Transcript adherence - OSF HealthCare

Medication Adherence:
“We Didn’t Ask, They Didn’t Tell”
JENNIFER BUSSELL MD FACP
American College of Physicians
IL-ACP Council
Co-Chair, PSQC
Northwestern Medicine
Feinberg School of Medicine
OSF May Day Medical Conference
May 5, 2016
✦ Dr Bussell has no conflicts of interest to disclose
Learning objectives
✦ Participants will understand why some patients
do not follow recommendations prescribed by
their physicians and health care team.
✦ Participants will learn to implement easy to use,
time efficient tools to help identify nonadherence
and tailor solutions for individual patients.
✦ By understanding the patient’s perspective,
participants will be able to engage patients in their
own health.
✦Definitions, Incidence, Impact of nonadherence
✦UNMASKING NONADHERENCE
– Video: Don't ask / Don't tell
✦WHY PATIENTS DON’T TAKE MEDS
– Video: Real Patient Interviews share stories
✦SOLUTIONS
– Blame free environment
– Resources
– Video: patient centered care
Keep a watch...on the faults of
the patients, which often make them
lie about the taking of things prescribed.
For through not taking
disagreeable drinks, purgative
or other, they sometimes die.
Hippocrates, Decorum
Medication Adherence
World Health Organization
definition
‘the extent to which a person’s behavior…
corresponds with agreed recommendations
from a health care provider’
Medication adherence implies patient
agreement with recommendations
Medication compliance implies patient
passivity
Individual medication taking
behavior
World Health Organization:
Increasing adherence may have a
far greater impact
on the health of the population than
any improvement in specific medical
treatments.
# of pills absent in Time Z
# of pills prescribed for Time Z
24 pills taken
= 80%
30 pills prescribed
Considered
Adherent if > 80%
24 out of 30 days!
X 100
TREATMENT
OUTCOMES
TREATMENT
ADHERENCE
OUTCOMES
PATIENTS DON’T TAKE THEIR MEDICINE
AS PRESCRIBED
50% OF THE TIME
25% OF INITIAL PRESCRIPTIONS
ARE NEVER FILLED
Osterberg L N Engl J Med. 2005;353(5):487-497
Fischer MA, Choudhry NK. Am J Med. 2011;124(11):1081.e9-22.
Fischer MA, J Gen Intern Med. 2010;25(4):284-290.
Rates of Nonadherence
✦Hypertension
– 50-80%
✦Hyperlipidemia
– 25-50% within 1yr
– 75% at 2yrs
✦ASA
– 20-30% at 1yr
Osterberg L, NEJM 2005 353;5:487-97
Brown MT, Bussell, J. Mayo Clin Proc. 2011 86(4):304-314
Early Medication Nonadherence
After Acute Myocardial Infarction
• Over 7,000 acute MI patients in over 200 hospitals
treated with percutaneous coronary intervention
• Adherence assessed at 6 weeks with Moriskey scale
• Self-reported moderate to low adherence = ? %
ALMOST 30%
Mathews R, et al. Circ Cardiovasc Qual Outcomes. 2015.
Long-term persistence of statin use
in the elderly over 5 yrs
60
N= 34,501
% of patients
50
40
30
20
10
0
3
6
12
18
24
30
Months
36
42
48
54
60
Benner J JAMA 2002 288;4 455-461
Persistence Declines Rapidly
Glader EL Stroke 2010;41(2):397-401
85% OF PHYSICIANS BELIEVE
THE MAJORITY OF THEIR PATIENTS
ARE ADHERENT
85% OF PATIENTS SURVEYED
STATE THAT THEY WOULD
NOT TELL THEIR DOCTOR
THAT THEY WERE NOT PLANNING
ON BUYING A MEDICINE
Brown MT Family Practice Mgt; March/April 2013
McHorney,C Current Medical Research and Opinion 2009 25:1; 215-238
Quiet! I Can’t Hear You When Your Talking!!
Baron,R Ann Int Med 1985;103:606-11
Don’t ask…..
