pharmacist can then follow up with the physician’s patients at scheduled appointments after treatment is initiated, to assess medication adherence and any challenges to the prescribed therapy. This collaboration reduces prescriber time burdens, provides a better care experience for patients, and helps increase positive health outcomes.
Connected drug devices
- Connected drug devices link a drug-delivery device — such as auto-injector, smart inhaler or pump — to an app and cloud data system, enabling drug use monitoring that typically provides data in real time. These are a true representation of medication adherence and can be used to compare patient-reported adherence using self-report scales.
- These systems improve medication adherence through reduced dosing errors, along with improved patient alerts and medication reminders as well as adherence data for providers. They present an opportunity for clinical pharmacists to ascertain valuable medication adherence data to use in medication therapy management (MTM) services.
- The connected drug-device market is projected to grow 35.4% from 2019 to 2026, during which pharmacists will have significant opportunities to reinforce training on smart drug-delivery devices in both the community and clinical settings. RxLive provides remote patient monitoring (RPM) services to help track patient data upon request.
Summary: Patient skills impact medication adherence
Medication adherence is significantly improved by patients’ skills in using drug-delivery devices, retaining information through memory formation, communication, physically functions and building confidence. Pharmacies in clinical and community practice can utilize technology such as connected devices in addition to patient self-reported data to help assess and improve medication adherence. Pharmacists are uniquely positioned to assess for medication nonadherence attributed to patient skill sets with the ability to identify and empower patients through teach-back method training, reinforcement, and instructional materials to build the skills necessary for patients to successfully adhere to their medication regimens and optimize clinical outcome
Adherence to Long-Term Therapies — Evidence for Action. World Health Organization (WHO)
Development and Psychometric Evaluation of the Self-Efficacy for Appropriate Medication Use Scale (SEAMS). Journal of Nursing Measurements
Improving Medication Understanding and Adherence Using Principles of Memory and Metacognition. Policy Insights Behav Bain Sci
Medication Adherence: WHO Cares? Mayo Clin Proc
Misuse of Medical Devices: A Persistent Problem in Self-management of Asthma and Allergic Disease. Ann Allergy Asthma Immunol
Stress Effects on Working Memory. Front Behav Neurosci
Study: Proactive Efforts Improve Adherence. Express Scripts
The Brief Medication Questionnaire: A Tool for Screening Patient Adherence and Barriers to Adherence. Patient Education and Counseling (PEC)
Their Brains on Google. Science and Technology Law Review