what percent of bolivians have access to adequate medical care? 50% 75% 80% 95%
Mayo Clin Proc. 2011 Apr; 86(4): 304–314.
Medication Adherence: WHO Cares?
Abstract
The treatment of chronic illnesses commonly includes the long-term use of pharmacotherapy. Although these medications are effective in combating illness, their full benefits are often non realized because approximately 50% of patients do not accept their medications as prescribed. Factors contributing to poor medication adherence are myriad and include those that are related to patients (eg, suboptimal health literacy and lack of interest in the handling conclusion–making process), those that are related to physicians (eg, prescription of circuitous drug regimens, communication barriers, ineffective communication of data about adverse effects, and provision of care by multiple physicians), and those that are related to wellness care systems (eg, office visit time limitations, limited access to intendance, and lack of health information technology). Because barriers to medication adherence are complex and varied, solutions to amend adherence must be multifactorial. To appraise full general aspects of medication adherence using cardiovascular disease as an example, a MEDLINE-based literature search (Jan 1, 1990, through March 31, 2010) was conducted using the following search terms: cardiovascular disease, wellness literacy, medication adherence, and pharmacotherapy. Manual sorting of the 405 retrieved articles to exclude those that did non address cardiovascular affliction, medication adherence, or health literacy in the abstract yielded 127 articles for review. Additional references were obtained from citations within the retrieved articles. This review surveys the findings of the identified articles and presents diverse strategies and resources for improving medication adherence.
Go along a watch…on the faults of the patients, which frequently brand them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die.
Hippocrates, Decorum
In its 2003 report on medication adherence,1 the Globe Health Arrangement (WHO) quoted the statement by Haynes et al that "increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments." Among patients with chronic illness, approximately l% do not have medications as prescribed.1,2 This poor adherence to medication leads to increased morbidity and death and is estimated to incur costs of approximately $100 billion per twelvemonth.3 Thus, Hippocrates' exhortation to the physician to "not merely be prepared to do what is right himself, simply also to brand the patient…cooperate"4 has consistently failed for more than than 2000 years. Today'south always more complicated medical regimens make it fifty-fifty less likely that physicians will be able to compel compliance and more than important that they partner with patients in doing what is right together.
This review will discuss general aspects of medication adherence, using cardiovascular disease (CVD) every bit an example, and provide the dr. with various practical strategies and resources for improving medication adherence among their patients.
METHODS
We conducted a MEDLINE database literature search limited to English- and not–English-language articles published between January 1, 1990, and March 31, 2010, using the following search terms: cardiovascular disease, health literacy, medication adherence, and pharmacotherapy. Of the 405 articles retrieved, those that did not address CVD, medication adherence, or health literacy in the abstract were excluded, leaving 127 for inclusion in the review. Additional references were obtained from citations within the retrieved manufactures.
For editorial comment, see folio 268
GENERAL ASPECTS OF MEDICATION ADHERENCE
Medication-taking behavior is extremely circuitous and individual, requiring numerous multifactorial strategies to better adherence. An enormous amount of enquiry has resulted in the development of medications with proven efficacy and positive benefit-to-chance profiles. This millennium has seen a new and greater focus on outcomes. However, we seem to have forgotten that betwixt the former and the latter lies medication adherence:
Handling → Adherence → Outcomes
The WHO defines adherence to long-term therapy as "the extent to which a person's beliefs—taking medication, following a diet, and/or executing lifestyle changes—corresponds
with agreed recommendations from a health care provider."1 Often, the terms adherence and compliance are used interchangeably. However, their connotations are somewhat different: adherence presumes the patient's understanding with the recommendations, whereas compliance implies patient passivity. Every bit described by Steiner and Earnest,v both terms are problematic in describing medication-taking behavior because they "exaggerate the physician's control over the procedure of taking medications." The complex problems surrounding the taking of medication for chronic illness cannot easily be distilled into one discussion. Recognition of this complication will help avert assigning blame exclusively to the patient and assist in identifying effective solutions.
