Download Bender BG, Rand C. Medication non-adherence and asthma treatment cost. Curr Opin Allergy Clin Immunol. 2004;4(3): p.191-5. Review.

Medication non-adherence and asthma treatment cost
Bruce G. Bendera and Cynthia Randb
Purpose of review
The purpose of this review is to describe the impact of asthma
treatment non-adherence on patients and the healthcare
system, and to outline areas of responsibility towards improved
adherence.
Recent findings
The average cost of healthcare expenses for each person in the
United States in 2002 was US$5440. In that year, there were
800 million medical encounters. However, adherence research
suggests that a significant portion of the healthcare advice and
prescriptions dispensed in these encounters was wasted. The
annual cost to the healthcare system caused by non-adherence
has been estimated at US$300 billion dollars. The responsibility
for improving adherence has usually been placed on the patient
and healthcare provider. However, if non-adherence is to be
more effectively addressed, other components of the healthcare
and pharmaceutical industries must also take responsibility.
Summary
Treatment non-adherence compromises treatment effectiveness
and drives up the healthcare costs related to asthma and other
chronic conditions. Collaborative efforts to improve adherence
to treatments for chronic illness, recently promoted by the
World Health Organization, must include multiple components
of the healthcare system, must recognize that the costs of
adherence promotion are outweighed by cost savings after
improved adherence, and must support research to develop
new and better strategies for improving adherence.
Keywords
adherence, asthma, cost
Curr Opin Allergy Clin Immunol 4:191–195.
#
2004 Lippincott Williams & Wilkins.
a
Department of Pediatrics, National Jewish Medical and Research Center, Denver,
Colorado, USA; and bDivision of Pulmonary and Critical Care Medicine, Johns
Hopkins University Medical Center, Baltimore, Maryland, USA
Correspondence to Bruce G. Bender, PhD, National Jewish Medical and Research
Center, 1400 Jackson Street, Denver, CO 80206, USA
Fax: +1 303 270 2177; e-mail: [email protected]
Current Opinion in Allergy and Clinical Immunology 2004, 4:191–195
Abbreviation
WHO
World Health Organization
# 2004 Lippincott Williams & Wilkins
1528-4050
DOI: 10.1097/01.all.0000129449.73727.cf
Introduction
Patient non-adherence to treatments for chronic illness
compromises treatment success and patient quality of
life while increasing healthcare costs. A recent World
Health Organization (WHO) book addressed the
worldwide problem of treatment non-adherence, which
averages only 50% in developed countries and is even
lower in developing countries, and concluded that
increasing adherence may have a more beneficial
impact on the health of the population than improving
specific treatments [1 . .]. The WHO report is targeted
at policy-makers and health managers in order to
increase awareness of the far-reaching problem of poor
adherence rates among patients with chronic illness
and to stimulate multidisciplinary efforts to increase
adherence.
Healthcare costs related to non-adherence
The United States is the largest consumer of healthcare
in the world, with total health costs reaching US$1.6
trillion in 2002, representing 14.9% of the gross domestic
product [2]. The average cost of healthcare expenses for
each person in the USA in 2002 was US$5440, with an
average of 3.1 physician office visits per person [2],
resulting in a total of over 880 million physician office
visits. However, adherence research suggests that a
significant portion of the healthcare advice and prescriptions dispensed at these 880 million medical encounters
was wasted. DeMatteo [3] estimated that over 188
million medical visits result in patients failing to adhere
to physician advice. Although acknowledging that it is
impossible to estimate precisely the waste and excess
cost associated with non-adherence, the meta-analysis
by DeMatteo [3] on the prevalence of non-adherence
suggests that the costs may be as high as US$300 billion
a year.
