National Diabetes Education Program WebinarEmpowering Patients

October 15, 2015

Joanne Gallivan, MS, RD—Director, National Diabetes Education Program, National Institutes of HealthGood afternoon everyone and thank you for joining the National Diabetes Education Program’s Webinar Empowering Patients to take their Medicine, What Can We Do? I am Joanne Gallivan; I am Director of the National Diabetes Education Program at the National Institutes of Health.

As a joint program the National Institutes of Health and the Centers for Disease Control and Prevention the NDEP’s mission is to reduce the burden of diabetes in the United States by facilitating adoption and proven approaches to prevent or delay the onset and the progression of diabetes and its complications.

I think many of you know that we host a variety of webinars throughout the year to support all of you working to improve diabetes management outcomes and to prevent or delay the onset of type 2 diabetes. I just want to review with you a few key items before we begin the main presentation.

All your lines are already muted so you do not need to mute yourself. We will have a Q&A session at the end of the presentation. If you would like to ask a question please submit it during the webinar using the “Questions Box” in the “Control Panel” and then we will read it out loud. Any questions not answered will be shared with Dr. John Ryan and Dr. Jennifer Bussell after the webinar so they can get back to you if they have not been able to answer your question.

This webinar is being recorded. We will post the video recording and presentation slides on the NDEP webinar page in the next three weeks and we will notify all of you when the files are available. You will also receive an e-mail from us this afternoon that asks you to evaluate this webinar, please give us your feedback because we use it to plan future events. And if you would like receive a certificate for completion of this particular webinar please send an e-mail to ndep@hagersharp.com and you can see that URL on the slide.

So, we are very, very excited to have two guest speakers for today’s webinar, Dr. John Ryan and Dr. Jennifer Bussell.

Dr. Ryan is Professor of Family Medicine and Director of the Division of Primary Care Health Services Research and Development at the University of Miami Miller School of Medicine. His clinical and research interest is in type 2 diabetes with an emphasis on high-risk populations and mechanisms for achieving behavior change.

Dr. Ryan designed and supervises a coordinated care program for managing diabetes that targets low income, high-risk patients followed in a community health center affiliated with a tertiary care hospital.

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The program’s model includes clinical diabetes support as well as diabetes self-management education and behavioral support programs that are aligned with cultures and health literacy levels of the target population.

After Dr. Ryan we will have Dr. Jennifer Bussell who is an Instructor of Clinical Medicine at Northwestern University Feinberg School of Medicine. She previously served as Clinical System Professor in the Department of Medicine at the University of Chicago and Associate Program Director of Internal Medicine and Transitional Year Residency at MacNeal Hospital.

Dr. Bussell speaks nationally to the Institute for Healthcare Improvement on improving medication adherence and is involved in developing the medication adherence module for the AMA’s STEPS Forward Program.

Dr. Bussell is a member of the Patient Quality Committee at Northwestern Medicine and serves as Chair of the Patient Safety and Quality Committee and as an Executive Board Member for the Illinois Chapter of the American College of Physicians.

We thank both of you Dr. Ryan and Bussell for your commitment to promoting medication adherence and for today’s webinar. I will now turn the program over to Dr. Ryan.

John G. Ryan, Dr.P.H.—Professor of Family Medicine and Director of the Division of Primary Care Health Services Research & Development, University of Miami Miller School of MedicineThank you, Joanne, and thank you everyone for joining us this afternoon. We are going to first provide some definitions of some of the key concepts and terms that we are going to be talking about for the next hour to make sure that we are all on the same page and have a similar understanding of what these concepts really are.

When we say “adherence” what we are talking about is the active, voluntary and collaborative involvement of the patient in a usually acceptable course of behavior to produce a therapeutic result, which is a pretty conventional definition.

The phrase “adherence” is actually gone under an evolution over the course of the past 20 years. It had been called “compliance” but that concept has been softened a bit to adherence and I have to say that my own bias is against adherence. I prefer something that is even more neutral. I like to say medication taking behavior and so you might hear that term during the course of this presentation on and off and in the future so you know what you are hearing.

Medication adherence actually involves two main concepts, first of all there is adherence and second is persistence. So, adherence is the intensity of drug use during the therapy and persistence is the overall duration of drug therapy. It is important to know that we are talking about two different types of using medication and there are different ways of measuring that and also there are different things that you as a clinician or as a provider, or as an educator would want to be aware of as you think about medication adherence to talk to your colleagues or your patients about it.