Measurement of medication adherence is challenging because adherence is an individual patient beliefs. The following are some of the approaches that have been used: (one) subjective measurements obtained by request patients, family members, caregivers, and physicians about the patient'south medication employ; (2) objective measurements obtained by counting pills, examining chemist's refill records, or using electronic medication upshot monitoring systems; and (3) biochemical measurements obtained past adding a nontoxic marker to the medication and detecting its presence in claret or urine or measurement of serum drug levels. Currently, a combination of these measures is used to assess adherence beliefs. Along with the monitoring of outcome, these tools assist investigators in studying medication adherence.
Patients are generally considered adherent to their medication if their medication adherence percentage, defined equally the number of pills absent in a given fourth dimension menses ("X") divided by the number of pills prescribed by the physician in that same time catamenia, is greater than eighty%3,6:
One limitation to calculating adherence using this method is that it assumes that the number of pills absent were actually taken by the patients. In addition, this method may not be representative of long-term adherence patterns because patients may exhibit white-coat adherence, or improved medication-taking behavior in the five days before and five days after a health care encounter.3
INCIDENCE OF NONADHERENCE
According to a 2003 report published by the WHO, adherence rates in developed countries boilerplate only well-nigh fifty%.1 Adherence is a key gene associated with the effectiveness of all pharmacological therapies but is particularly critical for medications prescribed for chronic conditions. Of all medication-related hospitalizations that occur in the The states, between one-third and 2-thirds are the upshot of poor medication adherence.iii A fair amount of data is available regarding medication adherence in CVD because, for many of the risk factors, adherence can be roughly approximated via the measurement of surrogate markers. For case, adherence to antihypertensive therapy can be approximated past measuring claret pressure (BP) control, and adherence to lipid-lowering therapy can exist approximated by measuring lipid levels. Because most inquiry is disease-specific and not focused on medication adherence lonely, this review will focus on medication adherence equally it relates to CVD. Examining adherence in patients with CVD is a useful model for helping physicians empathize medication adherence in other chronic conditions.
Cardiovascular complications resulting from hypertension, hyperlipidemia, and diabetes pb to substantial disability, morbidity, and mortality. For example, for every increase of 20 mm Hg in systolic BP and every increase of 10 mm Hg in diastolic BP, the chance of stroke and ischemic heart illness doubles.seven Considering of this increased gamble, comprehensive handling plans for patients with established CVD include antidiabetes, antihypertensive, and lipid-lowering (typically statin-based) therapies for patients who present with diabetes, hypertension, and dyslipidemia, respectively.8
Although it is well known that antidiabetes, antihypertensive, and lipid-lowering therapies significantly reduce the chance of ischemic events,9-11 long-term adherence to these medications is poor fifty-fifty amid patients who have already experienced a cardiovascular event (Effigy i).12 For example, despite the fact that pharmacological antihypertensive therapy has a positive prophylactic and tolerability profile and reduces the risk of stroke past approximately 30% and myocardial infarction (MI) past approximately 15%,11 evidence from a number of studies suggests that as many as l% to 80% of patients treated for hypertension are nonadherent to their treatment regimen.xiii-15 According to the WHO, this lack of adherence is the most important cause of failure to achieve BP control.1 Failure to achieve BP control significantly increases the risk of MI, stroke, and hospitalization.16,17 As expected, adherence to antihypertensive therapy reduces the risk of these events.eighteen
Persistence with secondary prevention medication in the 24 months after ischemic stroke in Sweden. Persistent apply of secondary preventive drugs declines rapidly during the showtime 2 years subsequently stroke.
From Stroke,12 with permission.
