medication adherence - ga health...

MEDICATION ADHERENCE WORKING TOGETHER TO HELP ACHIEVE BETTER TREATMENT OUTCOMES

In a survey

of 1,100 patients,

83% of patients would never tell

their doctor if they didn’t plan

to fill their prescription.4

Physicians often are not fully aware of patients’ nonadherence.1–3

An educational resource provided by Merck.

1. Kripalani S, et al. Development and evaluation of a medication counseling workshop for physicians: can we improve on ‘take two pills and call me in the

morning’? Med Educ Online. 2011;16:1–7. DOI: 10.3402/meo.v16i0.7133.

2. Stevenson FA, et al. A systematic review of the research on communication between patients and health care professionals about medicines: the

consequences for concordance. Health Expectations. 2004;7:235–245.

3. Goldberg Al, et al. Physician assessments of patient compliance with medical treatment. Soc Sci Med. 1998;47:1873–1876.

4. Lapane KL, et al. Misperceptions of patients vs providers regarding medication-related communication issues. Am J Manag Care. 2007;13:613–618.

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The best treatment can be rendered ineffective by poor adherence.1 – WORLD HEALTH ORGANIZATION

1. World Health Organization. Adherence to long-term therapies: evidence for action. 2003. who.int/chp/knowledge/publications/adherence_report/en/index.html. Accessed January 3, 2014.

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1

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Understanding Adherence

Research Findings

Merck’s Adherence Estimator® and Other Resources 1

2

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Understanding Adherence

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MEDICATION ADHERENCE is the extent to which patients take medications as prescribed by their health care provider.1

• Adherence implies collaboration between the physician and patient with active participation by the patient.1–3

• Adherence is more aligned with patient-centered care.2,3

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MEDICATION

ADHERENCE

1. Osterberg L, et al. Adherence to medication. N Engl J Med. 2005;353:487–497.

2. Varghese GN, et al. Using passive measures to improve patient medication adherence. Drug Benefit Trends. 2008;20:17–24.

3. National Council on Patient Information and Education. Enhancing prescription medicine adherence: a national action plan.

2007. talkaboutrx.org/documents/enhancing_prescription_medicine_adherence.pdf. Accessed January 3, 2014.

The cost of drug-related morbidity, including poor adherence,

has been estimated to be up to $290 billion annually.1

• Medication nonadherence has been associated with

greater health care use and increased costs.2

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$290,000,000,000

1. New England Health Institute (NEHI) Research Brief: Thinking outside the pillbox: a system-wide approach to improving patient medication adherence for chronic disease. 2009:1–21.

2. Roebuck MC, et al. Medication adherence leads to lower health care use and costs despite increased drug spending. Health Aff. 2011;30:91–99.

Poor adherence means patients with chronic illnesses

often fail to reach their treatment goals despite the availability of effective therapies.1

• On average, 15% of patients will not fill their first prescription.2

• In an analysis of pharmacy claims for over 350,000 patients from

2012, most patients stopped filling their prescriptions within

the first 6 months.3

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1. Ho PM, et al. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovasc Discord. 2006;6:48–56.

2. Gadkari AS, et al. Medication nonfulfillment rates and reasons: narrative systematic review. Curr Med Res Opin. 2010;26:683–705.

3. Data available on request from Merck, Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004 code. Please specify information package NOND-1084242-0001.

Adherence decreases over the first year of therapy.

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Prescription claims data are from the Truven Health MarketScan Commercial Database. Analysis includes more than 350,000 patients who used medications in the 6 therapeutic areas

shown. There was a 12-month look-back period and a 30-day grace period for patients to refill their prescriptions. Patients were tracked for 12 months in 2012 following the filling of a new

prescription. The number of patients who started any prescription medication in the therapeutic category between October 1, 2012, and December 31, 2012, are shown in Month 0

(representing a baseline of 100%) and the numbers and percentages of patients who refilled those prescriptions are shown by month in the figure above.

• Initiate activities designed to improve patient adherence to treatment

• Medication adherence should become part of routine conversations with patients2

Adherence by Disease State (2012)1

1. Data available on request from Merck, Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004 code. Please specify information package NOND-1084242-0001.

2. Haskard Zolnierek KB, et al. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47:826–834.

Medication nonadherence decreases the likelihood that patients will achieve their desired treatment goals.