I didn’t ask….
Don’t tell…
They didn’t tell…
UNMASKING NON ADHERENCE
✦VIDEO
Trouble Getting Started
Predictors of Primary Medication Nonadherence
N= 423,616
ADHERENT
NONADHERENT
24%=101,668
Adapted from Fischer M AJM 2011 124;1081.e9-e22
Primary Nonadherence
50
by drug class
N= 423,616
% Unfilled
40
30
20
10
0
Adapted from Fischer M AJM 2011 124;1081.e9-e22
10000
HEALTH CARE COSTS
DIABETES
137,277 patients under age 65.
9000
TOTAL COST ($)
8000
7000
6000
5000
4000
3000
2000
1000
0
%1-19
20-39
40-59
60-79
80-100
ADHERENCE LEVEL (%)
Sokol M Med Care 2005;43: 521–30
HEALTH CARE COST WITH MEDICATION
NONADHERENCE
Roebuck,MC. Health Aff.2011; 30,(1):91-8
Brown, MT., Bussell, J., AM J Med Sci.,2016; 351(4): 387-399
Impact of Nonadherence
✦Substantial increase in morbidity and
mortality- approximately 125,000 deaths/yr
✦Causes 10% of all hospitalizations
✦Of all medication related admissions
33-69% are due to poor adherence
TIME LOST !
Osterberg L NEJM 2005 353;5:487-9
Viswanathan M Ann Int Med 2012;157:785-95
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
Old process map
NOT AT
GOAL
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ASSESS DRUG
INTERACTIONS
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
PREAUTH
MEDICATION
REQUIRED
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ASSESS DRUG
INTERACTIONS
ADDITIONAL
TESTING
ORDER
PREAUTH
MEDICATION
REQUIRED
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 2ND
MEDICATION
ADDITIONAL
VISIT
ASSESS DRUG
INTERACTIONS
ADDITIONAL
TESTING
ORDER
PREAUTH
MEDICATION
REQUIRED
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ASSESS DRUG
INTERACTIONS
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
MEDICATION
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ASSESS DRUG
INTERACTIONS
ORDER
PREAUTH
MEDICATION
REQUIRED
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ASSESS DRUG
INTERACTIONS
ADDITIONAL
TESTING
ORDER
PREAUTH
MEDICATION
REQUIRED
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE NOT ADDRESSED
NOT AT
GOAL
SELECT 3rd
MEDICATION
ADDITIONAL
VISIT
ASSESS DRUG
INTERACTIONS
ADDITIONAL
TESTING
ORDER
PREAUTH
MEDICATION
REQUIRED
27 KEYSTROKES
NOT ON
FORMULARY
PATIENT CALL
RE: COST
REVIEW SIDE
EFFECTS,
DOSING,
COST,ETC
MEDICATION THERAPY
ADHERENCE IS ADDRESSED
New process map
GOAL
ACHIEVED
NOT AT
GOAL
IDENTIFY
IMPROVE
NONADHERENCE
ADHERENCE
NOT AT GOAL
INTERVIEWING IN A
BLAME FREE ENVIRONMENT
✦These are difficult to take every day. How
often do you skip one?
✦There are quite a few-how many of these do
you take?
✦Most people don't take all their meds
everyday. How about you?
✦When was the last time you took drug A? B?
The Morisky 8-Item
Medication Adherence Scale
1.Do you sometimes forget to take your high blood pressure
pills?
2. Over the past two weeks, were there any days when you did
not take your high blood pressure medicine?
3.Have you ever cut back or stopped taking your medication
without telling your doctor, because you felt worse when you
took it?
4. When you travel or leave home, do you sometimes forget to
bring along your medications ?
Morisky et al. J Clin Hypertens. 2008;10(5):348-354
The Morisky 8-Item
Medication Adherence Scale
5. Did you take your high blood pressure medicine
yesterday?
6. When you feel like your blood pressure is under control,
do you sometimes stop taking your medicine?