Comprehensive treatment plans for patients with CVD too include indefinite use of antiplatelet therapy.viii For patients with heart affliction, ischemic cerebrovascular disease, or peripheral artery disease, aspirin or clopidogrel monotherapy has a favorable do good-to-hazard profile; for patients who experience an ischemic cerebrovascular event, therapy with aspirin plus extended-release dipyridamole is an additional treatment option.nineteen For patients who experience acute coronary syndrome or undergo percutaneous coronary intervention with stent implantation, dual antiplatelet therapy with aspirin and either clopidogrel or prasugrel is recommended for at least 12 months for those non at a high hazard of bleeding.20
Similar adherence to antihypertensive therapy, adherence to statins and antiplatelet agents is poor, as are the outcomes associated with nonadherence. Within 6 months to 1 year after having been prescribed statins, approximately 25% to fifty% of patients discontinue them21-24; at the end of 2 years, nonadherence is as high as 75%.25,26 Achievement of the handling goals recommended past the National Cholesterol Education Program is too poor.27,28 With regard to antiplatelet therapy, studies that assessed long-term aspirin use constitute that rates of adherence across 1 year ranged from 71% to 84%.29-32 For dual antiplatelet therapy recipients, premature discontinuation of clopidogrel rates has been reported to occur in 12% to xiv% of patients within ane to three months of initiation33,34 and in up to 20% of patients beyond 6 months.35,36
Nonadherence to lipid-lowering and antiplatelet therapies is associated with an increased risk of agin cardiovascular outcomes.xvi,32,34,36-41 Aside from the increased risk of MI, stroke, and death, stent recipients who prematurely discontinue clopidogrel also have an increased rate of stent thrombosis.34,36,42-45 For example, in an analysis of 3021 drug-eluting stent recipients, discontinuation of clopidogrel within 6 months of stent implantation was the strongest predictor of 6-month stent thrombosis (hazard ratio, xiii.74; 95% confidence interval, 4.04-46.68; P<.001).43 In a report of 500 drug-eluting stent recipients, 13.half dozen% of patients discontinued thienopyridine therapy within 30 days.34 These patients had a 10-fold greater mortality rate at 1 year than those who continued thienopyridine therapy (7.5% vs 0.7%).34
CAUSES OF POOR MEDICATION ADHERENCE
Poor adherence to medical treatment severely compromises patient outcomes and increases patient bloodshed. Co-ordinate to the WHO, improving adherence to medical therapy for conditions of hypertension, hyperlipidemia, and diabetes would yield very substantial health and economic benefits.1 To improve medication adherence, the multifactorial causes of decreased adherence must exist understood. The WHO classifies these factors into 5 categories: socioeconomic factors, factors associated with the wellness care team and organisation in identify, disease-related factors, therapy-related factors, and patient-related factors.1 In broader terms, these factors autumn into the categories of patient-related factors, physician-related factors, and wellness system/team building–related factors.
Patient-Related Factors
Several patient-related factors, including lack of understanding of their disease,46 lack of involvement in the treatment determination–making procedure,47 and suboptimal medical literacy,48 contribute to medication nonadherence. In the Us alone, an estimated 90 one thousand thousand adults have inadequate health literacy,49 placing them at hazard for increased rates of hospitalization and poorer clinical outcomes.50,51 The patient's wellness beliefs and attitudes concerning the effectiveness of the treatment, their previous experiences with pharmacological therapies, and lack of motivation also affect the degree of medication adherence.3,52,53 Medication adherence continues to decline even after a catastrophic effect such as a stroke (Effigy 1)12; thus, it is not surprising that treating asymptomatic conditions to prevent the possible occurrence of adverse events years afterward presents an fifty-fifty greater challenge. Specific factors identified as barriers to medication adherence amidst inner city patients with low socioeconomic status were high medication costs, lack of transportation, poor agreement of medication instructions, and long wait times at the pharmacy.55 A lack of family or social back up is also predictive of nonadherence,52,56,57 as is poor mental health.3,53,58 These findings are clinically relevant for patients with CVD because studies take shown that depression and feet are common in patients with coronary artery disease or stroke.59-61 Indeed, the poorer outcomes experienced by patients with low and CVD may be due, at to the lowest degree in function, to poorer medication adherence past depressed patients.62,63
Dr.-Related Factors
Non simply practice physicians often fail to recognize medication nonadherence in their patients, they may also contribute to information technology by prescribing complex drug regimens, declining to explain the benefits and adverse furnishings of a medication effectively, and inadequately considering the fiscal burden to the patient.three,55 Ineffective communication between the chief intendance physician and the patient with a chronic disease such as CVD further compromises the patient'south understanding of his or her disease, its potential complications, and the importance of medication adherence.v Failing to elicit a history of culling, herbal, or supplemental therapies from patients is some other source of ineffective communication.