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Failure to reach

treatment goals

Medication Nonadherence Is Associated With1:

Increased hospitalizations

and emergency

department visits

A higher risk of

worse health

outcomes

1. Roebuck MC, et al. Medication adherence leads to lower health care use and costs despite increased drug spending. Health Aff. 2011;30:91–99.

Research Findings

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” “ If we are to improve medication adherence, we must first be

able to recognize those who are failing to adhere.1

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Merck is committed to research leadership in medication adherence.

• To better understand how to improve medication adherence, Merck

has conducted extensive research, including:

– Working with nationally recognized adherence experts

– Comprehensive evaluations of adherence publications

– Focus groups with health care consumers regarding their medication adherence

– Quantitative survey research to identify predictors of patients’ propensity to

adhere to prescription medications

— VACS 3 Project Team

1. Wagner JH, et al. Patient- and provider-reported adherence: toward a clinically useful approach to measuring antiretroviral adherence. J Clin Epidemiol. 2001;54:S91–S98.

10 Operating Tenets Based on

Peer-Reviewed Literature.

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The purpose of the 10 Tenets1,2:

• Expose common misperceptions regarding medication adherence

• Provide useful insights about patient medication decision-making

• Highlight the importance of patient beliefs in determining

adherence behaviors

1 2 3 4 5 6 7 8 9 10

Merck's 10 Tenets were identified from reviewing the extensive literature on

medication adherence and are used to frame our research strategy.1

1. McHorney CA. The adherence estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic diseases. Curr Med Res Opin. 2009;25:215–238.

2. McHorney CA, et al. Frequency of and reasons for medication non-fulfillment and non-persistence among American adults with chronic disease in 2008. Health Expectations. 2010;14:307–320.

Patients do not actively communicate their adherence

intentions to their health care professional.

• Among 1,100 adult patients in 6 states:

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83% of patients would never tell

their doctor if they didn’t plan

to fill their prescription.1

68% said they would never tell

their health care provider

that they did not want to

take a medication.1

1

TENET

1. Lapane KL, et al. Misperceptions of patients vs providers regarding medication-related communication issues. Am J Manag Care. 2007;13:613–618.

Health care professionals assume that

their patients are adherent.

• In a study of 138 adult patients receiving treatment, 74% of

physicians believed their patients to be highly adherent.1

Doctors cannot predict adherence with any more efficiency than

tossing a coin.2

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2

TENET

1. Goldberg Al, et al. Physician assessments of patient compliance with medical treatment. Soc Sci Med. 1998;47:1873–1876.

2. Turner BJ, et al. Improving on a coin toss to predict patient adherence to medications. Ann Intern Med. 2001;134:1004–1006.

There is no such thing as a

“nonadherent personality.”

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3

TENET

• Medication adherence has not been consistently linked to

personality, temperament, or other character dimensions.1

1. Hevey D. Adherence to health recommendations. In: Perk J, et al. Cardiovascular Prevention and Rehabilitation. London:Springer Verlag. 2007:293–300.

Adherence to prescription medications is largely

unrelated to adherence to self-care and lifestyle

recommendations.

• Self-care behaviors are not reliably or consistently associated with

a patient’s propensity to adhere to prescription medications.1

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4

TENET


There is no consistent relationship between demographic

characteristics and adherence across disease states.

• Research shows that the effects of demographic characteristics

such as age, gender, education, and income on adherence

were small.1

• Medication adherence cannot be assumed just by looking at

the patient.2

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5

TENET

1. DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42:200–209.


Patients want to know about their prescription

medications and feel frustrated when they

don’t receive enough information.1

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6

TENET

Health care professionals communicate

inconsistently about prescription medications.1

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TENET


Taking medications is a decision-making process.

Patients actively make decisions about

their medications.1

• It is very important to ensure that information about medication and

treatment is clearly conveyed to, and understood by, the patient.2

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8

TENET


2. Williams LK, et al. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol. 2004;114:1288–1293.

Nonadherent patients believe their nonadherence is rational behavior.

It is driven by their beliefs about their treatment, disease, and prognosis,

as well as their objective experiences with their treatment and illness.

• Perceived affordability and other personal considerations also

factor into the patients’ value decision.1

Multiple factors influence patient medication decisions, and many

patients make their medication decisions outside the physician’s

office. For these reasons, a patient’s personal considerations should

be determined and addressed at each prescribing visit.2

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9

TENET

1. DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42:200–209.


Patients can faithfully adhere to one medication,

nonfulfill another, and nonpersist to another.

