Transcript Slide 1

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
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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
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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
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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
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MEDICATION ADHERENCE
• Adherence rates are higher in which?
– Acute conditions
– Chronic conditions
• What is an acceptable rate of adherence?
– Some say 80%
– Variability
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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
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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
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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
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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
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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.
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MEASURING ADHERENCE
• Direct methods
– Observing therapy directly
– Measurement of drug or metabolite in serum
• Indirect methods
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Clinical responses
Patient interviewing, questionnaires
Treatment diary
Refill rate
Pill/medication counting
Electronic monitoring
Osterberg L, Blaschke T. NEJM. 2005; 353:487-97
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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?
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BARRIERS TO ADHERENCE
• Patient specific factors
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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
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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
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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
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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
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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
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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
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LET’S CHAT…
• Of the discussed barriers for
medication adherence, which have
you noticed in your experiences at the
clinic?
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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
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PREDICTORS OF POOR
ADHERENCE - CONTINUED
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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
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INTERACTIONS & ADHERENCE
Caregiver
Support
System
Patient
Health
care
provider
Pharmacy
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ADHERENCE IS GOOD!
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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
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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
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LET’S CHAT…
• Of the discussed studied strategies,
which of them do you think are/are not
practically feasible for real-world
application? Why?
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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
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TOOLS FOR ADHERENCE
• Reminders
– Medication Event Monitoring System (MEMS)
– Blister packs
– Alert watch
• Online resources
– MyMedSchedule.com
– Smart phone apps
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EXAMPLE OF ADHERENCE
TOOL
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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
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PATIENT MEDICATION LIST
http://kidsmeds.info/attachments/wysiwyg/1/My_Medication_Information_Sheet.pdf
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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
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QUESTIONS?
• [email protected]
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