A multi-part series on challenges and solutions to better medication adherence
Long-term use of medication is fundamental in the treatment of chronic illnesses, yet it relies upon patient adherence to optimize 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.
Medication nonadherence is due to many factors, but one unfortunately is simple: too few people have the multiple skill sets to know how to manage their meds on their own. That’s one of the factors causing a huge incidence of medication nonadherence throughout the U.S.; sadly, a full half of patients with chronic illnesses don’t take their meds as prescribed. This of course leads to increased morbidity and mortality, potentially unnecessary hospitalizations and an approximate cost to the nation of between $100 billion and $289 billion every year.
As an article published in Frontiers in Pharmacology noted, “After four decades of research on adherence to medication, the progress is disappointing and adherence remains a fragmented construct.” Sadly, the RxLive clinical team has found the same…both in our years of experience prior to joining RxLive and since. So we decided to do something about it as part of our delivering value-based pharmacy services.
After a deep dive into peer-reviewed literature and sharing our own experiences, we’ve categorized the impediments to adherence — including a lack of patient skills — into six major “buckets.” This helps us raise the bar of medication adherence for each patient and the U.S. population as a whole. These buckets include:
- Understanding and knowledge (health literacy)
- Social and behavioral factors (both external and internal)
- Side effects
- Access to care and burden of the regimen
Spending the time to determine and then deep dive into the factors within these buckets has enabled our clinical team to better evaluate each patient’s situation. This understanding guides our pharmacists in helping patients better understand what factors are at play and how their adherence can be effectively improved. Through motivational interviewing and empathic listening, in our medication consults we keep all of these intertwined potential issues in mind. This enables us to help patients better comprehend what may be standing in their way of better health and a more-satisfying life.
How the lack of skills influences adherence
Skills doesn’t merely include whether or not a patient can successfully open a prescription bottle with a child-proof cap…though that certainly can be one challenge. Skill levels that impact adherence includes the ability to use drug-delivery devices, communication issues, forgetfulness/memory retention, lack of confidence and, yes, physical capabilities.
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 the 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 missing 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 — which studied adherence among patients with hyperlipidemia, hypertension and diabetes — 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. Also, the historical Ebbinghaus’ forgetting curve, recently replicated, reveals that 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 likely to confuse dosing for their medications with a recollection of prior medication regimens. They can also experience difficulty associating paired items or instructions within a regimen, such as whether they should or should not take a medication with or without, or before or after eating.
Young adults — Unfortunately, growing research also shows low medication adherence rates in young adults. In a 2016 assessment of 1.4 million persons with diabetes, Express Scripts reported that half of those aged 20 to 44 weren’t adherent to oral diabetic medication, mainly calling 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 can also negatively affect 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. (This is why having a loved one or other caregiver attend doctor’s appointments can be so helpful, for note-taking and potentially questions for clarification.) 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 could 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, fatigue, pain, tremors, cognitive functioning, or altered emotional status. Lack of physical skills affects medication adherence by causing difficulties in opening pill bottles, using medical devices, other administration of medication (such as measuring liquids), 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 that impact focus and color recognition, and an inability to walk or drive to appointments or treatments.
Confidence-building skills that increase a patient’s perception of self-efficacy are 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 to raise 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 a 2019 Gallup annual survey, pharmacists ranked among the top professionals for honesty and ethics, indicating their potential impact on creating and sustaining trusting patient relationships that can lead to optimal medication adherence by building patient confidence.
Overconfidence — In contrast, overconfidence can lead to medication nonadherence, as reported in studies examining 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 circumstances such as consuming a high-salt or high-carb meal, or based on how they perceived their bodies were functioning at a given time.
How pharmacists can identify lack of skills that impact adherence
Clinical pharmacists can leverage their pharmacy knowledge and patient-observation skills during counseling sessions to identify lack of skills that can affect adherence. Physical skills, communication skills, forgetfulness and understanding of devices can be assessed during the teach-back method while observing the patient as they repeat back 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.
Identifying a nonadherence risk due to a lack of one or more valuable skills can also be identified through patient self-reporting when prompted by open-ended pharmacist or staff questions during pharmacy visits.
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 late for refilling their scripts. Pharmacists can also recommend that patients use medication schedule charts, alarms, pill organizers, patient-medication diaries and other 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 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 or decline, 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 knowing they have a trusted pharmacist to turn to when questions arise, and by seeing measurable improvements in their skills from the repetition and reinforcement that regular touchpoints provide. RxLive generally recommends scheduled follow-ups at 6-month intervals. For patients with significant skill barriers, timely pharmacist follow-ups help ensure that 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 and be reinforced.
- Ongoing medication review is also important, 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 the RxLive team does 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. This enables drug-use monitoring that typically provides data in real time. This data is a true representation of medication adherence and can be used to compare patient-reported adherence using self-report scales.
- These connected systems improve medication adherence by reducing dosing errors and improving patient alerts and medication reminders. They also provide valuable adherence data for providers and clinical pharmacists, enabling pharmacists to use the data to drive appropriate 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 on request to help track patient data.
Summary: Dealing with patient skills that 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 use technology such as connected devices in addition to the patient’s self-reported data to help assess and improve medication adherence.
Working as an extension of the prescriber’s office team, clinical pharmacists are well-equipped and positioned to assess medication nonadherence attributed to patient skill sets. We strive 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 their interwoven clinical, satisfaction and financial outcomes.
The Internet Has Become the External Hard Drive for Our Memories. Scientific American
Improving Medication Understanding and Adherence Using Principles of Memory and Metacognition. Policy Insights from the Behavioral and Brain Sciences (PIBBS)
Teach-back Interactive Module (PDF). Agency for Healthcare Research and Quality (AHRQ)
Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States. Annals of Internal Medicine
Misuse of Medical Devices: A Persistent Problem in Self-management of Asthma and Allergic Disease. Annals of Allergy, Asthma & Immunology
Self-efficacy Impact Adherence in Diabetes Mellitus. Open Access Text (OAT)
Self-report Measures of Medication Adherence Behavior: Recommendations on Optimal Use. Translational Behavioral Medicine
Three Types of Self-efficacy Associated with Medication Adherence in Patients with Co-occurring HIV and Substance Disorders. Journal of Multidisciplinary Healthcar