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The scope of the problem, here is a set of bullets that rather succinctly illustrate some of the important things that we know about this issue and some of the things we do not know. So, first we know that the adherence rate for diabetes medications is represented by an incredibly broad range in the medical literature from 36 to 93%. So, to me this suggests that we really do not have a clear idea of what medication non-adherence rates are for diabetes medications and this is complicated because of the frequency with which all medications are changed during the course of treating the patient. It is also complicated by the way in which insulin is prescribed and administered.

All of the characteristics make meaning and use of these medications extraordinarily complicated and not always reliable. Furthermore, adherence rates differ depending on the demographics of the target population or comorbidities that exist in the target population. So, depending on the study and depending on the target population rates are going to vary and sometimes be wildly different.

As much as we like to be able to succinctly say, adherence rates for diabetes medications is “x” or “y” we really are unable to make a broad blanket statement at this point. What we do know, very well in fact, that less than 1% of patients who are medication non-adherent actually disclose that to their physicians suggesting that a provider may think that the patient is using their medication as prescribed but is very unlikely to know for sure.

We also know, from clinical trials, that a 10% increase in non-adherence, to for example metformin, is associated with an increase of 0.14% in HbA1c glycosylated hemoglobin level. We also know that a 10% increase in non-adherence to statins is associated with a 4.9% increase in LDL cholesterol.

Conversely, we know that each 10% increment in diabetes medication adherence increases the HbA1c levels by 0.16%. So, these are not unimportant changes. These are not insignificant clinical changes and lab values. So, it also suggests to us that small tweaks in the matter in which patients use or do not use their medications can have potentially serious implications for the extent to which their condition is controlled.

Finally, there are estimates suggesting that improving adherence to diabetes medication could prevent almost 100,000 emergency department visits in a year and 341,000 hospitalizations annually using 4.7 billion dollars. So, obviously, again, this is not an insignificant problem whether we are talking about an individual patient, the healthcare system or the healthcare system at large in the country.

We see the reasons for medication non-adherence is multifactorial which is to say that there are a great many factors that may contribute in medication non-adherence or that may mitigate against medication non-adherence.

So, this is kind of conceptual model is actually vitally important for us to look at, consider, think about not only for the course of this presentation but also as you go forward if you are interested in taking any actions to reduce medication non-adherence in any patient population. I am going to talk a little bit about some of these factors and then we will drill down on some of these factors later on in the presentation in a little bit more detail.

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Framework, so, I do not know how many people are accustomed to working with a framework but this kind of a model is critical for understanding the problem like medication non-adherence. First, because it illustrates what kind of interventions may be useful for us to develop but it also shows value and dimensional intervention number one that addresses only one factor and that likely could be various---a multidimensional intervention with getting multiple factors at one time is more likely to be effective.

So, let’s take a little bit of a deep dive on this model because it is fairly important. First is the patients, but this shows that the language patients perceive their illness whether they are likely to think that medication is going to help or not can effect medication taking behaviors.

So, for example, we have a large Asian population here in Miami and many of our older patients with diabetes can have the perception that diabetes is something that comes from God and that they cannot do anything about it. So, that is definitely going to impact the way they think about taking their medications.

Another component of this factor is the extent to which patients perceive their medications. So, for example many of our patients have the belief that insulin is a habit-forming drug or that being prescribed insulin means that they have failed to conform their diabetes using other mechanisms so it is a negative perception. So moving patients to a different stage on the continuum of how they perceive their illness takes a lot of education and counseling.

Cognition, including memory and mental health, which also includes depression, plays an important role in medication non-adherence. Older patients with other mental health diagnosis could potentially use some triggers to help them to remember their medications.

Another consideration for cognition is the extent that the patient has internalized the motivation for taking the medication. So if the motivation for taking the medication comes from within they are more likely to be adherent than if the motivation is from an external source.

And finally, I want to say another quick argument about cognition, it is important for us to consider that most patients with diabetes have had numerous hypoglycemic episodes because of cognitive capabilities those patients may also be impaired and they will require some extra counseling and education, and again, potentially some reminders or physical mechanisms for helping them to take their medication as recommended.

Demographics we know from research that patients belonging to minority groups are more likely to be less adherent with their DM medications. We also need to enter the characteristics of the medications themselves, for example, potential adverse reactions that may cause a patient to stop using them. Another consideration here is that if they are using multiple medications instead of a single combined medication or medication prescribed three times a day instead of a once daily formula.

All of these factors interact with external stimuli as the patient does. So, an example of an external influence that may alter a patient’s medication taking behavior is a commercial from a legal firm looking for patients to sign onto a class action suit like 1-800-BAD-DRUG. I am sure we have all seen those on TV or have had patients asking us about the danger of taking something based on watching a commercial.

