US Pharm. 2012;37(4)(Compliance suppl):3-6.
Poor adherence to appropriate medication therapy has been shown to
result in complications, death, and increased health care costs.1-4
Medication adherence in patients with chronic conditions such as
diabetes, hypertension, hyperlipidemia, asthma, and depression is a
significant problem requiring intervention.5-12 According to the World Health Organization’s (WHO) World Health Report 2003,
the degree of medication nonadherence is so great and the consequences
are of such concern that more people worldwide would benefit from
efforts to improve medication adherence than from the development of new
medical treatments.13 In fact, a number of studies have
shown that, in developed countries, patients with chronic conditions
have adherence rates of 50% to 60%, despite evidence that medication
improves quality of life and prevents death.5-10 In
developing countries, when poor access to health care, possible lack of
diagnosis, and limited availability of medications are taken into
account, poor adherence threatens all efforts to treat chronic
conditions such as diabetes, depression, and HIV/AIDS.11
The rate of patients who persistently take their medication for a
chronic condition drops most significantly after the first 6 months of
therapy.14-17 Acceptable rates of adherence in some trials are 80% or greater, while those for HIV are considerably higher (95%).17
Of all medication-related hospital admissions in the United States, 33%
to 69% are related to poor medication adherence. The resulting costs
are approximately $100 billion annually.17 It has been estimated that 125,000 deaths per year in the U.S. can be attributed to medication nonadherence.18
A retrospective analysis of patients aged under 65 years that was
conducted between 1997 and 1999 concluded that diabetic patients with
poor medication adherence had a 30% yearly risk of hospitalization,
while those with high adherence (defined as following the medication
regimen 80%-100% of the time) had a 13% risk.19 In the same
analysis, total health care spending for patients with low medication
adherence was almost twice that of patients with high adherence.
It was estimated in 2001 that more than 89,000 deaths from
cardiovascular disease would have occurred in hypertensive patients aged
40 years and older who were not receiving antihypertensive medication
therapy.20 Patients who are diabetic or who have heart
disease are 48% less likely to die prematurely when they are adherent to
their medication regimen.21 In addition, asthma patients who
are adherent to their medications are 11% less likely to have an
emergency room (ER) visit or to be hospitalized.21
When counseling about medication adherence for the three major
disease states—diabetes, hypertension, and hyperlipidemia—it is
important to educate the patient about the consequences of not
appropriately treating these conditions, which can result in heart
attack, heart failure, stroke, paralysis, and potentially permanent and
devastating alterations to their quality of life. Pharmacists must paint
a picture of the situation and remind patients why they are taking the
medication in the first place.
It has been said that a primary determinant of treatment success is adherence to therapy.22 As defined by the WHO, adherence
is the degree to which the patient’s behavior is in agreement with the
health care provider’s recommendations. This is a collaborative approach
between the patient and the provider in which the patient’s values,
lifestyle, and beliefs coincide with the provider’s medical advice and
opinion. Compliance, which is often confused with adherence,
refers to a patient’s obedience to therapy under the authority of the
provider, rather than to a collaborative approach. Another term that
relates to adherence is persistence, which is the patient’s
ability to continue taking the medication for the duration of treatment.
When a medication is initiated, discussing the intended course of
therapy with the patient has been shown to help keep the patient
persistently following his or her medication regimen.12
Factors That Impact Adherence
The most consistently reported factors impacting adherence are low
literacy, lack of health insurance coverage, poor social support, family
instability, and homelessness.12 Forty-five percent of U.S. adults have a literacy level at or below eighth grade.12
It has been reported that one-half of adults lack the skills to
complete tasks related to following medication-label directions,
comprehending nutrition labels, describing symptoms, or using a map to
locate health facilities.23 This can be a particular problem
in ethnic groups that already have a low English-literacy level.