Even more troubling are the healthcare costs resulting
from non-adherence-related disease exacerbations. For
example, when a non-adherent asthma patient presents
with continuing symptoms, the physician may unnecessarily step up therapy because he or she believes
that the patient is non-responsive to the original less
intensive, and less costly, therapy. In addition, when a
patient fails to respond to an apparently appropriate
therapy, the physician may feel compelled to order
expensive diagnostic tests to try and understand the
patient’s poor response to treatment. Although not all
non-adherence results in dangerous or costly complications, research across a range of chronic diseases,
including asthma, suggests that non-adherence results
191
192 Outcome measures
in excess urgent care and hospitalizations. For example, Milgrom et al. [4] demonstrated that pediatric
asthma patients who were the least adherent were
more likely to have asthma exacerbations requiring a
prednisone burst. On a national level, Iskedjian et al.
[5] estimated the economic burden of hospitalization
attributable to patient non-adherence with controller
therapy in Canada. Using national health statistics and
an average admission rate as a result of non-adherence
of 5.2% (based on literature review), they concluded
that Canadian hospital expenditures caused by nonadherence exceeded US$1.6 billion.
Finally, even when patients follow physician advice as
far as filling prescriptions and initiating therapy,
research suggests that a portion of all prescribed
medication is wasted or discarded. For example, a
study by Morgan [6] used home-based pill counts and
surveys to examine the economic impact of wasted
prescriptions among older outpatients (465 years).
Morgan [6] found that waste (i.e. no intention of using
remaining medication) represented 2.3% of total
medication costs and that the average annual cost of
the wasted medication was US$30.47 (range US$0–
131.56). The study estimated that this modest perperson cost of waste would translate into a national
cost for adults older than 65 years of age of over
US$1 billion per year.
The overall implications of these analyses are clear and
compelling. As healthcare costs spiral upwards and
national health policy debates consider severe limitations
on healthcare benefits, strategies to reduce non-adherence-related costs offer a promising (and cost-effective)
avenue for intervention and cost-savings.
Changing patient behavior
Despite a large published literature addressing the
problem of how to change patient behavior in order to
improve medication adherence, remarkably little success
has been recorded. Patients in adherence–intervention
studies may achieve higher scores on a test of asthma
knowledge, and report increased medication use, but
most frequently an objectively established change in
disease status is not achieved [1 . .,7]. Because many
factors can contribute to treatment non-adherence, no
single intervention will affect change in each individual.
Patient understanding of the disease and its treatment is
essential for treatment adherence and improved outcomes, but studies employing comprehensive asthma
education programmes often do not result in significant
change [1 . .,7]. Patient education remains an important
component in the comprehensive care of asthma, but it
is likely to affect change only in that group of patients for
whom a lack of information is the primary reason for
non-adherence.
Changing adherence behavior is a difficult but not
impossible task. Smoking, which is both physiologically
and psychologically addicting, is a behavior very resistant
to change. Nonetheless, comprehensive efforts to reduce
smoking frequency have resulted in a decrease over the
past 25 years in the proportion of Americans who smoke.
Furthermore, the Surgeon General’s Report in 2000
outlined a plan for cutting US smoking rates in half that
included: (1) the implementation of school-based antitobacco programmes; (2) a media campaign including anti-tobacco messages from popular celebrities;
(3) encouragement of the inclusion of state-of-the-art
smoking cessation programmes in health insurance
plans; (4) the training of physicians to address tobacco
cessation more effectively; (5) the passage of legislation
that would include stricter indoor air regulations; and
(6) increased funding to develop more effective smoking cessation interventions. The application of a broad
spectrum of strategies that influence behavior may
similarly help to improve the self-management of
chronic medical conditions including asthma, diabetes,
and hypertension. Whereas the healthcare provider has
the most direct contact with patients and therefore the
greatest opportunity to affect behavior change, the
caregiver cannot alone improve the patient’s management of chronic illness, relieve the patient of disease
burden, and reduce healthcare costs.