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Then we also have to think about the healthcare system or physician factors that may contribute to or protect against many patient nonadherence, so for the healthcare system we have to figure in about co-payments, frequency of needing prescription refills, the validity of the medications that we know, etcetera.

For the physician we have to think about the quality of what we call the therapeutic alliance. This describes the nature of the relationship between the provider and patient. We have to think about whether the patient feels satisfied with the doctor or that the doctor is taking enough time to talk to the patient, or if the patient is fully informed about potential side-effects. We used to call this doctor/patient relationship but that relationship actually began with the doctor it includes every member in the healthcare team and any incident to which the patient feels satisfied with the overall healthcare experience.

So, just a word about considering multifactor nature of medication nonadherence, planning and introducing intervention, in my population, here in Miami, I have received a considerable amount of funding to help patients without any health insurance so that we could cover their pharmacy co-payment. So, we are introducing a tremendous intervention to address what we call “cost-related medication non-adherence.”

To take advantage of this program patients have to present to a central pharmacy in the hospital that is not necessarily something that is easy for our patients to do. And we also found, later on, that patients with any kind of mental health diagnosis ended up having higher medication non-adherence rates than those patients who did not have those mental health diagnoses. So, we would have actually probably had better outcomes if we had some kind of counseling or behavioral health component to this.

So, with that discussion I am going to turn the presentation over to Jennifer who is going to take a deeper dive on some of these factors from her perspective as a physician, but I recommend to you that you keep this central model of mine during the course of her comments, think about these factors after the webinar is over and think about where you might have some influence in making changes that would reduce this particular issue of medication non-adherence for your patients. Jennifer?

Jennifer K. Bussell, MD, FACP—Instructor of Clinical Medicine, Northwestern University Feinberg School of MedicineThank you Dr. Ryan. So, among patients with chronic illness such as diabetes approximately 50% of patients do not take their medications as prescribed and 25% of initial prescriptions are never filled. A 2003 report on medication adherence, by World Health Organization, stated that increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any improvement of specific medical treatment.

Medication taking behavior is complex and individual, and requires multifactorial strategies to improve adherence. And although long-term use of medications are effective to decrease mortality and morbidity their full effect is really not realized and for medication treatment to show outcome benefits patients must have medication adherence, the key factor, associated with the effectiveness of all pharmacological therapies and is particularly critical for medications prescribed for chronic conditions such as diabetes.

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For instance, nearly 85% of adult patients surveyed in six US States reported that they would never tell their provider if they did not plan on buying a prescribed medication. Physicians or healthcare providers, on the other hand, tend to assume that their patients are adherent. The two studies listed on this slide nearly 85% of surveyed physicians believe that the majority of their patients were adherent.

There really is a great need to screen for non-adherence because patients do not voluntarily tell their healthcare provider about their adherence intentions nor their behavior. Not addressing medication therapy is really an opportunity lost and significant time wasted.

We are all about efficiency, efficiency, efficiency in healthcare and we are in a crunch for our time limitations and when our patients that we see do not reach their A1c goal what do we do? We add another medication or we increase their current medication. We assess the drug interaction, we order those medications, we review the side-effects, the dosing and the costs and if, God forbid, it is not on their patient’s formulary we have to go through the pre-authorization, additional phone calls, additional visits, additional tasks all that combined is an incredible amount of time and effort that we have gone through to ensure the patient is hopefully reaching their A1c goal or their better diabetes control.

Whereas, if we were to address their medication adherence or it is identified, their medication adherence or non-adherence is identified, then the patient is able to improve their medication adherence and reach their goal therefore time and frustration is saved for all of us.

How do we go about doing that? Well we assess our medication adherence in many different ways and medication adherence measurement is challenging because adherence is an individual patient behavior and there are times when some of the approaches have been used to assess medication adherence such as subjectively, objectively, which is really done mostly for our research and having opportunities of data for our patients and we have objective, subjective and biochemical ways and they are all positive and influential in some of the ways.

But really in a clinic setting most of us in healthcare ask our patients to assess their medication adherence taking behavior and by asking the appropriate questions in a blame-free environment we can accurately assess which medications patients are taking and how they are taking them.

As a routine outpatient visit patients may be asked twice, maybe three times to list their medications on a form while they are waiting in the outpatient waiting area, again when the nurse brings the patient into the room and maybe the third time by the healthcare provider as they go through the medication list.

However, simply listing medications or even doing the medication reconciliation and running the medication list does not and is not addressing whether medications are actually being taken. Therefore, if a healthcare provider assumes that the medication list or medications listed are being taken there starts the misconception and miscommunication with our patient.

Assessment of medication taking patterns may be more efficient by asking a number of direct questions in a non-judgmental way giving our patients an opportunity to tell the truth of their medication taking behavior.