• Patients also may make decisions about each medication based

on the information they possess about that medication and the

conditions it treats.1

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10

TENET

Understanding the tenets can help health care professionals

understand the breadth of patient medication adherence behaviors

that are seen in everyday medical practice and also can help dispel

common myths about medication adherence.2


2. Haskard Zolnierek KB, et al. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47:826–834.

The Key Predictors of Medication Adherence

Merck’s extensive research has led to the identification of 3 key predictors of medication adherence behavior1:

• Commitment toward medication – intellectual, psychological, and emotional commitment to the perceived need for treatment and the importance of adherence

• Concern about medication – concerns about experiencing side effects, and about short- and long-term safety

• Cost of medication – affordability (perceived financial burden) and the value of treatment

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Rx COMMITMENT Rx CONCERN

Rx COST

MEDICATION

ADHERENCE


Merck’s Adherence Estimator®

and Other Resources

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Understanding patients' beliefs can help with conversations about

medication adherence.

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Early identification of patients with a likelihood for nonadherence

could be important to support these patients individually.1

CONCERN:

“The possibility of

side effects really

worries me.”

COST:

"I don't think

I can afford this

medication."

COMMITMENT:

"I don't think I

really need this

medication."

1. Schoberberger R, et al. The COMpliance PraxiS Survey (COMPASS): a multidimensional instrument to monitor compliance for patients on antihypertensive medication. J Hum

Hypertens. 2002;16:779–787.

The Adherence Estimator is an evidence-based, patient-centered resource designed to

help gauge the likelihood of a patient's nonadherence.1

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Merck has developed the

Adherence Estimator®

The Adherence Estimator®: Development Process1,2

Theory1 Theory

Research1

Cross-Sectional

Psychometric

Modeling1

Predictive

Validation2

Implementation

Continuum of increasing evidence

The Adherence Estimator asks questions about 3 key areas:

• Patients’ commitment to the need for prescription medication

• Patients’ concerns about prescription medication

• Patients’ perceived financial burden due to the cost of prescription medication


2. McHorney CA, et al. Validity of the adherence estimator in the prediction of 9-month persistence with medications prescribed for chronic diseases: a prospective analysis of data from pharmacy claims.

Clin Ther. 2009;31:2584–2607.

1. ADMINISTER the Adherence Estimator.

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Use the Adherence Estimator® for patients with certain chronic, asymptomatic

conditions who have just received a new prescription for an oral medication.

Short and concise features

help make it easy1:

– 1 minute to complete

– Immediate scoring

Agree

completely

Agree

mostly

Agree

somewhat

Disagree

somewhat

Disagree

mostly

Disagree

completely I am convinced

of the importance

of my prescription

medicine.

1

Agree

completely

Agree

mostly

Agree

somewhat

Disagree

somewhat

Disagree

mostly

Disagree

completely I worry that my

prescription medicine

will do me more harm

than good.

2

Agree

completely

Agree

mostly

Agree

somewhat

Disagree

somewhat

Disagree

mostly

Disagree

completely I feel financially

burdened by my

out-of-pocket expenses

for my prescription medicine.

3

The Adherence Estimator has been validated for oral

medications prescribed for certain chronic,

asymptomatic conditions (eg, high cholesterol,

diabetes). It has not been validated for symptomatic

conditions (eg, asthma). For symptomatic conditions,

even medications that should be taken continuously

may be prescribed or taken on an as-needed basis.


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Keep in mind, the Adherence Estimator1:

• Should be used soon after the initiation of a newly prescribed oral medication for certain

chronic, asymptomatic conditions

• Is designed to be completed separately for each new medication prescribed

• Can be administered in the physician's office. Ideally, it should be completed by the

patient rather than directly administered via interview format by the health care provider

Take time to reassure patients that:

• The physician’s office is a place they can feel comfortable answering the survey openly

and honestly

• There are no correct answers to the survey—only their opinions and concerns matter


2. ASSESS results with the Adherence Estimator Interpretation Guide.1

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• Slide the survey into the Interpretation Guide

• Tally survey score to gauge the likelihood of a patient not adhering to the new medication

