Download MEDICATION ADHERENCE

MEDICATION
ADHERENCE
WORKING TOGETHER TO HELP ACHIEVE
BETTER TREATMENT OUTCOMES
In a survey
of 1,100 patients,
Physicians often are not fully
aware of patients’ nonadherence.1–3
83%
of patients would never tell
their doctor if they didn’t plan
to fill their prescription.4
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.
An educational resource provided by Merck.
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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Understanding Adherence
Research Findings
Merck’s Adherence Estimator®
and Other Resources
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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
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.
MEDICATION
ADHERENCE
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The cost of drug-related morbidity, including poor adherence,
has been estimated to be up to $290 billion annually.1
$290,000,000,000
• Medication nonadherence has been associated with
greater health care use and increased costs.2
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.
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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
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.
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Adherence decreases over the first year of therapy.
Adherence by Disease State (2012)1
• Initiate activities designed to
improve patient adherence
to treatment
• Medication adherence
should become part of
routine conversations
with patients2
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.
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.
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Medication nonadherence decreases the likelihood
that patients will achieve their desired treatment goals.
Medication Nonadherence Is Associated With1:
A higher risk of
worse health
outcomes
Increased hospitalizations
and emergency
department visits
Failure to reach
treatment goals
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.
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Research Findings
10
“
”
If we are to improve medication adherence, we must first be
able to recognize those who are failing to adhere.1 — VACS 3 Project Team
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
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.
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10 Operating Tenets Based on
Peer-Reviewed Literature.
Merck's 10 Tenets were identified from reviewing the extensive literature on
medication adherence and are used to frame our research strategy.1
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2
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5
6
7
8
9 10
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. 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.
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TENET
1
Patients do not actively communicate their adherence
intentions to their health care professional.
• Among 1,100 adult patients in 6 states:
68%
83%
said they would never tell
their health care provider
that they did not want to
take a medication.1
of patients would never tell
their doctor if they didn’t plan
to fill their prescription.1
1. 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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TENET
2
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
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.
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TENET
3
There is no such thing as a
“nonadherent personality.”
• 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.
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TENET
4
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
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.
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TENET
5
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
1. DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42:200–209.
2. 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.
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TENET
6
TENET
7
Patients want to know about their prescription
medications and feel frustrated when they
don’t receive enough information.1
Health care professionals communicate
inconsistently about prescription medications.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.
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TENET
8
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
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. 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.
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TENET
9
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
1. DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42:200–209.
2. 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.
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TENET
10
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
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
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. Haskard Zolnierek KB, et al. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47:826–834.
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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
Rx COMMITMENT
Rx CONCERN
MEDICATION
ADHERENCE
Rx COST
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.
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Merck’s Adherence Estimator®
and Other Resources
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Early identification of patients with a likelihood for nonadherence
could be important to support these patients individually.1
COMMITMENT:
"I don't think I
really need this
medication."
CONCERN:
“The possibility of
side effects really
worries me.”
COST:
"I don't think
I can afford this
medication."
Understanding patients' beliefs can help with conversations about
medication adherence.
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.
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Merck has developed the
Adherence Estimator®
The Adherence Estimator is an evidence-based, patient-centered resource designed to
help gauge the likelihood of a patient's nonadherence.1
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
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. 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.
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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.
1. ADMINISTER the Adherence Estimator.
1
2
3
I am convinced
of the importance
of my prescription
medicine.
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.
Agree
completely
Agree
mostly
Agree
somewhat
Disagree
somewhat
Disagree
mostly
Disagree
completely
Agree
I feel financially
completely
burdened by my
out-of-pocket expenses
for my prescription medicine.
Agree
mostly
Agree
somewhat
Disagree
somewhat
Disagree
mostly
Disagree
completely
Short and concise features
help make it easy1:
– 1 minute to complete
– Immediate scoring
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.
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.
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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.
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
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.
27
Use the Adherence Estimator® for patients with certain chronic, asymptomatic
conditions who have just received a new prescription for an oral medication.
2. ASSESS results with the Adherence Estimator Interpretation Guide.1
Total
8-36
High likelihood for nonadherence (less than 32% probability for adherence)
2-7
Medium likelihood for nonadherence (32%-75% probability for adherence)
0
Low likelihood for nonadherence (greater than 75% probability for adherence)
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
prescription medicine
is necessary
CONCERN
The belief that
prescription medicine
will do more harm
than good
COST
The belief that
prescription medicine
is not affordable
LOW
0
MEDIUM
0
7
HIGH
14
7
20
MEDIUM
14
4
MEDIUM
2
HIGH
LOW
4
0
LOW
2
0
20
0
LOW
0
0
0
• Slide the survey into the Interpretation Guide
• Tally survey score to gauge the likelihood of a patient not adhering to the new medication
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.
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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.
3. ADDRESS the patient’s concerns about adherence with personalized communications
and helpful resources.
• 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
!
COMMITMENT
?
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.
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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.
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.
– 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
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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.
Patient Education Brochures
A full range of brochures covering a number of issues
patients may need to understand better.
– 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
32
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.
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®.
– 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
33
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.
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.
– 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)
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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.
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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