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Some of the questions we may ask “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 do not take all their medications every day how about you?” Some of these questions in a blame-free environment may allow your patients to tell the truth and how we ask is important and it does matter.

Here are some self-reported medication measures that are used with pretty decent validity. Most self-reported medication measures have a wide variable of validity, however, these are in the literature to be pretty good, strong validity and have shown reliability and significant relationship between self-reported adherence and A1c in adults with type 2 diabetes and it is convenient, low cost and we all, in healthcare, need to be aware when we are giving patients these self-reported measures to complete that patients may have white coat adherence where patient’s medication taking behavior five days before or five days after they have an encounter with a healthcare provider will be better and we call that white coat adherence. So, they can truthfully state that they have done better with their medication adherence whereas if you were to ask for the self-reported measures over three months or maybe a month before you may get a different response.

Documentation of inquiry is not enough, going through the list, going through the patient’s medication list and assuming that this is accurate is not enough and once the identification of non-adherence is known the next step is critical, developing a differential diagnosis as to why the patient is not adherent.

Most patients have really good reasons why they are not taking their medications as prescribed. Patient’s barrier to medication adherence may be due to lack of understanding of their disease, cost of medication, forgetting to take their medications, however, the greater obstacle may be due to lack of involvement in treatment decision making process, suboptimal medical literacy, undiagnosed or untreated depression, patient’s health belief and attitudes that Dr. Ryan talked about concerning effectiveness of their treatment, lack of motivation, mistrust with the healthcare system.

A few years ago my colleague and I received a grant from ACP to create a teaching video and we had the opportunity to interview our patients regarding their medication taking behavior and I was surprised to learn the degree of mistrust our patients, my patients, had with the healthcare industry.

They commented about pharmaceutical industry supporting physicians as they saw the drug representatives in the office distributing samples and medications. They mentioned about the mistrust from the African-American patient population with the history of the Tuskegee Syphilis Study for 40 years where patients with syphilis were not being treated with penicillin even though penicillin was available. The Women’s Health Initiative with the estrogen and progesterone hormone replacement therapy with confusion regarding it is recommended and thereafter the study it is not recommended, it is essentially is harmful.

So, it was an eye opening of how much mistrust the patients have towards the healthcare industry. And in non-adherence the cause of medication non-adherence in the majority of our patients are intentional, they are choosing to not take their medications it is not simply forgetfulness for the majority of our patients.

Patients are more likely to disclose their true medication taking behavior when patients have trust in their healthcare provider and how is that trust developed. It is developed when there is a high-level of

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competence in their healthcare provider or by their healthcare provider but alongside that there must be a high-level of caring that is provided and many of us have long-term relationships with our patients, how many of us have taken care of the same patients for more than three, five years? Many of us have and those long-term relationship are key in developing trust with our patients.

We as healthcare providers are passionate about improving care of our patients and their health outcome because we know what happens, we have seen the complications of our patients when their diabetes is not well-controlled. We have taken care of diabetes patients with their uncontrolled or complications of their foot ulcers and what happens when that is not well controlled or infection spreads. We have seen our patients not have their A1c optimally controlled or uncontrolled and seeing diabetic nephropathy leading to dialysis, increased risk of cardiovascular disease.

So, we are passionate with that knowledge about optimizing patient treatment and it is sometimes very difficult to think about why would patients choose not to be adherent to develop these complications. So, know that we do bring our own knowledge and emotions as we talk to our patients about their medication non-adherence.

Patients are most likely to follow a therapeutic regimen when there is a good rational behind it, they believe the benefit is expected, the potential side-effect is known and the importance of adherence has been discussed in detail.

Patients with chronic disease often take many medications multiple times a day and this slide reminds me of my patient, Mary, she is 89 years old, she is a widow, she has a history of hypertension, diabetes, cardiovascular disease, stroke, osteoarthritis on multiple medications and Mary goes to the pharmacy 11 times a month to fill her prescriptions. She said “you know I don’t mind going actually I like my pharmacist, but it really is in the icy Chicago winter months that I have a tough time.” This is crazy, 11 times a month.

Does refill consolidation, the complexity of getting your medications, the therapeutic complexity does that matter in medication adherence?

So, this is a study that was done by---to look at specifically that question in patients with chronic disease and therapeutic complexity is looked at as total number of prescriptions or number of fills for each drug, or number of different prescribers prescribing the medicine, or total number of pharmacies the patient has to go to, or number of times the patient has to go to the same pharmacy to get their medications.

