Transcript Patient Noncompliance With Medications

Patient Non-Compliance With
Medications
3rd Year Research Project
Class of 2007
Introduction
• Medication non-compliance
…..the world’s “other drug problem”
4
Medication Non-Compliance
• As dangerous and costly as many illnesses
• Increases the cost of healthcare as a result
of adverse outcomes
(i.e. hospitalizations, development of
additional illnesses/complications,
exacerbation of the disease or disease
progression, premature disability, or death)
4
Medication Non-Compliance
• In the United States, 50-70% of patients do
not properly take their medications
• Costs of patient non-compliance are
estimated at over $100 billion annually
5
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Definition
Compliance, simply defined as
“agreement.” With regard to medicine,
compliance means agreeing to take
medicine(s) as directed, and then following
through with that agreement…..accepting
the responsibility of taking medicine(s) as
agreed
8
Definition
Adherence is defined as the extent to which
a patient’s health behavior coincides with
their physician’s recommendations, whether
taking medications or following advice for
some type of behavioral change
Adherence vs. Compliance
• Adherence is a more accurate term than
compliance
• Compliance suggests a process in which dutiful
patients passively follow the advice of their
physicians
• Adherence, in contrast, better fits how most
patients actively participate in their care and
decide for themselves when and whether to follow
their doctor’s advice
Background Research
• Multiple studies done looking at adherence to
medication and recommended interventions to
improve compliance
• Typical adherence rates for prescribed medications
1
are about 50% with a range from 0% to 100%
• Adherence greater during first 6 months of follow
1
up and drops thereafter
• Chronic and asymptomatic disease have lower
1
adherence rates than acute ones
Recent Studies
• Primary Medication Adherence in a Rural
Population:
The Role of the Patient-Physician Relationship
and Satisfaction with Care
(Thomas H. Wroth, MD, MPH and Donald E. Pathman, MD, MPH )
– Prescription primary non-adherence is prevalent in
the rural South. Adherence may be improved by
remedying patient dissatisfaction and lack of
confidence in their physicians as well as addressing
transportation barriers
Recent Studies
• Effect of a Pharmacy Care Program on Medication
Adherence and Persistence, Blood Pressure, and
Low-Density Lipoprotein Cholesterol
– A pharmacy care program led to increases
in medication adherence, medication persistence, and
clinically meaningful reductions in BP, whereas
discontinuation of the program was associated with
decreased medication adherence and persistence
Background Research
• Although correlates of overall medication
adherence have been studied, little is known
about primary medication non-adherence
and whether it relates to how patients view
their physician, satisfaction with their care,
and how easy or difficult it is for them to
travel for care
Hypothesis
• Patient non-adherence with medications can
be attributed to 4 key reasons:
–
–
–
–
Language Barrier
Low Education Level
Poor doctor-patient interaction
System related obstacles
Objectives
1. To evaluate if language barriers interfere
with patient adherence with medications
2. To discover if low literacy has an impact
on patient adherence
3. To assess if doctor-patient interaction has
an effect on patient adherence
4. To find if there are system-based factors
that interfere with patient adherence
Purpose Of Our Study
To identify the factors that contribute to
patient non-adherence with medications in
an effort to optimize patient care and reduce
morbidity and mortality
Methods
• 3-page survey constructed with questions
written at 8th grade level in both English and
Spanish
• Questionnaires written in Spanish were
reviewed by certified interpreters to check
for accuracy
• Each Resident was assigned with the task of
completing a minimum of 30 surveys
Methods
• Questionnaires were given to “eligible”
patients upon registration for a clinic visit
• Some Residents surveyed their assigned
patients once they entered the patient’s
room
• Eligibility determined by inclusion and
exclusion criteria*
Inclusion/Exclusion Criteria
Inclusion
• Both genders
• All Ethnicities
• Age 18 years old
• Taking  1 prescription
medication not under the
exclusion criteria*
• Registered as FCC patient
for > 1 year
• Last visit to FCC w/in 6
months
*special inclusion for ASA for cardiovascular risk prevention
and calcium with vitamin D for postmenopausal women not on
HRT
Exclusion
• Age < 18 years old
• Pts. with dementia or
cognitive impairment
requiring assistance or
special needs
• FCC patient for < 1 yr.
• Last visit to FCC > 6 m.