Communication among physicians is often insufficient and may contribute to medication nonadherence. Direct communication between hospitalists and primary care physicians occurs in less than 20% of hospitalizations, and belch summaries are available at less than 34% of kickoff postdischarge visits.64 Inadequate communication between physicians, hospitalists, chief care physicians, and consultants likewise contributes to medication errors and potentially avoidable hospital readmissions.64,65
Health Organization/Team Building–Related Factors
Fragmented wellness intendance systems create barriers to medication adherence by limiting the wellness care coordination and the patient'due south access to care.66 Prohibitive drug costs or copayments also contribute to poor medication adherence.35,67 Wellness it is not widely available, preventing physicians from easily accessing information from different patient care–related venues, which in turn compromises patient care, timely medication refills, and patient-dr. communication. In an overtaxed wellness intendance system in which clinicians run into a large volume of patients without resources to meet individual patient needs, the amount of time a clinician spends with patients may exist insufficient to properly assess and understand their medication-taking behaviors. This lack of time may forbid engaging the patient in a discussion on the importance of medication adherence and strategies to accomplish success.
STRATEGIES TO Improve MEDICATION ADHERENCE
Between 2000 and 2002, the typical Medicare beneficiary saw a median of 7 physicians per year: 2 primary care physicians and five specialists.68 This finding highlights the demand for coordinated, multifactorial strategies to ameliorate medication adherence. However, given the enormous complexities involved in medication adherence, research on improving adherence has been challenging and by and large focused on single illness states. A recent Cochrane review of 78 randomized trials found no ane simple intervention and relatively few complex ones to be effective at improving long-term medication adherence and health outcomes,69 underscoring the difficulty of improving medication adherence.
Although improving medication adherence is challenging, clinicians can take several steps to assist patients' medication-taking behavior, and subsequently, outcomes. The ensuing discussion volition focus on strategies to improve medication adherence related to the areas of patient-, dr.-, and health arrangement/team building–related factors. A summary of available resources that can exist used to implement these strategies is found in Tabular array 1.
Table i.
Strategies and No-Cost Resources Aimed at Overcoming Barriers to Medication Adherence
Patient-Related Factors
Medication adherence is primarily in the domain of the patient.1 Because patients recall as little as 50% of what is discussed during the typical medical come across,70 effective patient education must be multifactorial, individualized, and delivered in a diversity of methods and settings exterior of the examining room. A key component of any adherence-improving program is patient educational activity. In ane recent prospective study of 1341 patients with hypertension, education of both the patient and physician was associated with improved BP control vs didactics of the medico alone.71 Formal health didactics programs, such equally diabetes self-direction education, have been shown to exist effective72; however, access to similar non–disease-specific programs is limited. In the absence of a formal programme, physicians would do well to emphasize the availability of other educational resources, including just not limited to pharmacists, community health programs, and interactive Web-based materials such equally those found at www.medlineplus.gov (Table ane). It might also be beneficial to recommend to patients that they engage local librarians to assistance them access the Internet.
The more than empowered patients feel, the more likely they are to be motivated to manage their disease and adhere to their medications. Thus, some other primal factor that tin can ameliorate patient-related medication adherence is actively involving patients in treatment decisions when possible. 1 simple fashion to involve patients is to ask what time of day they would prefer to take their medications. Ane patient may be more likely to attach to his or her medications if they were taken in the evening, whereas for another, the morning may be preferred. Simply the patient tin make this determination. Ascertaining how quickly patients would similar to achieve the desired medical outcome also engages the patients in their care. For patients with CVD, this would include how quickly they would like to accomplish controlled BP and lipid levels. Patients' answer to this question tin help the physician determine how quickly medication may need to exist titrated and how often patients volition need to exist seen in the office or undergo laboratory testing. If a number of alternative treatment options are recommended, offer patients choices encourages active participation in their treatment. For instance, in one case adherence to one medication or treatment is realized and a sense of accomplishment attained, moving to the next recommendation and treatment goal is more achievable. Similarly, the medico should avert prescribing numerous medications and behavioral modifications at whatever one visit considering this may overwhelm the patient and induce a sense of futility. If it is necessary to prescribe more than one drug or intervention during a given visit, a rationale should be provided for which are near important because it will help ensure that, if patients decide to stop taking their medications for any reason, they will discontinue the almost important medications final. It is also hoped that providing a rationale would encourage patients to inform their physicians of any plans to alter medications, assuasive for give-and-take.