What do we know in this study? Well, the average number of patients fill their prescriptions, they filled 11 prescriptions at five pharmacy visits, and if you look all the way towards the right of this graph, this chart, some patients were on 23 medications or greater 10% of the patients and to fill their prescriptions over 90 days, this is a study that is identifying and highlighting the statin medication, the number of visits the patient went to in order to get their 11 medications was five pharmacy visits, but look at those patients who are on more than 23 medications they had to go 11 times or more to get their medications filled.

If we were to increase the refill consolidation so they decrease the number of times the patient has to go to the pharmacy to get their medications or decrease their therapeutic complexity overall the adherence

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will improve. Therefore, we should all strive toward improving and decreasing their therapeutic complexity to improve medication adherence.

As patients are asked to take their medications twice a day, three times a day, four times a day know that their adherence decreases. So, prescribing patients the metformin long-acting XR once a day versus metformin twice a day will decrease patient’s adherence as we increase their dosing frequency.

When patients are given multiple medications that also affect’s patient’s adherence. If you look at patients all the way to the right having 10 medications already on their regimen and you are adding one more medication onto their medication therapy know that the adherence will decrease by 20% overall.

So, any opportunity we can to really look at their medication list to see is every medication absolutely necessary to improve this patient’s outcome and if you truly need to add additional medication think about a combination pill for that patient.

Simplifying regimens and therefore using daily medication dose, adjusting medications to take it at the same time a day, avoiding prescribing medicines with special requirements and using combination medication will help patients improve their medication adherence.

This is a large study, over 63,000 patients, to see if switching among different appearing medications is associated with increased rates of medication non-persistence, so stopping their medication for a short period of time due to the pills appearing differently when patients pick up their medicine.

Changes in pill colors significantly increase the risk of non-persistence, the risk of interruption in medication use and in short-term healthcare providers perhaps maybe when we are talking about medication adherence improvement may want to mention to our patients the possibility that the pill color may change and it is the same medication or perhaps pharmacists might need to take greater care to alert patients when changes in suppliers leads to new pill character and in a systematic improvement hopefully in the future the FDA, the Division of Generic Drugs, will recognize this impact of physical attributes the color, the size of the medication does affect patient’s mediation adherence.

Communication, we have always known that effective communication is important in patient or healthcare patient relationships and this is a study that was done to see if there is an association between patient communication rating and medication refill adherence?

A large population study of diabetic patients done in California looking at a Kaiser Permanente Survey and they looked at patients taking at least one oral hypoglycemic medication, lipid medication, antihypertensive medication and they assessed the patients regarding effective communication by looking at the four item consumer assessment healthcare providers system survey and the trust survey with healthcare providers and what they found is that patients assessment of their healthcare provider who did not involve patients in decision-making did not understand patients problems with treatment, did not elicit confidence and did not trust were more likely to have poor adherence especially in oral hypoglycemic medications they had higher rates of poor refill adherence and stronger association when the patient’s healthcare provider communication was less than effective.

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A focus group study of oral diabetes medication therapy initiation in intensification found that patients viewed medication therapy initiation as evidence of personal failure and an increased burden and viewed medication therapy intensification as increasing their risk of diabetes related complications and de-escalating as their primary treatment goal.

It is really important to have the effective communication to let our patients know what to expect when starting a new medication or adjusting medications and patient-centered communication that promotes active patient involvement really does foster improved medication adherence.

When we are starting patients on metformin we do need to let them know that they will have GI side-effects and empower patients to titrate their medication slowly as they tolerate the GI symptoms. One of my colleagues really gives a terrific metformin patient instruction that I highlighted here and I use this exact copy as I take care of patients when I am starting patients on metformin so that they are aware of what to expect and how to increase their metformin.

I was not aware how many patients still receive their medications from a local community pharmacy. There are over 55,000 community pharmacies in the United States and approximately 70% of patients still receive their medications from their local pharmacy. So, they are a huge resource, as part of the healthcare team, to improve medication adherence as well for our patients.

This is a Pennsylvania project study it was done to evaluate the impact of pharmacy-based interventions and adherence of five chronic medication class’s, diabetic medication being one of them, and it screened a large number of patients, nearly 30,000 patients, with poor adherence risk and followed these patients who were educated regarding their medication by the pharmacist. The data shows that not only did they significantly improve the adherence for these patients, especially the oral diabetes medications, there also was significant reduction in patient’s annual healthcare spending for these oral hypoglycemic agents of $341.00 and the estimated savings for these members was quite huge as highlighted up on the top of 1.4 million dollars per year.

Another study that was shown to be effective with involving the pharmacists in face-to-face education of your patient population as they went to go pick up their medications and adherence for the antihypertensive agents and anti-lipid medication significantly improved as well.

