There’s no question that medication adherence is a problem. How big a problem? Well, according to an article in The American Journal of Medicine, 28% of new prescriptions never get filled, and among patients who do fill their prescriptions, adherence rates are less than 50%. The problem with these numbers is that they represent not only grief for the patient, but for the entire healthcare system.
According to Dave Walker, a pharmacist that blogs at pharmacy 2.0 and ½, “although the causes and proposed solutions to the medication adherence/compliance problem vary widely and are often debated, it seems one thing can be agreed upon by all… it is a very costly healthcare problem in the U.S. today. The cost of non-adherence was estimated to be $290 billion annually by the New England Healthcare Institute NEHI in 2009. It’s now estimated by some to be in the neighborhood of $330 billion or more annually.†That’s a lot of money.
The problem is well defined, i.e. people aren’t taking their medications properly, but the solution has eluded the healthcare system for a long time. The issue has been debated and discussed as long as I’ve been a pharmacist. Have we made progress? It’s hard to say. I suppose it all depends on what your definition of progress it. Looking around today we have lots of medication adherence tools at our disposal. We have reminder systems, mobile applications, smart medication organizers, alert systems for medication bottles, and so on and so forth.
All these toys have a place in medication adherence, but the fundamental problem goes well beyond their scope. Medication adherence is a multi-faceted problem with roots in psychological behavior, socioeconomic background, demographics, etc.
However, as alluded to in Dave’s post mentioned above, it begins and ends with the pharmacist. “A recent report published by the National Community Pharmacy Association NCPA identified what I believe to be the biggest factor for combating the medication adherence problem: “The biggest predictor of medication adherence was patients’ personal connection (or lack thereof) with a pharmacist or pharmacy staff.â€â€
A patient’s use of medication should begin by developing a relationship with a pharmacist, and in my opinion that should happen at the point of care, which is often in the hospital. Patients should speak with a pharmacist upon admission, and again upon discharge. No patient should ever leave the hospital without speaking to a pharmacist and without medications in hand. This goes back to my days as a pharmacy student at UCSF. As part of my fourth year general medicine rotation it was my job to interview each patient that was admitted to my team’s service. I was responsible for ascertaining their medication use and beginning the medication reconciliation process. Upon discharge it was my job to have the patient’s prescriptions filled at the UCSF outpatient pharmacy, pick them up, deliver them to the patient bedside, perform patient consultation and education, and close the loop on our medication reconciliation process. It was an effective system, especially for patients that were frequent flyers.
This is an oft-overlooked opportunity within healthcare systems, especially those that don’t have a hundred fourth year pharmacy students running around the hospital. But that shouldn’t stop facilities from engaging patients even if they have to bring in pharmacists from outside their system. They should look for community pharmacies in the area that would be willing to partner with their healthcare system to provide bedside medication delivery and consultation, thus beginning the process of building a working relationship between patient and pharmacist. As the patient moves from the hospital back into their daily routine they can continue to grow a relationship with the community pharmacies. The payoffs are huge, especially for those patients with chronic diseases like diabetes, asthma, hypertension, hypercholesterolemia, and so on.
Not all patients are willing or able to be compliant, but some are. Using Dave’s number of $330 billion annually, a conservative positive impact of 10% cost avoidance is more than $30 billion a year. Not too shabby.
Time constraints may be addressed by developing a team-based approach to health care ( Table 1 ). The team-based approach includes training nonphysician staff to perform duties traditionally completed by physicians, thus allowing the physician more time to discuss the patient’s medication adherence patterns. For example, during a telephone reminder for an upcoming appointment, clerical staff might remind patients to bring in all their medications and pill boxes for review at the office appointment. Other aspects of a team-based approach to health care include assessment of nonadherence by office staff and pharmacists, pharmacist-based patient education, phone call reminders, Web-based tools, and assignment of a case manager. Because these activities occur outside of the physician-patient encounter, they will not lengthen the visit and may increase efficiency. The importance of a team-based approach to managing medication use is highlighted by the medication therapy management services (MTMS) mandated by the 2003 Medicare Prescription Drug Improvement and Modernization Act.