7. Taking medication everyday is a real inconvenience for
some people. Do you ever feel hassled about sticking to your
blood pressure treatment plan?
8. How often do you have difficulty remembering to take all
your blood pressure medication?
Morisky et al. J Clin Hypertens. 2008;10(5):348-354
The Adherence Estimator
I am convinced of the importance of my
prescription medication.
Agree
Disagree
I worry that my medication will do more harm
than good to me.
Agree
Disagree
Agree
Disagree
I feel financially burdened by my out of pocket
expenses for my prescription medication.
McHorney,C Current Medical Research and Opinion 2009 25:1; 215-238
✦Documentation of inquiry is not
sufficient
✦Identification of nonadherence is key
✦The next step is critical
✦Develop a differential diagnosis
PIC OF AN OBSTACLE
OBSTACLES
✦VIDEO
UNINTENTIONAL
(Forgetful)
NONADHERENCE
CAUSES
INTENTIONAL
(Or other cause)
Osterberg L N Engl J Med. 2005;353(5):487-497
OBSTACLES
UNINTENTIONAL
✦ FORGETTING
✦ SHIFT WORK
✦ COST
✦ CONFUSION
✦ WORK RESTRICTIONS
VS
INTENTIONAL
✦ MISTRUST
✦ FEAR OF SIDE EFFECTS
✦ MENTAL ILLNESS
✦ LACK OF BELIEF IN BENEFIT
✦ FEAR OF DEPENDENCY
✦ FEAR IT IS DANGEROUS
✦ LACK OF DESIRE
✦ NO APPARENT BENEFIT
✦ ALTRUISM
Competence and caring in
relation to building trust
Paling, J BMJ 2003;327: (7) 745-8
Brown, MT., Bussell, J., AM J Med Sci.,2016; 351(4): 387-399
Our
Knowledge and Emotion
? % of doctors
informed the patient of duration of
cardiovascular therapy
17%-Cardiologist
34%-Internists
40%-Family Practice
Tarn D. Arch Intern med 2006;166:1855-1862
DON’T KILL THE MESSENGER!
DO WE TELL PATIENTS THAT THEY WILL
NEED TO STAY ON A MEDICINE FOR THE
REST OF THEIR LIVES?
WHY NOT?
✦
✦
✦
✦
WE DON’T WANT TO DELIVER BAD NEWS
CONCERN IT WILL CAUSE PATIENT TO RESIST THERAPY
CONCERN IT WILL INCREASE DURATION OF THE VISIT
FEAR IT WILL INCREASE THE PATIENTS’ CONCERN
THAT THEY WILL BECOME DEPENDENT ON THE DRUG
OBSTACLES
✦ PATIENT
– Cost/Health literacy/Access
– Rational nonadherence
– Mental illness
✦ PROVIDER
–
–
–
–
Failure to recognize/complicated regimens
Inadequate communication/relationship
Accusatory approach ‘shamed’
Negative attitude toward the patient
✦ PROCESS
–
–
–
–
Fumbled hand-offs
Insufficient time to develop trust
Lack of educational resources
Low refill consolidation
Refill Consolidation
Proportion of medications filled per pharmacy visit
Therapeutic Complexity and Adherence
N=1,827,395 Patients
✦Total number of prescriptions
✦Number of fills for each drug
✦Number of different prescribers
✦Total number of pharmacies
✦Number of pharmacy visits (non mail order)
✦Consolidation of refills
Choudhry N Arch Intern Med. 2011;171(9):814-22
Therapeutic Complexity
over 90 days among statin users
N=1,827,395 Patients
8
90th Percentile
Mean
% Patients
7
6
5
4
3
2
1
0
1
3
5
7
9
11 13 15 17
9
21 23 25 27 29 31 33 >35
Total Medications, No.
CHOUDHRY ARCH INT MED 2011 171;93 P 814-21
PHARMACY VISITS
over 90 day period for statin users
N=1,827,395 Patients
16
90th Percentile
Mean
% PATIENTS
12
8
4
0
0
1
2
3
4
5
6
7
8
PHARMACY VISITS, No.