There is quite a bit of literature coming forward regarding does co-payment or not having the co-payment improve medication adherence and initially there was quite a bit of information in the literature about value-based care where patients had their co-pay so that they had a stake in the financial portion of healthcare, however, in patients with chronic illness co-payment does matter as far as when it comes to medication adherence. Reducing co-payment or lack of co-payment did improve medication adherence for patients.

As Dr. Ryan spoke of earlier patients come to us with their own beliefs and their own knowledge and emotions. Some of the things that he had mentioned earlier, some patients may believe that insulin is a habit forming drug or that patients may come with previous hypoglycemic events and finds that to be one of the significant dislikes of an adverse event and does not want to go back on that medication. So, patients do come to us with their own experience, belief, knowledge, emotion regarding medicines.

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We need to address the behavior of patients who have tastes for the present rather than future and propose that perhaps some of our patients may have this impatient personality which are unlikely to adhere to medications that require long-term use. We propose that if impatient genotype does exist, assessing the patient’s view of future while stressing immediate advantage of adherence may improve adherence rate more than emphasizing potential distinct complications. So, therefore rather than attempts to change the character of those who are impatient it may be wise to ascertain the patient’s individual priorities particularly as they relate to immediate versus long-term gains.

For example, for our diabetic patients stressing the importance and the improvement of the visual acuity rather than avoidance of retinopathy may result in greater medication adherence.

I strictly remember one of the patients we had videotaped in the past who was so excited about her beautiful eye glasses, that she had that she had spent a lot of money on, that she loved wearing, however, she could not wear them when her diabetes was not well-controlled, when her A1c was high, and she wore the other cheaper glasses that she did not like as much, just connecting that and highlighting that importance that if your A1c, if your diabetes, is optimally controlled you can wear those cool glasses that you love all the time was much more influential for that patient than talking about avoiding retinopathy years from now.

Know that most people have an innate tendency to prefer smaller/sooner to larger/later rewards. The reward of adherence in management of chronic disease is to avoid complications. So, patients may adhere to their therapy and never receive their reward.

We in healthcare are very much future oriented while our patients may not consider themselves as having a future to look forward to. So, as we take care of our patients it is vital that we identify why the patient is non-adherent after we have discovered non-adherence and tailor the solutions to individual patients.

These are some of the highlights. Health literacy is significant in our country, over 90 million US adults have limited literacy and only 10-12% of patients are proficient in health literacy. Most patients, greater than 85% of patients hide their limited literacy from their co-workers, healthcare providers, even their children.

These are some really terrific information references where you can go to perhaps to get a little bit more of help as we take care of our patients in our clinic.

Cost is an issue for some patients and these are very helpful drug assistant programs that are available with easy access.

The article does highlight quite a bit of comprehensive strategies and resources for improving medication adherence and you can also take a look for comprehensive review as well.

In summary, 50% of patients do not take medications as prescribed and simply asking patients if they are taking their medications is not enough. How we ask is critical and developing a differential diagnosis to determine the cause is vital. Recognize that most non-adherences are intentional and we need to tailor the

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solution and individualize the conversation and please involve the patient in developing their treatment plan. Thank you.

Joanne Gallivan, MS, RDThank you Dr. Bussell and thank you Dr. Ryan for that excellent presentation. I just want to spend a few minutes with you before we open it up for Q&A to share with you one of the NDEP’s newest on-line resources promoting medication adherence in diabetes.

The NIDDA and our partners identified the need to support healthcare professionals, all of you, in clinical and community settings with tools and information to improve medication taking behavior among people with diabetes.

We formed a multidisciplinary task group that was led by Dr. John Buse, former Chair of the NDEP, who is at the University of North Carolina School of Medicine, to help develop a resource that has practical tools for healthcare teams and their patients as well as the scientific evidence surrounding medication adherence.

This slide shows the home page for the promoting medication adherence in diabetes website, again, it offers all of you resources and tools to help improve your medication taking behavior in your patients, it is divided into three sections and I will review each one briefly.

Please note that all the resources have been reviewed by expert members of our task group and are selected because in addition to addressing the topic of medication adherence they incorporate evidence-based strategies for improving medication adherence and they are relevant to all of you in a clinical or community-based setting.

We want to continue collecting resources and articles for this resource in a variety of formats whether it is a website, a video, a tip sheet or a journal article. So, if you know a resource that is really focused on medication adherence and diabetes please visit the “submit a resource” page and complete the on-line submission form.

The resources for patients page features resources such as handouts and websites that healthcare professions can use with your patients. Some of the resources included in this section identify resources by financial assistance to help all of you help your patients address medication taking behaviors related to medication and cost.