LOW

0 0

HIGH

14 14

MEDIUM

2 2

MEDIUM

7 7

MEDIUM

4 4

LOW

0 0

HIGH

20 20

LOW

0 0

LOW

0 0

High likelihood for nonadherence (less than 32% probability for adherence)

Medium likelihood for nonadherence (32%-75% probability for adherence)

Low likelihood for nonadherence (greater than 75% probability for adherence)

8-36

2-7

0

If a patient falls into medium or high categories, you can use the appropriate Response Card to

help support your discussion

COMMITMENT

The belief that


is necessary

CONCERN

The belief that


will do more harm

than good

COST

The belief that


is not affordable

Total


! COMMITMENT

3. ADDRESS the patient’s concerns about adherence with personalized communications

and helpful resources.

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• Speak with the patient about his or her specific issues and concerns

• Provide patient with educational resources that address specific adherence issues

• Provide the card(s) that best describes the barrier(s) as noted below based on the

patient’s responses to the Adherence Estimator Survey

? CONCERN $ COST

Merck also offers a variety of other resources to help you as you help patients

understand their condition, treatment plan, and prescribed medications.

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Research showed that motivational messages increased

patients’ intention toward future adherence.1

Merck, in collaboration with George Mason University, conducted qualitative and quantitative

research to develop, evaluate, and test effectiveness of medication adherence messaging.

1. Kreps GL, et al. Development and validation of motivational messages to improve prescription medication adherence for patients with chronic health problems. Patient Educ Couns. 2011;83:375–381.

Work with your Merck Representative to identify Merck

resources that can help your patients better understand their

condition and help you have a better conversation with your patient

about the importance of staying on their medication.

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– Tips and cautions for discussing medications with patients

Example: Before they leave your office, ask patients to explain or demonstrate how they will perform

the recommended treatment, monitor the disease, or take the prescribed medication.

– Questions that can help you get to what patients are really thinking

Example: Open-ended questions, such as “What are some of the signs you need to watch for that tell

you when to take your medicine?” are an effective way to engage the patient.

– Interactive exercises including sample scenarios of patient interactions

Improve communication techniques with:

The Teach Back Technique

Interactive workbook for health care providers to help

them discover if patients truly understand and are willing

to follow their treatment instructions.





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– How and why it’s important to take your medication(s) as prescribed

– What your condition means to your health and how following your doctor’s treatment plan can help

you manage your symptoms

– Tips on how to manage your condition and stick with your treatment plan

Patient Education Brochures

A full range of brochures covering a number of issues

patients may need to understand better.





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– Patients will be encouraged to:

o Learn all they can about their new medication

o Schedule regular follow-up appointments as directed by their doctor

o Understand their condition

o Discuss dosing options

o Buy in bulk from a mail-order service

Resource Cards

Help patients feel more comfortable about taking their medication by

handing out the appropriate card(s) at each prescribing visit.

Suggestions are offered to help overcome each belief revealed by the

Adherence Estimator®.





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– Program resources include:

o Health condition and general wellness information

o Recipes and fitness ideas based on national nutrition and fitness guidelines

o Tools for tracking nutrition, activity, and health conditions

o Weekly e-mails with tips and updates

o Rx for Health section, including the Adherence Estimator® and other adherence tools and resources

o Support and encouragement for caregivers as well as for the people in their care

o Updates to HCPs on their patients' activity in MerckEngage

o Resources and health information in English and Spanish (espanol.merckengage.com)

MerckEngage®

A free health support program, available on desktop and mobile devices,

that offers resources to help consumers achieve their health goals in

partnership with their HCP, including improved adherence to their HCP's

treatment plan.

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1

2

3 Adherence is a marathon,

not a sprint.1

1. Cancer Care. Adherence and CML: overcome the challenges to taking your pills. CML Series. media.cancercare.org/publications/original/150-fs_cml_adherence.pdf?1340688984. Accessed January 3, 2014.

Adherence Estimator® is a registered trademark of Merck Sharp & Dohme Corp., a

subsidiary of Merck & Co., Inc., Whitehouse Station, NJ, USA. US and non-US

Patents Pending. Copyright © 2008 Merck Sharp & Dohme Corp., a subsidiary of

Merck & Co., Inc. All rights reserved.

Copyright © 2014 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.

All rights reserved.

NOND-1105546-0000 01/14

medication adherence - ga health...

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