In a recent report, WHO sited the worldwide problem of
the treatment of non-adherence in both developed and
developing countries and across all chronic conditions,
including communicable diseases such as tuberculosis
and HIV/AIDS, mental and neurological conditions such
as depression and epilepsy, substance dependence, and
a range of other conditions including asthma, hypertension, and cancer. The international panel of writers of
the WHO report took the following position with regard
to which elements of the healthcare system must assume
responsibility for improving disease management:
‘Over the past few decades we have witnessed several
phases in the development of approaches aimed at
ensuring that patients continue therapy for chronic
conditions for long periods of time. Initially the patient
was thought to be the source of the ‘‘problem of
compliance’’. Later, the role of the providers was also
addressed. Now we acknowledge that a systems
approach is required. The idea of compliance is
associated too closely with blame, be it of providers or
patients, and the concept of adherence is a better way of
capturing the dynamic and complex changes required of
many players over long periods to maintain optimal
health in people with chronic diseases’ [1 . .].
Widespread change in the patient self-management of
chronic illness will occur when, as with the campaign to
Medication non-adherence and asthma treatment cost Bender and Rand 193
lower smoking rates, the problem is approached from
multiple avenues using multiple strategies. To accomplish this, neither the patient nor the healthcare provider
can be expected to assume sole responsibility for
effective disease self-management. The healthcare
provider, healthcare industry, and pharmaceutical industry must all accept responsibility for helping enable
patients to care for their asthma better.
Healthcare provider
The relationship between the healthcare giver and the
patient has a large influence on whether the patient
will engage in healthcare behaviors sufficient to
ensure successful treatment of the disease. The
Expert Panel Report: ‘Guidelines for the diagnosis
and management of asthma’ [8] emphasized that
patient education must occur within this caregiver–
patient ‘partnership’. This relationship has a more
powerful influence on adherence than almost any
other factor [9,10]. The strength of the physician–
patient treatment alliance, as rated by the physician,
predicted treatment adherence and non-routine office
visits in the year after hospitalization of 60 adolescents
with severe, chronic asthma [11]. In psychotherapy for
emotional disorders, stronger therapeutic alliance has
similarly been positively related with better outcomes
[12]. In some cases, the behavior and attitude of the
patient prevents the healthcare giver from developing
an optimal working relationship. However, there is
considerable evidence that the behavior of the
physician plays a significant role in defining the
strength of the treatment alliance. Patients are more
adherent to their treatment regimen when their
physician has answered all the patient’s questions
[13] and communicated clearly [14] and positively
[15 .]. The physician’s interest in spending time with
a patient, attempting to understand his/her beliefs and
perceptions about the illness, communicates the desire
to develope a partnership that will result in treatment
success [15 .].
Healthcare industry
The healthcare industry includes insurance companies,
health maintenance organizations, and the hospitals,
clinics, and medical centers that provide clinical care.
The needs and objectives of these organizations are
sometimes in conflict. For example, the amount and
type of healthcare that medical facilities may wish to
offer is restricted by patients’ healthcare insurance
policies. Furthermore, the need for insurance providers
and health maintenance organizations to remain profitable may at times conflict with the patient’s wish to
receive quality healthcare in a rapid and unrestricted
manner. Nonetheless, the objectives of increased
patient adherence and consequent improved disease
control are in the best interests of both the healthcare
industry and the patient. Patients who are adherent to
their treatment plan and are able to self-manage a
chronic illness effectively are less burdensome to
healthcare providers. Such patients are less frustrating
to their provider and are less likely to require
emergency medical services, in turn saving money for
the insurer.
Because many emergency room visits and hospitalizations for asthma can be traced to treatment nonadherence [16], increased adherence can be cost saving
for insurance and health maintenance organizations.