9
10
11
12
13 >14
CHOUDHRY ARCH INT MED 2011 171;93 P 814-21
Therapeutic Complexity and Adherence
N=1,827,395 Patients
16
1- # visits
# meds filled
% Patients
14
90th Percentile
Mean
12
10
8
6
4
2
0
0
10
20
30
40
50
60
70
80
90
100
Refill Consolidation,%
Choudhry N Arch Intern Med. 2011;171(9):814-22
Therapeutic Complexity and Adherence
N=1,827,395 Patients
Greater therapeutic complexity
was associated with
lower medication adherence
(especially for newly initiated meds)
Choudhry N Arch Intern Med. 2011;171(9):814-22
Variations in pill appearance
and the risk of Nonadherence1
CHANGES IN PILL COLOR INCREASED RISK OF NONADHERENCE
80% OF ALL MEDS IN US ARE NOW GENERIC2
A PATIENT TAKING 5 MEDICINES, EACH PRODUCED BY 5 GENERIC
MANUFACTURERS THEORETICALLY FACES OVER 3000 POSSIBLE ARRAYS
OF PILL APPEARANCES (55)
IF TAKING 9 MEDS, PATIENTS EXPERIENCE 36 OPPORTUNITIES/YR TO
CHANGE APPEARANCE
UK MANDATED INHALER COLORS BE COORDINATED
1.KESSELHEIM, CHOUDHRY JAMA INTERN MEDICINE 2013;173(3):202208
Medication Reconciliation
Courtesy of nursing.advanceweb.com
Medication Reconciliation
Cornish P Arch Intern Med. 2005; 165: 424-429
Fumbled Hand Offs
✦Direct communication between hospitalists
and Primary Care Providers occurs in less
than 20% of hospitalizations
✦Discharge summaries are available at less
than 34% of first post-discharge visits
✦Med rec is one of the Joint Commission
Hospital National Patient Safety Goals
Kripalani S JAMA. 2007; 297(8): 831-841
Creative Solutions
Medication
Usual barrier
Best solution
Diuretics
Urinary urgency
Patient directed timing
ACE inhibitor
Cough, hair loss
angioedema
Trial off drug for 1 month
Discontinue if angioedema
Beta blockers
Fatigue, depression
Change drug
Warfarin
Frequent monitoring,
Evening dose forgotten
Home monitoring,
Take in am
Novel oral anticoagulants
GI upset
Replace with warfarin
Antidepressants
Discontinuation syndromes Use ‘forgiving’ long acting drugs
Sexual dysfunction
Patient directed timing, use PHQ-9
Bisphosphonates
GI upset
Decrease frequency
Metformin
Diarrhea
Diarrhea may take 7 days to resolve
will reoccur if 3 day drug holiday
Statins
Myalgias
Evening dose forgotten
Decrease frequency, restart drug
Take with other meds in am
METFORMIN
The history of biguanides can be traced from the use of Galega officinalis
(French lilac) as a treatment for diabetes in medieval Europe.
Decreases hepatic glucose output and increases glucose utilization in peripheral tissue
Pros:
Significant A1C reductions, especially at high baseline A1C
Proven CV benefits in obese (UKPDS)
Preservation of beta-cell function
No risk of hypoglycemia
Modest weight loss or weight neutral
Extensively researched
Inexpensive
Decreases LDL
Cons:
Contraindicated in renal insufficiency*
Use cautiously in elderly
GI effects common
Risk of lactic acidosis
Baily CJ, Turner RC. Drug Therapy: Metformin. NEJM 1996;334:574-583
METFORMIN
INITITATING METFORMIN
-LOW DOSE
-EXPECT GI SIDE EFFECTS
-EMPOWER PATIENT DIRECTED TITRATION
-INCREASE DOSE 7 DAYS AFTER GI
SIDE EFFECTS HAVE RESOLVED
-EXPECT RETURN OF GI SIDE EFFECTS
AFTER A BRIEF DRUG HOLIDAY
(AS SHORT AS 3 DAYS)
Baily CJ, Turner RC. Drug Therapy: Metformin. New Engl Journ of Med 1996;334:574-583
METFORMIN PATIENT INSTRUCTIONS
To use metformin to lose weight and lower your sugar, please
follow these directions:
1. Metformin will give you a mild upset stomach and diarrhea but
this will go away within a few days as you body gets used to it.
