Medication Non-Adherence:

The Hidden Epidemic

Managing Medication Adherence & A Safe Hospital Discharge

David R Donohue, M.A., Qualitative Technologies, Inc. Milwaukee, WI

Dr. Tom Muscarello, Ph D, DePaul University, Chicago, IL

Henry J Kaiser Family Foundation, 2009

Incidence of Medication Noncompliance

50%50% of the 3.6 billion prescription medications dispensed annually in the United States are not taken

correctly by patients

U.S. Patients Do Not Take Medications as Prescribed

100%76%*88%

47%*

Rx prescribed Rx continuedRx takenRx filled

-12%-12%

-29%

* 22% of U.S. patients take less of the medication than is prescribedAmerican Heart Association: Statistics you need to know. http://216.185.102.50/CAP/pro/prof_statistics2.html. Accessed July 27,

2009.

Impact of Medication Adherence on Hospitalization Risk

0

10

20

30

40

50

60

1-19* 20-39*

40-59*

60-79*

80-100

Medication Possession Ratio

Diabetes Hypertension Hypercholesterolemia

*P<0.05 when compared to the 80-100% group

Hosp

italiz a

t ion

Ris

k

Sokol etal. Med Care 2005;43: 521-530

Impact of Medication Adherence on All-Cause Healthcare Costs

02,000

4,0006,0008,000

10,000

12,00014,00016,000

18,000H

ealt

hcare

Co

st

1-19* 20-39* 40-59* 60-79+ 80-100

Diabetes Hypertension Hypercholesterolemia

*P<0.05 when compared to the 80-100% group

+ P<0.05 when compared to the 80-100% group in Diabetes and Hypercholesterolemia Patients

Sokol etal. Med Care 2005;43: 521-530

Potential Barriers to Improving Adherence

Poor attitude Memory deficits Language Literacy Cultural beliefs Alternative health

beliefs Poor support Pride

Denial Fear or

embarrassment Side effects Religious beliefs Unable to “see”

results of drug therapy

Lack of choices Cost

Vermiere E, et al. J Clin Pharm Ther. 2007;26:331-342.

What is CMAG?

Developed from concepts presented by the World Health Organization (WHO) 2005.

Case Management Adherence Guidelines or CMAG provides an interaction and management algorithm to assess and improve the patient's knowledge and his/her motivation to take medications as they are prescribed.

The guidelines provide great flexibility in that individual patient needs can be taken into account.     

WHO White Paper on Adherence

The World Health Organization has made a strong case that medication adherence is based on three pillars: patient information, motivation, and behavioral skill requirements.

Adherence to Long-Term Therapies: Evidence for Action. WHO 2003

Case Management Adherence Guidelines. Copyright© 2005. CMSA

CMAG Algorithm

CMAG Assessment Tools

Tools to assess patient knowledgeHealth Literacy Test – Realm RMedication Knowledge SurveyModified Morisky Scale

Health Literacy

Health literacy is defined as the ability to read, understand, and act on health information.

Poor health literacy results in medication errors, impaired ability to remember and follow treatment recommendations, and reduced ability to navigate within the healthcare system.

The Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), a brief eight-item Health Literacy screening test

Bass Pf, Wilson JF, Griffith, CH. J Gen Intern Med.2003;18:1036-1038.

Medication Knowledge Survey

Assesses knowledge of various medications to be taken, their dosing schedule, benefits and storage

Useful as part of the knowledge assessment for CMAG to determine if the patient is in the high or low knowledge domain

CMAG Assessment Tools

Tools to assess patient motivationReadiness RulerDuke-UNC Functional Social

Support Questionnaire

Readiness Ruler

Assess willingness to change behavior

Zimmerman GL, Olsen CG, Bosworth MF. Am Fam Physician.2000:61;1409-1416

Social Support

Family or social support is a significant predictor of adherence to long-term medical therapy

Duke-UNC Functional Social Support Questionnaire

Eight-item, self-administered, multidimensional instrument

Broadhead WE, et al. Med Care.2006:27;221-223.

