Rebecca RuggearThursday, April 4, 2013

PB 449 Senior Seminar Oral Defense of Thesis

Thesis Statement

• In order to affect better patient outcomes, the burden of adherence needs to shift away from solely the patient to other stakeholders such as physicians and pharmacists.

What is adherence?• Adherence is “the extent to which a person’s behavior –

taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.”1,2

• The reason this responsibility is left to the patients is because, “it’s easier to blame patients and hold onto the simplistic view that cost is the key drive, rather than to understand the underlying symptoms that can lead to the right interventions at the right time to increase adherence.”6

1. Haynes, RB. (1979). Determinants of compliance: The disease and the mechanics of treatment. Baltimore MD, Johns Hopkins University Press.2. Rand, CS. (1993). Measuring adherence with therapy for chronic disease: implications for the treatment of heterozygous familial hypercholesterolemia. American Journal of Cardiology, 72:68D-74D.

Another look at responsibility

•  ”A significant barrier to effective medical treatment is the patient's failure to follow the recommendations of his or her physician or other healthcare provider.”12

• “Patients' health literacy is central to their ability to adhere. ”12

12. . Martin, L., et al. (1 September, 2005). The Challenge of Patient Adherence; 1(3): 189–199. Clinical Risk Management. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/citedby/.

Why are patients non-adherent?

• The five main reasons for non-adherence include9: – Negative side effects– Perceived under-performance of the product– Complexity of the treatment regime– No improvement noticed by patient– Cost

9. Forissier, T. (April 2012). Patient Adherence: Initiating the Journey, 2(4), 26-28.

Does adherence matter?

Express Scripts Drug Trend Report. (2011). Nonadherence: New Insights. Retrieved February 26th, 2013, from http://www.drugtrendreport.com/insights-and-solutions/nonadherence-new-insights/more-than-patient-education.

What are the numbers?• Adherence to long-term therapy for chronic illnesses in

developed countries averages 50%.1,5

– Rates are even lower in developing countries.• Non-adherence costs the U.S. health care system

between $100 billion and $289 billion annually.11

• Estimates of hospitalization costs due to medication non-adherence are as high as $13.35 billion annually in the US alone.11

1.Haynes, RB et al. (2001). Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, Issue 5. Sacket, D. et al. (1978). Patient compliance with antihypertensive regimens. Patient Counselling & Health Education, 11:18-21.

11. Viswanathan, M. et al. (December 2012). Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review. Annals of Internal Medicine.;157(11):785-795.

How does being adherent save money?• Higher rates of adherence contribute to economic

benefits8

– “Direct savings caused by reduced use of sophisticated and expensive health services needed in cases of disease exacerbation, crisis or relapse.”8

– “Indirect savings may be attributable to enhancement or preservation of, quality of life and the social and vocational roles of the patients.”8

– Reduction in the numbers of patients being hospitalized, days in the hospital and outpatient visits.7

• Cost to savings ratio of approx. 1:10 over a 3 year study

7. Sloss, EM et al. (2000). Selecting target conditions for quality of care improvement in vulnerable older adults. Journal of the American Geriatrics Society, 48:363-369.8. World Health Organization. (2003). Adherence to long-term therapies: evidence for action. WHO publications.

Specific savings•  Pharmacy costs for all

prescriptions filled, ranged from $2,867 to $3,780 per patient per year.10

• Annual medical spending was significantly lower for adherent patients. 

• Savings are mainly through reduced inpatient hospital days and emergency department visits.

10. Roebuck, M. C., Liberman, J. N., Gemmill-Toyama, M., & Brennan, T. A. (2011). Medication adherence leads to lower health care use and costs despite increased drug spending. Health Affairs, 30(1), 91-9. Retrieved from http://search.proquest.com/docview/847269644?accountid=29001

Disease state

Total health care costs

Average annual medical spending

Annual per person savings

Congestive heart failure

$39,076 $8,881 $7,823

Hypertension $14,813 $4,337 $3,908

Diabetes $17,955 $4,413 $3,756

Dyslipidemia $12,688 $1,860 $1,258

Positive impact on patient health“Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”3

3. Haynes, RB et al. (2001). Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, Issue 1.

Tackling The Problem• Objectives

– Determine general attitudes on whose responsibility it is for patient adherence.