2. Take ½ of a 500mg tablet and let your body get
accustomed to it. After you have no stomach symptoms
for 1 week, increase the metformin to 1 whole tablet.
Stomach upset and diarrhea may return every time
you increase the dose. These symptoms will go away
within a few days if you keep taking the metformin.
3. If you stop taking the metformin for even 2 days,
when you restart it all the stomach upset will return
-so try not to stop the medicine but if you do-restart
at the lower dose and let your stomach get used to it again.
4. We may increase the metformin every 2-3 months depending on how
much weight you lose and your A1c level. Metformin will not make your
sugar go too low-we never have to worry about that.
Patients’
Knowledge and Emotion
ADHERENCE IS DRIVEN BY
PATIENTS’ BELIEFS
* A ‘non-adherent personality’ does not exist.
* Adherence to medications is largely unrelated to
adherence to self-care and lifestyle.
* There is no consistent relationship between
demographic characteristics and adherence.
McHorney,C Current Medical Research and Opinion 2009 25:1; 215-238
SHADES OF GREY
* Patients actively make decisions about their medications.
* Non-adherence is rational behavior–it is driven by patient
beliefs and experiences.
* Adherence represents shades of grey – patients can be
faithfully adherent to one medication, non-fulfill on
another, and be non-persistent to another because they
hold different beliefs about each medication.
McHorney,C Current Medical Research and Opinion 2009 25:1; 215-238
GENOTYPE FOR IMPATIENCE
Reach G. Diabetologia. 2010;53(8):1562-1567
The Impatient Patient
✦ Prefers immediate rewards to efforts linked to long
term therapy.
✦ Prefers smaller-sooner to larger-later rewards.
✦ The reward of adherence is “to avoid complications".
✦ Paradoxically this type of reward is never “received".
Reach G. Diabetologia. 2010;53(8):1562-1567
The Impatient Patient
✦ We are future oriented ……
while patients may not consider themselves
as having a future to look forward to.
Reach G. Diabetologia. 2010;53(8):1562-1567
SOLUTIONS
✦VIDEO
The Physician Centered Interview
✦On the average, physicians interrupt
the patient 18 seconds after the patient
begins to speak
Adapted from American Academy of Health Care Communications and David Gullen MD MACP
The Patient Centered Interview
✦Patients who were not interrupted rarely
took more than one minute to complete
their list, and never took more than three
minutes.
Adapted from American Academy of Health Care Communications and David Gullen MD MACP
Why Not Interrupt?
✦The degree to which patients can tell their
own story affects outcomes of care
– Headaches are more likely to resolve
– Hypertension improves
– Better overall health ratings
– Fewer days lost from work
– Fewer functional limitations
Adapted from American Academy of Health Care Communications and David Gullen MD MACP
ONCE A DAY DOSING!
Osterberg L N Engl J Med. 2005;353(5):487-497
Summary
50% of patients do not take medication as prescribed
Simply asking if the patient is taking the medication is not sufficient
How you ask is critical
Develop a differential diagnosis to determine the cause
Recognize that most nonadherence is intentional
Tailor the solution and individualize the conversation
To study disease without
books
is to sail an uncharted
sea,
while to study books without patients
is not to go to sea at all.
William Osler
Thank you!
Questions?
Jennifer Bussell MD FACP
[email protected]
Links to Video
Courtesy of the
American College of Physicians
and CDC
Free access for your use
Medication Adherence
✦ http://vimeo.com/42194365 (21 minute version)
✦ http://vimeo.com/42144406 (5 minute version)