There are other resources in this section such as “my medications list” which has been created by the American Society of Health Systems Pharmacists and the questions to ask your healthcare team created by the Center for Improving Medication Management and the National Council on Patient Information Education that provides tools to enhance your patient interaction.

The resources for healthcare team page presents videos, presentations, training guides and assessments to help if you are interesting in finding resources to improve your own skills and the processes to promote medication taking behavior. You will find videos such as the medication adherence “We didn’t ask and they didn’t tell” from the American College of Physicians that highlights patient stories about why they

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had problems adhering to their medication routine. They also provide feedback from the patients and how physicians can improve their doctor/patient relationship.

We also have an assessment tool such as the rapid estimate of adult literacy in medicine revised and readiness to change rules which is available to help you identify areas that can affect medication taking behavior such as low literacy skills, which Dr. Bussell talked about, and patient’s willingness and ability to change behavior.

We also have the scientific evidence page which features journal articles to healthcare professionals and researchers. The articles address a wide variety of medication adherence topics such as assessment, barriers and interventions. We had to credit many, many people for the development and maintenance of this promoting medication adherence and diabetes resource and you can see all the names on the screen right now.

As we mentioned, independent experts in diabetes care and medication adherence including Dr. Ryan and Dr. Bussell will be provided as guidance and has helped to review all the resources. We also pretested this site with healthcare professionals before it was launched and improved some of the features of the site based on the feedback we received. We really thank all the individuals listed on this slide for giving their time and expertise for this project.

We also want to hear from you. If you have a success story, if you have any case studies demonstrating how you have successfully made changes to promote medication adherence in patients and any resources that you have used please share those with us. There is a section on the website where you can share any tools and stories that you have.

Now we are going to take some audience questions. If you have questions please type it into the questions panel on your Go To Webinar Screen. So, Candice I will turn it over to you to read our first question.

Candice Watkins-Robinson, MA—Hager SharpOkay. The first question is people are getting more interested in natural remedies and substitutions for medications what can we tell these individuals?

Jennifer K. Bussell, MD, FACPI think one of the health beliefs that comes with a patient is the natural remedies. So, one of the things that I do say when I am starting my patients on diabetic medication is that I talk about metformin because metformin comes from French lilac plants and once the patients hear “oh, it does” “yes, it’s natural, it comes from the French lilac plants.” And then I go through the benefits and the potential side-effect of that medication.

Sometimes for the patients who comes with that kind of background belief it is helpful to have a connection as to how certain medication has a background of natural ingredients and that maybe helpful for the patient to understand and be more open and willing to take that medication.

John G. Ryan, Dr.P.H.

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One thing I would like to say about that is at the same time---that is an excellent approach---the other thing to keep in mind that is---Jennifer talked a lot of being non-judgmental and this is the same kind of attitude that we would like to carryover in conversations with patients across the board including when they approach you with homeopathic remedies or remedies that Aunt Salida has mentioned.

We all have access to Google and great and powerful thing is as to you go on-line with the patient at the time that the patient is asking the question and do a search and demonstrate to the patient that you are interested in learning more about that therapy, look at the pros and cons, the benefits and disadvantages that might be available from an evidence-based approach on the web and have a conversation.

Take that next step and you can also talk about how you respect the patient’s thoughts and approach this to being creative with the therapy and at the same time you would like to be open to hearing their experiences, you do not want to shoot them down, and then a corollary to that is to reinforce your own recommendations so if its metformin, if it’s a sulfonylurea, if it’s an insulin you need to reinforce the behavior that you think that it is also important for the patient to consider using the recommended medication that you are making and to engage the patient in what could be potentially the conversation that will occur over several encounters.

And again, as I mentioned earlier, the goal here is to internalize the motivation for taking the medication that does not happen in one conversation that will happen over the course of several conversations.

Candice Watkins-Robinson, MAOkay, the next question, it seems my patients always tell me one story about their medications and then tell the check-in and check-out staff another story. Can administrative staff play a role in assessing medication adherence?

John G. Ryan, Dr.P.H.I am sure Jennifer has something to say about that also. Very quickly I have seen that something like this which is multifactorial the whole community needs to be on board and there should be training across the board, everyone needs to know a common understanding, a common purpose and a common approach, a standardized approach and messaging is very, very important with something that is related to behavior as medication taking is definitely a behavior that we want to encourage our patients to do. Jennifer did you have any thoughts?

Jennifer K. Bussell, MD, FACPIn our office it is really the automated responder when patients are having their appointments and they are being reminded of their appointment. It was actually I think my colleague’s receptionist that came up with the idea to say, could we put an automated responder there that patients must bring all their medications to every appointment, and so everyone does play a role when it comes to improving medication adherence. So, now we have an automated voice responder when patients are being told of when their appointment is it will also say “please, the doctor would appreciate that you come with all of your medications.”

