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MEDICATION ADHERENCE: CHALLENGES AND STRATEGIES Hanna Phan, PharmD, BCPS Clinical Assistant Professor, College of Pharmacy Assistant Professor, College of Medicine Residency Program Director, Pediatric PGY2 PharmD UA Pediatric Pulmonary Center February 14, 2012 CONFLICTS OF INTEREST • Nothing to disclose 2 OBJECTIVES • Define medication adherence and describe its affect on various disease states • Describe the health belief theories and their affect on medication adherence • Identify common reasons for poor adherence based on patient-specific factors such as socioeconomic status, health beliefs, etc. • Discuss possible strategies in improving medication adherence in children and adolescents 3 WISDOM TO PONDER… “Drugs don’t work in patients who don’t take them.” -C. Everett Koop, MD Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 4 MEDICATION ADHERENCE • A.K.A. medication “compliance” • “...the extent to which patients take medication as prescribed by their health care providers.” • Why is it important? – Compromises efficacy of treatment regimens, leading to a failure to achieve a desired treatment goal Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 5 MEDICATION ADHERENCE • Adherence rates are higher in which? – Acute conditions – Chronic conditions • What is an acceptable rate of adherence? – Some say 80% – Variability 6 RATES OF ADHERENCE • Clinical trial reported adherence for chronic conditions = 43 - 78% (all patient ages) • Pediatric medication adherence rates = 11 – 93% • Up to 69% of all hospital admissions are due to poor medication adherence ($100 billion+/year) • Up to 50% of admissions associated with drugrelated Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 Llorente RAA et al. J Cys Fib. 2008;7:359-67 Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64 7 RATES OF ADHERENCE • Asthma medications – Frequently fall below 50% (30 - 70%) – Chronic controller medication is main issue – Acute corticosteroid Rx • 44 - 98% filled • Up to 64% finished course – Main barriers • • • • Access to controller medication Health beliefs (fear of side effects) Scheduling Peer pressures Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64 8 RATES OF ADHERENCE • Cystic fibrosis (CF) medications – Dependent on treatment type • Greater with GI meds (e.g., enzymes) – up to 88% • Lower with respiratory meds - up to 30-60% • Lower with airway clearance – up to 30-40% – Main barriers • • • • Poor perception of efficacy (e.g., respiratory meds) Scheduling Peer pressures Access to health care (e.g., cost of medications) Llorente RAA et al. J Cys Fib. 2008;7:359-67, Zindani GN et al. J Adoles Health. 2006;38: 13-17 Bregnballe V. Pat Pref Adherence. 2011; 5:507-15, Latchford G et al. Pat Ed Counsel. 2009; 75:141-144. 9 MEASURING ADHERENCE • Direct methods – Observing therapy directly – Measurement of drug or metabolite in serum • Indirect methods – – – – – – Clinical responses Patient interviewing, questionnaires Treatment diary Refill rate Pill/medication counting Electronic monitoring Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 10 LET’S CHAT • From your own experiences as a patient at one time or another, what caused you to be non-adherent to a medication or regimen? 11 BARRIERS TO ADHERENCE • Patient specific factors – – – – – – Patient age Socioeconomic status Access to health care Family characteristics (including culture, health beliefs) Patient and/or caregiver psychosocial issues Perceived benefit (or lack there of) from treatment • Medication specific factors – Adverse drug effects – Inconvenience in dosing, lack of palatability 12 BARRIERS: INFANTS AND YOUNG CHILDREN • Caregiver is responsible for medication administration • Health beliefs of caregivers • Limited language skills of infants and young children (e.g., PRN rescue medication) Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 Llorente RAA et al. J Cys Fib. 2008;7:359-67 Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64 13 BARRIERS: INFANTS AND YOUNG CHILDREN • Time consuming treatments (e.g., nebulization) • Caregiver vs. child – battle for control • Ease of administration – Palatability – Frequency • Parental motivation 14 BARRIERS: CHILDREN • Lack of structured home environment – Caregiver and child’s schedules – Behavior and consequence • Parental motivation – Forgetfulness, stress – Lack of immediate benefit from chronic treatment – Health beliefs Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 Llorente RAA et al. J Cys Fib. 2008;7:359-67 Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64 15 BARRIERS: CHILDREN • Confusion with multiple medications – – – – Multiple drugs of same route, different timing Multiple pills/doses through out the day Acute treatment with chronic treatment Discharge follow-up (or lack there of) • Perceived efficacy and side effects – Caregiver perception Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 Llorente RAA et al. J Cys Fib. 2008;7:359-67 Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64 16 BARRIERS: ADOLESCENTS • Increasing independence, self-administer medication • Some of the same factors as children (e.g., home environment) – Lack of structured home environment – Confusion with multiple medications – Perceived efficacy and side effects Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 Llorente RAA et al. J Cys Fib. 2008;7:359-67 Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64 17 BARRIERS: ADOLESCENTS • Depression and high-risk behavior – Triad of behavior – depression, unhealthy behavior, non-adherence • Peer pressures, acceptance – Medication use in school, social events, etc. Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 Llorente RAA et al. J Cys Fib. 2008;7:359-67 Desai M , Oppenheimer JJ. Curr Allergy Asthma Rep. 2011; 11:454-64 18 LET’S CHAT… • Of the discussed barriers for medication adherence, which have you noticed in your experiences at the clinic? 19 HEALTH BELIEF THEORIES • Application in chronic conditions such as asthma, CF, attention deficit hyperactivity disorder • Health Belief Model – Focus on patient’s and caregiver’s assessment of: • Seriousness of disease • Perceived benefit from treatment • Planned Behavior Model – Address subjective norm (e.g., peer pressure) – Move towards accepting treatment US Department of Health and Human Services, National Institutes of Health. Theory at a Glance: Application to Health Promotion and Health Behavior. Second Edition, 2005. Available at: www.cancer.gov/cancertopics/cancerlibrary/theory.pdf. Accessed May 1, 2011. PREDICTORS OF POOR ADHERENCE • Presence of psychological problems, particularly depression • Presence of cognitive impairment • Treatment of asymptomatic disease • Inadequate follow-up or discharge planning • Side effects of medication Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 21 PREDICTORS OF POOR ADHERENCE - CONTINUED • • • • • • • Patient/caregiver lack of belief in benefit Patient/caregiver lack of insight into illness Poor provider-patient relationship Presence of barriers to care or medications Missed appointments Complexity of treatment Cost of treatment Osterberg L, Blaschke T. NEJM. 2005; 353:487-97 22 INTERACTIONS & ADHERENCE Caregiver Support System Patient Health care provider Pharmacy 23 ADHERENCE IS GOOD! 24 STUDIED STRATEGIES ASTHMA • Electronic monitoring and feedback (MDILogII™) – Monitors MDI inhalers, provided feedback to parents bimonthly • School-based supervised asthma therapy – School official observes student self-administer controller medication • Home based education + adherence feedback – 5 home visits with asthma educators +/- feedback Spaulding SA et al. J Pediatr Psychol. 2012;31:64-74 Gerald LB et al. Pediatrics. 2009; 123:466-74 Otsuki MO et al. Pediatrics. 2009; 124:1513-21 25 STUDIED STRATEGIES - CF • Adaptive aerosol delivery (AAD) – Nebulizer device w/ electronic capabilities to monitor when it is used, for how long, and if full dose taken • Automated medication dose reminder – Customized pagers, text messages • Cell Phone Intervention (CFFONE™) – Web-enabled cell phone – Reminders with CF information and support McNamara PS et al. J Cys Fib. 2009; 8:258-263 Johnson KB et al. J Telemed Telecare. 2011; 17:387-391 Marciel KK et al. Pediatr Pulmolol. 2010;45:157-64 26 LET’S CHAT… • Of the discussed studied strategies, which of them do you think are/are not practically feasible for real-world application? Why? 27 PRACTICAL STRATEGIES • Patient and family education – Formalized sessions or part of clinic visits • Medication reminders – Medication list – Cell phone reminders – Alarms • Simplifying medication regimen • Appropriate drug selection (e.g., ease, palatability) • Pharmacy reminders for refills 28 TOOLS FOR ADHERENCE • Reminders – Medication Event Monitoring System (MEMS) – Blister packs – Alert watch • Online resources – MyMedSchedule.com – Smart phone apps 29 EXAMPLE OF ADHERENCE TOOL 30 WHAT WE ARE DOING… • Adherence assessment with each clinic visit – Patient “quizzing” – “What, how, when, why” about medications • Patient and family education as part of clinic visit – “Homework” for older children and adolescents – Empower patient to taken ownership of health and treatments • Encouraged use of medication lists – Hard copy, electronic, mobile • Simplifying medication schedules 31 PATIENT MEDICATION LIST http://kidsmeds.info/attachments/wysiwyg/1/My_Medication_Information_Sheet.pdf 32 SUMMARY • Medication adherence – Rate is worse in chronic illnesses, affects patient outcomes and health resources • Depends on various factors – Age, psychosocial, health beliefs, etc. • It’s not a lone venture – Patient, Caregiver, Health care provider, Support • There are tools available, studied strategies to help improve adherence – Patient preference, team effort to improvement 33 QUESTIONS? • [email protected] 34