Inadequate health literacy is frequently underrecognized and therefore not addressed by physicians.73 Co-ordinate to data from the outset National Assessment of Adult Literacy, conducted in 2003, 77 million The states adults (35%) take basic or below basic wellness literacy, whereas simply 26.iv one thousand thousand (12%) have proficient health literacy.74 Many patients with basic or beneath basic health literacy may be unable to read a medicine bottle or poison warning.75 In another study, almost one-half of patients with low literacy admitted shame, which prevented them from seeking needed help.76 Of patients who admitted having reading problems and being ashamed, more 85% hid their limited literacy from co-workers or supervisors, and approximately 50% hid it from their children.76 The economic consequences of low health literacy skills are exemplified in a 1992 study conducted by the University of Arizona that showed that full almanac health intendance costs for patients enrolled in Medicare with low wellness literacy were four times greater than costs for patients with high health literacy.75 Comments such every bit "I'll read this when I get habitation" or "I forgot my glasses, can you read this to me?" are clues that the patient may have poor literacy. Simple tools to assist the clinician are presented in Table 1.
To help combat poor health literacy and its negative effect on medication adherence, a "shame-costless" environment must exist created. Possible solutions to poor patient literacy include providing the patient with pictorial and audiovisual educational cloth instead of written instructions. Given that less than 60% of the Usa population has English as their first language,75 providing data in the patient's native linguistic communication may too lessen the brunt of poor health literacy. For example, the Web site www.medlineplus.gov provides simple audiovisual instruction in more than xl languages and 250 topics. The topics available in multiple languages include several related to CVD, such as cholesterol, coronary artery affliction, diabetes, heart assault, hypertension, peripheral artery disease, and stroke.
Recognizing and treating mental illness must be a priority when treating patients for other chronic conditions such as CVD. Often, successful treatment of patients' coexisting illnesses depends on first treating any underlying mental disease.
Consideration of patients' economic condition is of paramount importance. Recognizing that patients' economic constraints will limit their power to adhere to their medication, the doctor may direct patients to programs that provide fiscal assistance. Such programs include pharmaceutical company–based assistance plans, land-based assistance plans, and pharmacies that provide 30-mean solar day supplies of widely prescribed medications, including many of those often prescribed for patients with CVD, for less than $5 (Tabular array one). A hospital social worker, practice champion, or community center volunteer may offer the time and resource necessary to assistance individual patients.
Doctor-Related Factors
The substantially improved adherence of patients who study a good relationship with their medico highlights the of import part of physicians in the medication adherence equation.3 Similar to any relationship, ane key to a good physician-patient relationship is effective communication. Thus, perhaps the foremost strategy physicians can use to increase medication adherence is to follow a patient-centered approach to care that promotes active patient involvement in the medical decision–making process. Equally part of such a patient-centered arroyo, the md should consider patients' cultural beliefs and attitudes. For instance, a common cultural attitude held by many patients is a preference for herbal remedies. Reassuring such a patient with diabetes that metformin is derived from the French lilac might ameliorate his or her acceptance of the therapy.
A contempo article past Reach54 addressed the beliefs of people who have a "gustatory modality for the present rather than the future" and proposed that these "impatient patients" are unlikely to adhere to medications that require long-term utilise. In it, he proposes that, if an "impatience genotype" exists, assessing these patients' view of the future while stressing immediate advantages of adherence may meliorate adherence rates more than emphasizing potentially distant complications. Reach54 suggests that rather than endeavour to change the character of those who are "impatient," information technology may exist wise to ascertain the patient'southward individual priorities, peculiarly as they relate to immediate vs long-term gains. For case, while advising an "impatient" patient with diabetes, stressing comeback in visual acuity rather than avoidance of retinopathy may result in greater medication adherence rates. Additionally, linking the cost of oft irresolute prescription lenses considering visual acuity fluctuates with glycemic levels may provide insight to the patient and an immediate fiscal motivation for improving adherence.