• Any medication(s) not
taken on a scheduled basis
• OTC meds
• NSAIDs
• Narcotics
Methods
• Patients allowed as much time as needed to
complete surveys, and able to use medication
bottles/lists for assistance
• Physicians reviewed surveys upon completion to
verify accuracy and make any necessary
clarifications during patient interview
• Questionnaires valid once signed by physician
Methods
• Data compiled to see:
– What percentage of patients know the
medications they are taking and for what reason
– What patients do when they run out of their
medication
– What reason(s) patients give for not taking their
medication as prescribed
Methods
• Data collected used to identify the specific
individual-based obstacles as well as
system-based obstacles involved in
medication adherence
Methods
• Identify problematic areas as defined by our
patient population
• Implement strategies in FCC to improve
medication adherence and standard of care
Survey
1. Circle your gender:
Female
Male
2. Circle your ethnicity (optional)
Caucasian
Hispanic
Africanamerican
Philipino American-Indian Other
Asian
3. Circle the language or languages that you speak:
English
Spanish
English and Spanish
4. How old are you? (Circle the one that apply)
18-30
31-45 46-65
65 or more
other
Survey
5. How long have you been a patient in Family Care
Clinic?
1-3 years
3-6 years
more than 6 years
6. What is your education level? (Circle the one that
applies better to you)
A. Don’t know how to read
B. Can read with difficulty
C. Can read very well
D. Finish elementary school
E. Finish High school
F. More than high school
Survey
7. What kind of insurance do you have?
MISP MEDICAL MEDICARE IEHP Exclusive Care
MOLINA
Self Paid
Pending
8. Do you know the medications you are taking?
Yes
No
9. Do you have the mediations with you?
Yes
No
10. Can you name them?
Yes No
11. Do you know what the medications you are
taking are for?
Yes No
12. How many medications are you taking?
13. How many times a day do you have take your
medicines?
Survey
14. Where do you get your medications?
RCRMC
Other Pharmacy
15.What do you do when you run out of medication?
(Circle what happens most often)
A.
B.
C.
D.
Call the pharmacy
Call the doctor’s office
Call the special line to refill medications
Go to the emergency room
E. Stop taking the medication
Survey
16.What are the reason(s) that you run out of
medication? (you can choose more than one)
[If you choose more than one, please put* next to the most common
•
•
•
•
•
•
•
•
•
•
reason]
A. Pharmacy lost the prescription
B. Language problem in communication with Pharmacy . If yes was
an interpreter available Yes No
C. Medications needs TAR form to be filled by the doctor
D. Didn’t have the copayment to pay medications
E. Pharmacy was closed when trying to get prescriptions
F. Pharmacy was to slow and left without getting the prescriptions
G.
Didn’t have doctor’s license number in prescription when trying
to get prescriptions outside the hospital
H. Hard time getting transportation to pharmacy
I.
Finish medications earlier than the next doctor’s appointment
J.
Waiting for doctor’s office to refill medication
Survey
17. Did you know there is a special phone line to refill your
prescriptions over the phone
Yes
No
18. If yes Have you ever use it? Yes No
If yes, were you able to refill your medications through it?
Yes No
If Not, you couldn’t do it because:
A. Didn’t understand how to use it?
B. Line was too busy most of the time and couldn’t get
through it
C. Unable to spell the name of your medication
D. Left message over the phone but didn’t get a call from
the Dr. telling you that your prescriptions were ready.
Survey
19. Reasons why you don’t take your medications as
prescribed: (Circle all the reasons that apply to you)
•
•
•
•
•
A. Forget to take it
B. Confusion as to what medication to take and when
C. Fear of side effects
D. Don’t know what the medications you are taking are for
E. Feel depressed or sad and don’t feel like taking the
medicines
• F. Disorganization, lose medications can’t find where are
they
Survey
20. What motivates you the most to take your
medications? (Circle all that apply)
•
•
•
•
•
Put * next to the main reason
A. The doctor during the visit
B. The nurses
C. Myself
D. My family
E. Friends
F. Other
21. Please write down any suggestions to improve
your own compliance with your medications