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When our patient is brought from the front desk to the room by the nurse the nurse also kind of goes up on that and says “oh, you brought your medication, well thank you for that.” So, it is kind of a positive reinforced behavior but everyone does take a role when it comes to improving medication adherence.

Candice Watkins-Robinson, MAThe next question is, how to do you address the needs of the patients who are experiencing the donut hole that are often not eligible for other drug programs?

Jennifer K. Bussell, MD, FACPAbsolutely, and that is a challenge for a lot of our patients as well. Some of the sites that I had posted earlier can be helpful for some patients. Some of the area within your local area may have a program. We have, where I am, which is the Northern Region of Chicago area, there are a couple of pharmacies that actually provide certain medications, very few, but that are partner for chronic illness such as atorvastatin, metformin and Apidra are free for patients if they come in with a prescription at certain pharmacies. So, you may have a local program that is available around you that you can kind of tap into but it is a challenge for patients who are in that situation and we have not solved that.

John G. Ryan, Dr.P.H.One other comment is Dr. Bussell and I do not have all the answers and we do look to the audience and the folks who are actually in the field with us to help us all understand opportunities for addressing this issue and Joanne pointed out sharing your success stories on the webpage and I know that we would all be grateful if when you find something that is useful to share it with us and share it with your colleagues through this mechanism.

Candice Watkins-Robinson, MAThe next question is, do you have any suggestions for patients that self-titrate more often than they should? There are a number of patients I work with that do not adhere to their prescribed dose regimen but rather take a range of doses.

Jennifer K. Bussell, MD, FACPYes, so that is actually more common than I think we would think in healthcare. So, I think prioritizing the importance of certain medications with the patient may be helpful, letting them know “this medication you must take it as prescribed because of potential side-effects” and you can review them. You may be able to discuss some of the forgiving medications and that some of the medications that maybe the patient does have the ownership to titrate depending upon their schedule or their symptoms.

I do have patients who take hypertensive medications such as lisinopril and they are on that medication, the ace-inhibitor medication, they take that always and I have patients who take their hydrochlorothiazide medication along with that, it is not a combined pill, they would rather have it separately and they take that medication, the hydrochlorothiazide medication, pending their symptoms of swelling and they do check their blood pressure at home and a reliable patient and they bring in the readings. And for that particular patient she is able to titrate the hydrochlorothiazide medication pending her symptoms.

For patients with diabetes with insulin, if we are talking about insulin medication, I always provide a titration on those patients so that they do have some flexibility depending upon their symptoms especially

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for a patient who has had a hypoglycemic event in the past and they are very, very concerned and afraid to take any insulin. So, it is really a give and take conversation with that patient.

Some patients, it may be difficult for them to not be able to titrate it, they may go on the evening schedule for their work or their lifestyle is of such that it makes it much more challenging to be regimented. So, for insulin I do give the guideline of flexibility so the patient can titrate up or down depending upon their readings.

Joanne Gallivan, MS, RDI think we have time for one more question Candice.

Candice Watkins-Robinson, MAOkay, the final question is, knowing that time is a factor how can pharmacies and diabetes clinics improve communication about patient adherence?

John G. Ryan, Dr.P.H.That is a good question.

Jennifer K. Bussell, MD, FACPYes it is.

John G. Ryan, Dr.P.H.That is a struggle that we all have because time is truly a factor. One way that we can approach that is to make sure that we have as large of a team as possible that focuses on the patient with diabetes that would include the pharmacist, that would include pharmacy techs, that would include the nurse and just to be sure that everyone has a role to play and participates in the messaging, and collects the information so that they understand whether the patient is taking their medication as prescribed or not. And then a feedback loop to the larger team so that they can compare notes and know what to do when the patient returns for a follow-up visit.

Joanne Gallivan, MS, RDThank you. Thank you Dr. Ryan and Dr. Bussell for leading this great discussion. I want to be mindful of everybody’s time and we are a little past the hour. I thank all of you for joining the webinar to learn more about NDEP and all of our resources including the medication resource please visit our website at www.ndep.nih.gov.

Again, we would appreciate your feedback on this webinar. Please remember to complete the evaluation form that you received this afternoon and if you would like to request a certificate of completion please send an e-mail to ndep@hagersharp.com.

As I said earlier, the webinar slides will be available on the NDEP website in the next few weeks and we will let everybody know when they are available. Thank you again. Thanks so much to Dr. Ryan and Dr. Bussell and have a good afternoon. Thank you, everybody.

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