Overall, by acknowledging the presence of cultural beliefs and attitudes, physicians tin can build trust with their patients and proactively address any civilisation- or belief-related adherence barriers.77 An essential component of effective physician-patient relationships is the cosmos of an encouraging, "blame-free" surroundings, in which patients are praised for achieving handling goals and are given "permission" to honestly answer whatsoever questions related to their handling.
By asking the advisable questions, physicians can accurately appraise which medications patients are taking and how they are taking them. At a routine visit, patients may exist asked twice to listing their medications (eg, on a course while waiting to be seen and again when the nurse escorts them to the exam room). Notwithstanding, simply listing medications does non address whether they are actually being taken. Thus, if the physician assumes that the medications listed are being taken, the scene for miscommunication is fix. Cess of medication-taking patterns may be more efficiently obtained past request a number of direct questions in a nonjudgmental mode (Tabular array ii).
TABLE 2.
Questions a Clinician Tin can Ask to Appraise a Patient'south Medication Adherence
Inquiring whether patients plan on "rationing" or "sharing" their medication for financial or other reasons is essential because this is a common practise often kept from physicians. If physicians are enlightened that patients plan to ration their medication, they will exist able to discuss the importance of taking the medication equally directed or to prescribe a different medication that is more than "forgiving." Forgiving drugs are defined as those for which a missed dose is less detrimental to long-term outcomes.78 Alternatively, physicians might prescribe a drug taken on a monthly basis or administered by depot or transdermally.
Physicians have several opportunities to meliorate medication adherence when prescribing drugs. Prescribing the maximum number of doses possible at once, thereby limiting the frequency of pharmacy visits, and acknowledging the patient's economic status by adhering to their formulary ameliorate adherence by minimizing economic barriers. An increased number of pills ingested per day may too subtract adherence.29,79-81 A recent study by Benner et al81 of approximately 6000 patients enrolled in a managed care setting focused on the effect of previous prescription brunt on hereafter adherence rates when antihypertensive or lipid-lowering therapy were added. Adherence rates decreased to 41%, 35%, and xxx% in patients who received 0, 1, and 2 previous medications, respectively; amid patients with 10 or more previous medications, adherence was twenty% (Figure ii). It is interesting to note that adherence rates were increased by initiating antihypertensive and lipid-lowering therapies concurrently. To help gainsay the decreased adherence associated with polypharmacy, physicians should consider prescribing stock-still-dose combination pills when possible. Indeed, data advise that adherence to multidrug antihypertensive and lipid-lowering therapy regimens is improved when single- vs multiple-pill regimens are used.82-84 For example, a meta-analysis of fixed-dose vs free-drug regimens in more 20,000 patients identified a 26% decrease in the risk of nonadherence associated with a fixed-dose combination.82
Percentage of patients adherent (proportion of days covered ≥80%) to antihypertensive (AH) and lipid-lowering (LL) therapy, by prescription brunt.
From Am J Health Syst Pharm,81 with permission. ©2009, American Lodge of Wellness System Pharmacists, Inc. All rights reserved.
Medications with once-daily dosing may be preferable to medications with multiple doses per twenty-four hours because minimizing the frequency of dosing has been shown to improve adherence.85 In a meta-analysis, adherence ± SD to once-daily dosing was constitute to be 79%±fourteen%; to twice-daily dosing, 69%±15%; to dosing three times per mean solar day, 65%±16% (P=.008 vs once-daily); and to dosing four times per mean solar day, 51%±xx% (P<.001 vs once-daily; P=.001 vs twice-daily dosing) (Figure 3).3,86 These information suggest that a 10% subtract in adherence will occur with each additional daily dose. Because complex handling regimens are associated with decreased adherence,79 physicians would be wise to prescribe drugs that can be taken at the same fourth dimension of day. If circuitous treatment regimens cannot be avoided, open acknowledgement of this by the md may improve the dr.-patient relationship, thus increasing adherence.