Inadequate disease management frequently underlies
the largest healthcare costs related to asthma, including
on average more than US$500 per emergency room visit
and US$2000 per hospitalization [17]. Urgent care,
including hospital stays and visits to the emergency
room or urgent care clinic, amount to almost US$2 billion
[18]. When indirect costs such as work absenteeism are
taken into account, the total cost of poorly controlled
asthma is much higher [19]. The potential cost-savings
achieved by promoting adherence must be weighed
against the apparent cost savings of restricting access to
care, shortening office visits, and passing increasing
medication costs to patients. Physicians and other care
providers who experience pressure to see more patients
in shorter office visits often report that they are allowed
insufficient time to address patient adherence [20]. If
increased emergency room and hospital visits by patients
who are not well motivated or informed about caring for
their illness are at least partly the result of shortened
office visits, then the apparent cost savings resulting
from seeing more patients in less time are not real.
Similarly, the apparent cost savings anticipated when
insurance companies shift increasing medication cost to
patients must be calculated against the cost resulting
when patients stop taking medication for their heart
disease [21].
Pharmaceutical industry
Drug development, manufacturing, marketing, and
pricing all have a potential impact on patient acceptance
and adherence. That patients are more adherent to
medications that are easily taken has been understood
for many years [22–25]. Recognizing these phenomena,
pharmaceutical firms have increasingly attempted to
develop once-daily treatments, to obtain US Food and
Drug Administration approval to convert multiple-dosing
regimens to once a day, and to produce asthma
medications with tablets rather than inhaler delivery
systems.
Developing medications with higher patient acceptance
helps adherence, but the pharmaceutical industry could
do more to assist in the pursuit of improved selfmanagement. Much of the research in the adherence to
194 Outcome measures
asthma metered-dose inhalers has advanced because of
the availability of electronic devices that allow researchers to collect information about the patterns of medication use. The most recent generation of dry-powder
inhaled medications include a variety of delivery systems
that do not accept electronic adherence-tracking equipment. As new asthma medications are developed, the
inclusion of technology that can be adapted to monitor
adherence would represent an important contribution to
increasing patient adherence.
conveyed in the popular media, communication training
for physicians, and increased funding to test new
adherence intervention strategies.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
.
of special interest
..
of outstanding interest
Sabate E, editor. Adherence to long-term therapies: evidence for action.
Geneva: World Health Organization; 2003.
An international group of authors make the case for the large degree to which the
treatment non-adherence in both developing and developed countries leads to
poorly controlled illness.
1
..
Improvement in medication labels and package inserts
may also promote better adherence. Most labeling
regulations are content based, and few package inserts
are written to be easily read by patients or to be
informative and adherence promoting. Most patients
throw away the inserts without reading them. An
exception to this is found in Australia, where
performance-based and tested package inserts are
consumer friendly, written clearly and in a manner
that makes them useful and encouraging to patients
[1 . .].
Finally, it would be helpful for pharmaceutical firms to
consider the growing phenomenon of patient rejection of
new, expensive drugs for which they are expected to
shoulder a large portion of cost in their insurance plan.
The management of high medication costs must be the
responsibility of the pharmaceutical industry as well as
the health insurance industry, the care provider, and the
patient.
Conclusion
Treatment non-adherence compromises treatment effectiveness and drives up healthcare costs related to
asthma and other chronic conditions. The responsibility
for improving adherence has usually been placed on the
patient and healthcare provider. However, if nonadherence is to be more effectively addressed, other
components of the healthcare industry must also take
responsibility. Healthcare systems, including many
health maintenance organizations, often direct the
length and duration of treatment, including the amount
of time healthcare givers are able to spend with
patients. They determine reimbursements and fee
structures, the allocation of resources for physician
training, procedures for the continuity of care, and the
manner in which information about patient progress is
recorded and tracked. A consideration of their impact
on adherence when health delivery systems are
designed can contribute significantly to the improved
self-management of asthma and other chronic illnesses.
Finally, collaborative efforts to improve adherence to
treatments for chronic illness, recently promoted by
WHO [1 . .] may follow the success of anti-tobacco
efforts, including an adherence-promoting message
2
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