– Determine reasons for non-adherent behavior.– Research tactics and effectiveness of those tactics to

increase patient adherence.

• Subjects– Healthcare Professionals

• Pharmacists• General Practitioners• Specialist Physicians• Nurses/Physician Assistants

– Patients (M/W aged 30+)

Where do we find them?• Healthcare professionals

• Web-based survey (Surveymonkey.com) – Fielded through affinity groups on LinkedIn

» 61 responses (26 complete)» Patient Adherence Solutions» Patient Adherence, Compliance & Communication

Strategy for Pharma» Pharmacists» Therapy Compliance

• Patients– High traffic area intercepts & web posts

• 33 responses• Survey link (Polldaddy.com)

THE RESULTS ARE IN…

Conflicting Perceptions

HCPs and Patients differ on how adherent they believe patients are.

It’s simple, patients don’t adhere because…

The team leader to tackleadherence is…

HCPs speak out about patient non-adherence

• Healthcare providers reasoning for why they believe patients are not adherent 100% of the time.– “They are not properly educated on their medications.

Doctors skip this part.”– “They are hard headed, they diagnose and treat their selves

according to hearsay.”– “It is socioeconomic, belief systems, and education that are

variables in this equation.”– “I have noticed several patients that feel like giving up. They

are overwhelmed with the amount of medications that are thrown at them on a regular basis without any non pharmacological alternatives. Other patients have time constraints or, being human, they just forget.”

HCPs speak with their patients.• HCPs say the topic of adherence is brought up very

often by their patients that are taking medication.

We can all get along

• Patients & HCPs agree, the burden of taking medication is primarily on patients.– Burden of actually taking medication should stay on patient

but education should be provided by HCPs.– The responsibility of adherence needs to be a multi person

effort that includes HCPs.

Team efforts drive steps towards a solution• Patients trust their HCPs knowledge and skills.

– General Practitioners and Specialist Physicians are most impactful following the patient.• Utilize this relationship to convey knowledge to patient, so

they understand their medication regime and importance.

• HCPs need to devote time to addressing patient concerns and stressing importance of adherence.

Sources1. Haynes, RB et al. (2001). Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, Issue 2. Haynes, RB. (1979). Determinants of compliance: The disease and the mechanics of treatment. Baltimore MD, Johns Hopkins University Press.3. Rand, CS. (1993). Measuring adherence with therapy for chronic disease: implications for the treatment of heterozygous familial hypercholesterolemia. American Journal of Cardiology, 72:68D-74D.4. Express Scripts Drug Trend Report. (2011). Nonadherence: New Insights. Retrieved February 26th, 2013, from http://www.drugtrendreport.com/insights-and-solutions/nonadherence-new-insights/more-than-patient-education. 5. Sacket, D. et al. (1978). Patient compliance with antihypertensive regimens. Patient Counselling & Health Education, 11:18-21. 6. Minoff, R. (1 November, 2012). It’s Time to Put On Your Thinking CAP. PM360. Retrieved February 26th, 2013, from http://www.pm360online.com/its-time-to-put-on-your-thinking-cap/.7. Sloss, EM et al. (2000). Selecting target conditions for quality of care improvement in vulnerable older adults. Journal of the American Geriatrics Society, 48:363-369.8. World Health Organization. (2003). Adherence to long-term therapies: evidence for action. WHO publications.9. Forissier, T. (April 2012). Patient Adherence: Initiating the Journey, 2(4), 26-28.10. Roebuck, M. C., Liberman, J. N., Gemmill-Toyama, M., & Brennan, T. A. (2011). Medication adherence leads to lower health care use and costs despite increased drug spending.  Health Affairs, 30(1), 91-9. Retrieved from http://search.proquest.com/docview/847269644?accountid=2900111. Viswanathan M. et al. (December 2012). Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review. Annals of Internal Medicine.;157(11):785-795.

12. Martin, L., et al. (1 September, 2005). The Challenge of Patient Adherence; 1(3): 189–199. Clinical Risk Management. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/citedby/.

Questions or Concerns?