Adherence to medication according to frequency of doses. Vertical lines represent 1 SD on either side of the hateful rate of adherence (horizontal bars).
From North Engl J Med,iii with permission from the Massachusetts Medical Society. All rights reserved.
When prescribing a new medication, the physician should provide the patient with all necessary and important information, including the name of the medication; its purpose (eg, to lower BP); the rationale for choosing it (eg, other drugs are bachelor to lower your BP, simply this 1 is equally effective and is available on your insurance programme's formulary list); the frequency of dosing (eg, once daily); when information technology should be taken (eg, in the morning with your other medications); how long it should be taken (eg, for i year or lifelong); and any potential agin effects, their likelihood of occurring, whether they will resolve without intervention, and how the handling plan may modify if they practise not resolve. Unfortunately, physicians oftentimes fail to communicate all of this information to their patients. In one study, Tarn et al87 found that in more than 65% of audiotaped cases they analyzed, physicians had omitted at least one piece of critical information when discussing a new medication with a patient.87 Instruction regarding the duration of medication utilise was lowest (17%) for cardiovascular medications.87
Patients' perceptions of agin effects contribute significantly to decisions regarding medication adherence. In a written report of patients with hypertension, agin furnishings were listed as the most common business among patients who were not adherent to their antihypertensive medication.88 Nonadherence to medications secondary to adverse effects is termed rational nonadherence, which Garner89 defines equally "the abeyance of a prescribed therapy considering of concern for, or the presence of, medication side furnishings." Garner farther states that rational nonadherence "is nearly incommunicable to circumvent if a patient'south specific side-effect concerns are not substantially addressed." Therefore, it is disquisitional that agin consequence profiles are considered when prescribing a medication and discussed with the patient before the initial prescription and at every visit thereafter.
Using the teach-back approach (ie, asking patients to repeat the important points) and asking patients to read and interpret the medication characterization are ways in which the physician tin ostend that patients understand all aspects of their new medication, which in turn increases adherence. Patient medication lists with pictograms are helpful and are bachelor at sites listed in Table 1. Use of motivational interviewing is some other effective communication tool. Motivational interviewing, a counseling technique originally developed to help care for addiction, is designed to assistance patients place and overcome reasons they may be reluctant to alter their behavior.90 A meta-analysis of 72 randomized controlled trials showed significant benefit for motivational interviewing in achieving cholesterol and BP control, with psychologists and physicians able to achieve an effect in 80% of the studies.91 A randomized trial conducted in 190 African Americans with hypertension showed that the addition of motivational interviewing led to steady maintenance of adherence during a 1-year flow, in contrast to the control group, in which adherence rates declined significantly.92
Health System/Squad Building–Related Factors
The health system in which a physician practices is integral to achieving the ultimate goal of improved patient wellness. Because medication adherence is an of import correspondent to improved patient health, health care systems must evolve in a way that emphasizes its importance. Health organisation changes are necessary to ensure that sufficient time is allotted to discussing aspects of medication adherence.93 Time constraints may be addressed by developing a team-based arroyo to health care (Table ane). The team-based arroyo includes training nonphysician staff to perform duties traditionally completed by physicians, thus allowing the medico more time to discuss the patient'due south medication adherence patterns. For example, during a telephone reminder for an upcoming engagement, clerical staff might remind patients to bring in all their medications and pill boxes for review at the office appointment. Other aspects of a squad-based approach to health intendance include assessment of nonadherence by part staff and pharmacists, chemist-based patient pedagogy, telephone call reminders, Web-based tools, and assignment of a example director. Considering these activities occur outside of the physician-patient come across, they volition not lengthen the visit and may increase efficiency. The importance of a team-based approach to managing medication use is highlighted by the medication therapy management services (MTMS) mandated by the 2003 Medicare Prescription Drug Comeback and Modernization Act.94 Medication therapy direction services, which are provided by insurers mainly through community-based pharmacists, are designed to provide teaching and counseling to improve patient understanding of their medications, improve medication adherence, and find adverse drug reactions. Preliminary studies suggest that patient participation in MTMS programs improves medication adherence and patient outcomes95-97; thus, physicians should encourage eligible patients to participate in MTMS programs.