Answer Rate
-TOTAL OF PATIENTS INTERVIEWED→ 296
-NOT ALL PATIENTS ANSWERED ALL THE
QUESTIONS
-OF 21 QUESTIONS 13 (62%), WERE
ANSWERED BY MORE THAN 290
PATIENTS
-6 (23%) QUESTIONS WERE ANSWERED
FOR AT LEAST MORE THAN 250
PATIENTS, MOST OF THESE QUESTIONS
WERE REGARDING
KNOWLEDGE OF MEDICATIONS BEING
TAKEN
SEX
105
35%
191
65%
Female
Male
3
th
er
1%
O
an
-In
di
an
er
ic
0
7
Am
2%
Ph
ilip
in
o
an
20
As
i
an
80
er
ic
100
Af
ric
an
am
120
Ca
uc
as
ia
n
pa
ni
c
Hi
s
ETHNICITY
160
49%
140
143
31%
91
60
15%
40
43
1%
0.30%
4
1
LANGUAGE SPOKEN
36
12%
104
35%
153
52%
Spanish
English
English and Spanish
AGE
36
12%
21
7%
83
28%
154
52%
18-35
36-49
50-65
65 or more
Number of years been a patient in FCC
57
21%
132
48%
84
31%
1-3 years
3-6 years
> 6 years
LEVEL OF EDUCATION
140
35%
120
115
100
23%
80
18%
60
77
16%
60
54
40
7%
20
23
0
Read with
difficulty
Read well
Elementary
school
High school
More than high
school
TYPE OF INSURANCE
180
160
52%
140
120
153
100
25%
80
76
24
6%
3%
19
OL
IN
A
1%
5
4
3
M
ca
re
e
Ex
clu
siv
IE
HP
ED
IC
AR
E
M
ED
IC
AL
M
M
IS
P
0
1.7%
1%
10
Pe
nd
ing
20
ed
i
8%
ed
i-M
40
M
60
Knowlegde of medications being taken
42
14%
255
86%
YES
NO
DO YOU HAVE THE MEDICATIONS WITH YOU
160
57%
140
120
144
42%
100
106
80
60
40
20
0
YES
NO
CAN YOU NAME THEM
250
68%
200
31%
150
203
100
94
50
0
YES
NO
KNOWLEGDE OF WHAT ARE MEDICATIONS FOR
300
250
200
88%
241
150
100
50
11%
32
0
YES
NO
NUMBER OF MEDICATIONS TAKEN
120
100
37%
38%
99
96
80
23%
60
61
40
20
1%
0
one to three
four to six
more than six
3
Don't
know
TIMES PER DAY MEDS NEED TO BE TAKEN
90
80
70
33%
31%
84
80
60
50
19%
48
40
12%
30
31
20
10
0
One
Two
once and twice a
day
Three
PHARMACY USED
131
44%
RCRMC
166
56%
OTHER PHARMACY
he
he
ph
ar
m
160
140
120
100
80
60
40
20
0
ac
do
y
ct
or
Ca
's
of
ll t
fic
he
e
sp
ec
ia
ll
in
e
G
o
St
to
Ca
o
ER
ll p
p
ta
ha
ki
rm
ng
ac
m
y
ed
or
s
sp
ec
N
ia
Co
ev
l li
m
e
ne
rh
e
to
as
R
ru
CR
n
ou
M
C
t
ph
ar
m
ac
G
y
o
to
Ti
ju
an
a
Ca
ll t
Ca
ll t
WHAT DO YOU DO WHEN YOU RUN OUT OF MEDS
44%
135
21%
64
14%
42
9%
4%
13
27
3%
8
2%
7
0.6%
2
0.3%
1
KOWLEDGE OF PHONE LINE TO REFILL PRESCIPTIONS
125
159
44%
56%
YES
NO
SUCCESS IN GETTING PRESCRIPTIONS BY PHONE
84
43%
112
57%
Of the 84 that
couldn’t refill,
5 didn’t
understand
how to use it
YES
NO
REASONS WHY PATIENTS DON'T TAKE
MEDICATIONS
120
35%
100
80
105
22%
13%
60
68
56
40
4%
17
17
15
0.30%
we
ak
5%
or
go
Fe
tte
ar
n
of
sid
e
ef
fe
ct
s
No
an
sw
er
De
pr
es
s
or
sa
Di
d
so
rg
an
iz
at
io
n
Ha
s
n’
tf
Fo
rg
et
0
5%
on
25
Co
nf
us
i
20
To
8%
MOTIVATION TO TAKE MEDICATIONS
250
200
56%
201
150
100
22%
80
50
15%
54
2%
1%
0
Myself
Doctor
Family
6
Nurses
2
Friends
4%
16
Other
M
FC
C
ed
s
10
ot
he
r
ie
nc
y
m
ef
fic
ex
pl
ai
n
s
0
ac
y
re
fill
10
ph
ar
m
or
e
tio
ns
Su
gg
es
60
Im
pr
ov
e
No
SUGGESTIONS TO IMPROVE COMPLIANCE
80
70
74
50
40
30
20
19
16
7
4
Conclusion
Medication Non-Adherence is
Multifactorial
Prerequisites to Adherence
1)
2)
3)
4)
6
Demographics
Psychosocial & Behavioral Characteristics
Medication Characteristics
Healthcare Delivery System
Characteristics
Demographic Variables
• Age
• Socio-economic status of the patients
– e.g. unstable living quarters, limited access to
healthcare facilities, burdensome schedules,
language barrier, limited level of education,
lack of financial resources to pay for
medications
Socioeconomic Factors
Psychosocial & Behavioral
Characteristics
• Patients’ medication-taking behavior
• Patients’ beliefs about and attitudes towards
their disease
– More likely to be compliant if they feel
threatened by their disease, or if they believe
their medication will actually cure or control
the disease
Medication Characteristics
• Complexity of the regimen
• Effects of the regimen
Characteristics Associated with
Decreased Compliance
7
•
•
•
•
>4 meds
More frequent daily doses
Patient confusion re: med regimen
Patients’ belief that they cannot follow the
regimen
• Fear of side effects
Healthcare Delivery System
Characteristics
• System-related obstacles
– Pharmacy waiting time, difficulty obtaining
medication refills, insurance complications
• Lack of knowledge and understanding of
their disease state and regimen
– Relationship between the patient and the
healthcare provider
System-Related Obstacles
• #1 concern: Pharmacy
• Only 2.3% of those surveyed, claimed to
have never run out of medications!