Decreased health literacy has been reported with increasing age, such
that adults aged 60 years may not understand basic materials such as
medication labels. See TABLE 1 for tools used both to assess
health literacy, medication literacy, and willingness to change
behaviors and to evaluate the degree of social support available to the
patient.24-27 Patient beliefs about the diagnosis and
medication benefits also have been shown to affect the adherence rate
regardless of whether the patient can afford the medication. This means
that patients may have a low perceived need for the medication and more
concerns about side effects, thus possibly choosing to forgo the cost of
the medication based on their beliefs.28
As providers, pharmacists can use the patient education program Ask
Me 3, which is designed to promote communication between health care
providers and patients, to improve adherence and outcomes. The Ask Me 3
questions are: What is my main problem? What do I need to do? and Why is it important for me to do this?29
Pharmacists should instruct their patients to ask these three
questions, and they should state them to the patient and answer them in
the event that the patient does not ask. It is equally important that
the patient rephrase what the pharmacist has communicated in order to
verify the patient’s comprehension and to clarify whether the
information fits the patient’s beliefs. When answering these questions,
particularly with asymptomatic patients, it is helpful for pharmacists
to remind patients of the consequences of failing to take their
medication, such as a devastating or life-ending event (heart attack or
stroke) in patients with cardiovascular disease.
Prerequisites for medication adherence may include being interested
in one’s health and understanding the diagnosis; comprehending the
impact or potential impact of the diagnosis; believing that what has
been prescribed will help; and knowing precisely how to take the
medication and for how long. Other prerequisites may be determining how
to fit the medication into one’s daily routine; valuing the results of
treatment more than the cost of therapy; believing that one can fulfill
the treatment plan; and feeling that the provider has true concern for
the patient as a person, as opposed to just treating the disease.12
The following steps have been shown to increase adherence: verifying
the patient’s understanding of the disease and its treatment and
providing education where gaps in understanding exist; correlating
medication-taking with other daily routines; using medication organizers
or charts; reducing the pill burden, if possible; providing care
support (i.e., health care team); and recognizing any struggles or other
sociobehavioral issues that may affect adherence.12
How to Overcome Adherence Challenges
Many different factors can affect adherence. The first step, and the
one that is most often missed, is to identify which factors are
preventing adherence. One way to identify adherence gaps is to perform a
medication reconciliation—best done using pharmacy adjudication
records—allowing for discovery of pharmacy-dispensing gaps. This might
reveal the need for a simplification of the dosing regimen.30 See TABLE 2 for a list of factors that affect adherence and strategies for overcoming them.29,31,32
Strategies to overcome low health literacy include creating a
shame-free environment that promotes open dialogue; using plain language
versus medical terminology; providing written communication on a
fifth-grade level; using picture or video instruction; involving family
members in the instruction; having the patient repeat the instruction;
and following up by telephone to confirm the patient’s understanding.12
The inability to pay for health care can be a deterrent to adequate
adherence; however, the degree to which patients value their medication
or perceive it to help their condition, along with their beliefs about
side effects, can influence their decision to forgo treatment,
regardless of cost.28 Patients with depression show a greater
tendency to be deterred by their beliefs and medication costs, thereby
putting those with diabetes and depression at even greater risk for
medication nonadherence. This is true for patients who have depression
with other comorbid conditions. Providers should initiate more in-depth
discussions about medication cost concerns in patients with depression.28
Lack of prescription coverage can be a major roadblock to medication
adherence. There are several options for patients who do not have
prescription coverage, including Medicare Part D (for patients eligible
for Medicare), Medicare Extra Help (for those who have Medicare but have
limited income and resources), Medicaid programs, the Together Rx
Access Card (25%-40% off brand-name prescription products), Partnership
for Prescription Assistance (free medications to qualified patients),
NeedyMeds Drug Discount Card (80% off the price of prescriptions),
Coast2Coast Rx Card (free diabetes supplies and up to 55% off medication
costs), and discount cards offered by some pharmacy benefit management
companies and individual pharmaceutical companies.33-40 This
list of discount cards is not all-inclusive. The $4 generic program is
another option offered by some large chain pharmacies and supermarket
pharmacies; in some cases, independent pharmacies offering this program
may match pricing.41 All of these discount programs have restrictions, so check their respective Web sites (TABLE 3).33-41
Lastly, some employers offer reduced copayments or medication
deductibles to patients who participate in a health program for chronic
Poor adherence to medication regimens is multifactorial, involving
the patient’s beliefs about and understanding of the diagnosis and how
the medication will help his or her prognosis.22 Three important questions to answer for the patient are: What is the patient’s main problem? What does the patient need to do? and Why is it important for the patient to do this?
After these questions have been answered, ascertain that the patient
believes that this treatment will help. Afterward, probe for any issues
that may result in low adherence, such as low literacy, inability to pay
for the medication, and poor social support, among many others.29
The first step is to check medication adherence and persistence by way
of a pharmacy medication reconciliation that utilizes pharmacy
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