Increased implementation of electronic medical records and electronic prescribing has the potential to increase adherence past identifying patients at run a risk of nonadherence and targeting them for intervention. A large U.s.a. report showed that a greater than 30-day delay in filling an initial prescription for a statin independently predicted medication nonadherence.98 However, increased utilise of electronic records would allow for the implementation of systems that could place delayed filling on an initial prescription, thus allowing the doc to intervene and perhaps prevent poor adherence. Some pharmacies already use automated reminders to alert patients that their prescriptions should be refilled and remind physicians to contact their patients who do not refill their prescriptions.
Initiating long-term medications during hospitalization for an acute issue, rather than offset therapy after belch, may improve adherence. In a post hoc analysis of the EPILOG (Evaluation of PTCA to Amend Long-term Event) trial of patients undergoing percutaneous coronary intervention, those prescribed lipid-lowering therapy while hospitalized were iii times more likely than those prescribed therapy afterwards hospital release to exist adherent at vi months.99 Initiating therapy while patients are hospitalized is thought to improve adherence because patients and their caregivers are focused on cardiovascular risk and how it tin can be reduced during this "teachable moment."100 Many patients perceive that medications initiated while they are in the hospital are essential for their wellness.100
A critically important wellness system–related factor that improves medication adherence, every bit well as patient safe, is appropriate medication reconciliation. Medication reconciliation is the procedure of creating the most accurate list possible of all medications a patient is taking, including drug name, dosage, frequency, and route, and comparison that list against admission, transfer, and/or discharge orders. The goal of medication reconciliation, a national priority of the Joint Commission on Accreditation of Healthcare Organizations, is to ensure provision of correct medications to patients at all transition points and avoid medication duplication and errors.101 On the footing of the observation that main intendance physicians practise not receive the hospital discharge summary before the patient's side by side contact or treatment 66% of the fourth dimension,68 much greater emphasis on medication reconciliation is needed if medication adherence and patient safety are to amend. An important component of the reconciliation process is the use of a personalized, upto-date medication listing for patients to go along with them at all times (for sources of downloadable medication lists, come across Tabular array i). These personalized medication lists are particularly of import for patients with chronic conditions such as CVD, which typically necessitate the use of multiple medications. By reviewing medication lists at every visit, physicians can ensure that other physicians accept not prescribed new medications without their knowledge. For example, if a patient is seeing his or her main care medico for the first fourth dimension afterwards an MI, an updated medication list will aid ensure that the master care physician is enlightened of any new medications. Furthermore, the list tin can serve as a basis to talk over bodily medication usage patterns with the patient.
CONCLUSION
Strong show shows that many patients with chronic illnesses have difficulty adhering to their recommended medication regimen. Believing that medication nonadherence is the "error" of the patient is an uninformed and destructive model that is best abandoned. Every bit the old Surgeon Full general C. Everett Koop reminded us, "Drugs don't work in patients who don't take them."iii Thus, physicians must recognize that poor medication adherence contributes to suboptimal clinical benefits, particularly in light of the WHO's statement that increasing adherence may have a greater effect on health than any comeback in specific medical treatments.1 The multifactorial nature of poor medication adherence implies that only a sustained, coordinated effort will ensure optimal medication adherence and realization of the full benefits of current therapies. Current recognition of the importance of medication adherence has resulted in the development of many useful Web-based resources.
Supplementary Material
Acknowledgments
Editorial assistance with searching the literature, analogous revisions, and creating figures and tables in preparation of this manuscript was provided by Melanie Leiby, PhD, and additional aid with correspondence and permissions was provided by Barbara A. Murphy, both of inScience Communications, a Wolters Kluwer business, and funded by the Bristol-Myers Squibb/Sanofi Pharmaceutical Partnership. The authors would like to give thanks Joyce Pallinger, MS, MLIS, Director, and Karly Vesely, MLIS, Medical Librarian, of the MacNeal Hospital Library for additional support in obtaining references.
Footnotes
An earlier version of this article appeared Online First.
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