Modified Morisky Scale

Patients on existing therapy Morisky 4 item validated adherence predictor

scale Two new items to recognize patient

understanding of medication benefits as well as refill behavior

Allows patients to be categorized as either High or Low on Knowledge and Motivation domains

Morisky DE, Green LW, Levine DM. Med Care. 1986;24:67-74.

New to CMAG RevisionRecognize unique needs of those working successfully with inpatients

Hospital Discharge

The Hospitalized Patient

Acknowledges patients higher level of acuity

Case managers may only be involved with a small percent of inpatients

Case managers & Nurses have a decreased period of time to interact and plan positive interventions with patients

Successful Discharge

Collaboration with other healthcare providers both within and outside the inpatient setting is extremely important to ensure a Successful Discharge

Steps to Ensure a Successful Discharge

Educate the patient and ensure patient understanding on their diabetes disease and other chronic disease process and factors that can influence their condition

Ensure the patient has the resources to manage their diabetes and other chronic diseases after discharge from the hospital

Make certain that the discharge will be “safe” for the individual patient

Ensure that the patient understands the plan for transition of care into the post discharge setting

Make certain that the patient has access to the follow up care and therapy

 

Information for Patients to Ensure a Successful Discharge

Patients that are educated regarding their diabetes and other chronic disease treatments are more likely to remain adherent to treatment recommendations

Patients discharged from the hospital with new medications must be monitored for compliance followup

Information for Patients to Ensure a Successful Discharge

Medications that are prescribed during hospitalization need to be reconciled with other medications.

Patients need to know how to monitor their diabetes and other chronic diseases and treatments in an outpatient setting.

Questions Addressed With Patients Prior To Discharge

What is wrong with me and what will this condition mean to my long-term health?

What do I need to do when I get home to treat my condition successfully?

Who should I contact if I have questions regarding my treatment after I am discharged?

What are things that I need to watch for to know if my condition is getting worse and what should I do if these occur?

How will I pay for my outpatient medical supplies or services? What resources are available?

Why discharge counseling and adherence

messaging are important for the hospital?

Maintain Accreditation JCAHO, NCQA, CMS

Successfully compete with other hospitals in the community Patient satisfaction Publicly available quality rankings

Financial Prevent readmissions Promote timely patient discharges

Competitive Advantage for Hospital Discharge Planning

All hospitals seek to be viewed as providing an outstanding level of care

Hospitals work to maintain a high level of patient satisfaction Discharge counseling is one of the last points of

contact with the patient

Patients and payers can now easily compare quality indicators on hospitals in their community www.hospitalcompare.hhs.gov www.jcaho.org/quality+check/home.htm

Current State of Hospital Discharge Counseling and Adherence Messaging

Studies of patients recently discharged from the hospital have found that:

< 50% of patients could state their diagnosis accurately

< 50% of patients could list all their medications

< 25% of patients could state common side effects and what to expect from their medications

Patients taking three or more medications were more likely to have problems with medication knowledge and scheduling

King, 1998; Makaryus, 2005

Key Elements of Successful Discharge Planning

Recruit a champion or mentor Build a multidisciplinary hospital team Review ALL baseline data Develop protocols and order sets that include

appropriate evidence-based therapies Conduct hospital staff conferences to introduce

process and gain buy in from all stakeholders Continue data analysis and report results back to

hospital staff on a regular basis Evaluate data and look for opportunities for

improvement at all levels Create an adherence program and measure it

AHA, Get with the Guidelines

Coordination of Care and Transition of Care Outside the Hospital

Transition of Care to the Outpatient Setting

Involve family and all caregivers in patient education

Ensure that each patient has a plan for outpatient follow up

Facilitate referral for outpatient services and healthcare providers

Assist patients with resolving issues relating to the cost of outpatient services and treatments

Evaluate Adherence Intention prior to discharge using CMAG tools