Simplifying the Patient Adherence Puzzle
Non-adherence is a major problem in health care worldwide but it need not remain the elephant in the room. In order to solve this costly conundrum, the problem must be faced head on and broken down into manageable components.
Louise Kelly speaks to Elizabeth Oyekan, vice president of Operations at Kaiser Foundation Health Plan of Colorado.
Simply put, patients who adhere to medical treatment have a better prognosis and create fewer costs. Pressure to reduce costs in the health care system is, in turn, contributing to a focus on home use and patient compliance in the pharmaceutical industry.
US-based nonprofit health plan Kaiser Permanente has more than 9 million patients under its national umbrella and, even with expert physicians and advanced electronic systems in-house to help identify, diagnose and treat these patients, the problem of non-adherence nonetheless remains. This is one problem that can be addressed when approached in the strategic manner, maintains Oyekan. “Studies report that there are as many as 250 reasons to explain why prescribed medication is not taken. But by having an effective framework in place, determining where medication adherence is most likely to break down, we can then strategically start to manage it.”
In order to determine the leading factors of non-adherence in patients, Kaiser Permanente has adopted a model established by The American Heart Foundation, based on prescriptions written by a physician for 100 individual patients. Says Oyekan: “Immediately 12 of the 100 will decide that they are not going to take the medication. Of the remaining 88 patients of the group that actually collect the prescription from the pharmacy, another 12 then will decide that they are not going to take it before they get home.”
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That leaves just over 75 per cent who actually get home and start taking the prescribed medication. But within 30 – 90 days of that (depending on their medication benefit), 29 patients will reduce or stop taking the medicine, according to this model. So when these 100 patients are reviewed six months later, less than 50% will be taking their medications as prescribed – no wonder the health outcomes expected are not being realized.
“By breaking the big problem down, the issue becomes a relatively manageable thing to tackle”
Now aware of the non-adherence stages, Kaiser Permanente has identified the leading reasons for stopping taking medication at each stage. “By breaking the big problem down, the issue becomes a relatively manageable thing to tackle,” says Oyekan, adding, “Once the barriers are recognized, it becomes evident what the solutions should be.”
One of the most challenging reasons for refusing prescribed medications is the patient’s value system – they decide that this medication does not correlate with their moral or religious beliefs and this is probably the hardest challenge to overcome, according to Oyekan.
“Physicians are taught not to discount the beliefs of their patients but to first and foremost, understand what their patients are talking about. It’s also recommended where appropriate, to help patients see how the medication prescribed can actually complement some of their cultural beliefs,” she says.
However, the physician will need to give patients a time frame for treatment with appropriate alternative remedies if the patient is insistent on these methods. “It is also essential that the patient is made fully aware, not only of the consequences of not taking the medication, but rather of not treating the condition. This nullifies the opportunity for the patient to present justification,” believes Oyekan.
But perhaps more surprisingly, it was found that a factor in primary non-adherence has been caused by the use of electronic records. Without a slip of paper in the patient’s hand, an unintended consequence of game-changing digital records is that patients will simply forget that they have prescriptions waiting for them at the pharmacy. But by having this information, Oyekan says that organizations could then strategically mitigate this barrier by employing voice recognition reminders that have reportedly increased the number of patients coming to collect their prescriptions by 40 percent.
Naturally, cost always is a consideration and a major barrier to patients taking their medications. So, from a quality and financial perspective, Kaiser Permanente’s physicians prescribe high quality generic medications if one is available.
In addition, Oyekan reports that many organizations now have medical financial assistance (MFA) because the reality is that patients are not going to take their medications if they can’t afford it. “Therefore, it is so much cost effective to have a MFA program in place and keep patients healthy rather than admitting a patient to the hospital due to complications from medication non-adherence,” she says, adding, “Many organizations also work with the pharmaceutical companies which have programs in place themselves that allow patients to get their medications at a reduced cost.”
“Many patients assume that when the first bottle is finished, they have completed the necessary course of treatment”
But drawing from the model figures above, 88 per cent will remember to collect their prescription so why would another 12 be lost to non-adherence before reaching their home? The consultation and written information given to the patient by the pharmacist about the medication was found to be a major reason that succeeded in deterring patients from actually taking the treatment, according to Oyekan, but again the solution was simple. “We have trained pharmacists about being careful when relaying the safety/side effects information – like any TV advertisement – start with the benefits, don’t withhold the negative aspects, but always end on a positive note,” she says.
“But the side effects are indeed very real for some patients so it’s necessary to put some sort of defense in place to mitigate those side effects. Full awareness including what to do if the side effects occur or how to treat these side effects should help in this regard.”
And while forgetfulness was a factor in those not collecting their prescriptions initially, it also plays a large part in why those at home taking medications tend to stop after a time. Says Oyekan: “Again, we have used Interactive Voice Response – or IVR – calls to improve patients picking up subsequent prescriptions. Many patients assume that when the first bottle is finished, they have completed the necessary course of treatment. The onus here is again on the physician and the pharmacist to make the patient aware that they will be on this medication for a long time.”
In order to ensure physician and pharmacist dedication in minimizing non-adherence, many organizations including Kaiser Permanente have linked adherence to something more profound – patient health outcomes and national measures – so that the issue of medication non-adherence is embedded in patient’s treatment plan. Rates of adherence can now be broken down and applied to individual organizations and pharmacies so that the figures can be compared against their peers – heightening the awareness for physicians and pharmacists to play their part and make a difference in the lives of patients.
Elizabeth Oyekan will be sharing more insights from Kaiser Permanente's Patient Adherence strategy at this year's Patient Summit EU in London this October. To find out more about her presentation, or to see which other industry experts and patient groups will be presenting, visit the official website.
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