…..so what about the other 97.7% of patients
who do run out of medications?
System-Related Obstacles Cont’d
• 13% simply stop taking the medication or
go to the ER
• 14% use the Prescription Refill Line
• 21% call their Doctor
• 44% call the Pharmacy
Knowledge of Prescription Refill Line
YES
NO
56%
44%
Didn’t Use
Used It
57%
43%
Didn’t Know
How
4%
??????
????
96%
Pharmacy
• Most popular method of refilling medications, and
yet:
– Language problems when communicating w/ Pharmacy
staff
– Medication Tars
– Pharmacy hours too limited
– Too long of a wait, patients unable to wait
• 36% of patients had these specific pharmacy
complaints
Physician-Patient Relationship
• Nearly 70% of patients cited themselves as
the motivating factor in adhering to
medication regimens
• What does this mean?
Patient education is a must! It’s our duty as
physicians to explain medical conditions,
treatment options, prognosis in terms that the
patient can understand
Strengths/Weaknesses
Strengths
• Non-Bias
• Willingness of
Physicians Involved
• Good Sample Size
• Thoroughness
• Applicable to RCRMC
Patient Population
Weaknesses
• Human error
• Length of Survey
• Language Barrier
• Selection Bias
Recommendations –
System Based Obstacles
• Medication Card
• Upon registration, the patient will be given a
medication card at the front desk (unless the
patient has an old card)
• Patient will first attempt to fill out the card in the
waiting room
• Nurse will review the card and verify the
medications by the bottles and note from previous
visit
• Physician will do the final review and completion
of the card
Recommendations –
System Based Obstacles
• Write prescription on-line
• Ex. www.assuredscript.com
• Medications can be easily reviewed, and
medication list can be printed out
• Cost?
Recommendations –
System Based Obstacles
• Extend open hours for RCRMC Pharmacy
• New outside county pharmacy for MISP
patients
• Write from the list of Walmart $5
prescription or Costco special price
medications
Recommendations –
System Based Obstacles
• Stamp the refill line number on the
appointment card
• Post refill line number on the door inside
the room
• Email address for pharmacy refill
• Easier access of medication profile inside
the hospital computer system
Recommendations –
Language Barrier
• One full time Spanish interpreter for
pharmacy
• Interpreter phone at pharmacy
Recommendations –
Doctor-Patient Interaction
Strategies for increasing adherence :
3
• Provide rationale for tx. in patient’s language
• Collaborate on tx. plan
• Frequent follow-up
• Positive reinforcement
• Family counseling/therapy
Recommendations –
Doctor-Patient Interaction
• Doctor to prescribe more medication refills
(ex. 6 refills for chronic meds)
• Doctor to ask for side effect of medications
at the start of the clinic visit
• Doctor to ask if patient needs medication
refill before next appointment
• Doctor to remind patient at the end of every
visit to take medications
Recommendation –
Front Office-Patient Interaction
• When the patient is called to confirm
appointment, remind the patient to bring the
bottles of their medications
References
1.
2.
3.
4.
5.
6.
7.
8.
“Interventions to Enhance Patient Adherence to Medication Prescriptions”;
Clinician’s Corner
Up-To-Date: Adherence to Pharmacologic Therapy
“Adherence to Pharmacologic Therapy in Patients with Type 2 Diabetes
Mellitus”; American Journal of Medicine; Vol. 118, May 2005
Zuger, Abigail. “The ‘Other’ Drug Problem: Forgetting to Take Them,” The
New York Times, June 2:Section F, Page 1, Column 2, 1998
Santella, T., Wertheimer, A.. “Medication Compliance Research: Still So
Far to Go,” The Journal of Applied Research; Vol. 33, 2001
Berger, Bruce. “Improving Treatment Adherence: A Motivational
Interviewing Approach,” Walgreens.com, 2002
Claxton et al., “A Systematic Review of the Associations between Dose
Regimens and Medication Compliance,” Clinical Therapeutics, 23 (8):
1296-1310, August 2001.
http://www.innoviant.com/members/mempub/WhatisCompliance.pdf
Thank you