In Brief C. Everett Koop, MD, said, “Drugs don’t work in patients who don’t take them.” There is a lot of evidence that patients are not taking their medica- tions as prescribed. Lack of medication adherence contributes to poor patient outcomes and billions of health care dollars spent unnecessarily. This article reviews medication adherence in the United States, common reasons for lack of adherence, and strategies for improving medication-taking in patients.

Promoting Medication Adherence in Older Adults . . . and the Rest of Us

Taking medications as directed seems not. Although 1.47 billion new and like such an easy thing, doesn’t it? renewed prescriptions were dispensed Barbara Kocurek, BS, PharmD, Pop a pill in your mouth, and swal- in the United States in 2007 at a low it down with some water. So much cost of $286.5 billion, research has BCPS, CDE easier than adhering to a meal plan shown that people are not taking their or exercising, right? Unfortunately, medications as directed.1,2 And this is 80 Diabetes Spectrum Volume 22, Number 2, 2009 despite the fact the prescription medi- Table 1. General Medication Adherence Statistics3–5 From Research to Practice/Pharmacological Management of Type 2 Diabetes cations undergo a rigorous approval process to prove their safety and effi- • Patients with chronic diseases normally take only 50% of prescribed cacy. Table 1 lists some medication doses. adherence statistics.3–5 • Twenty-two percent of patients take less than what is stated on the label. Several studies have been published • Twelve percent of patients do not fill their prescription at all. looking specifically at medication • Twelve percent of patients do not take medication at all after they buy adherence in people with diabetes. A the prescription. recently published systematic review a big consequence. Nonadherence can plan categorized the factors underlying reported that adherence rates to diabe- lead to poor blood glucose control, nonadherence as patient-, medication-, tes medications varied from 31 to 87% which can then lead to diabetes-related in retrospective studies and from 53 to prescriber-, and pharmacy-related. 98% in prospective studies.6 complications, reduced functioning, One or all of these factors can con- Difficulty with taking medications lower quality of life, and premature tribute to patients’ ability to take as prescribed can occur in anyone. death. Patients with hypertension who medications as directed. Research has shown it affects both take < 80% of their antihypertensive Patient-related factors males and females of all ages and doses have a fourfold increased risk of 3 Many patients do not take medica- across the spectrum of education and a cardiac event. A recently published tions as directed simply because they socioeconomic status. Often, difficulty study identified two factors—taking with taking medications has been diabetes medication doses more than forget. Often, patients do not take thought to be a problem seen primar- twice daily and the ability to read medications correctly because they ily in older adults; however, age itself the diabetes medication prescription do not understand the directions on has not been identified as a risk fac- label—as significantly related to A1C the prescription labels. Health literacy tor for medication nonadherence. The in those with poorly controlled diabe- is defined as the capacity to obtain, 12 results of one study found that patients tes (defined as an A1C of> 9%). process, and understand basic health who were more likely to be nonadher- information and services needed to Poor Medication Adherence is a ent were actually 65 years of age and make appropriate health decisions. < Serious Public Health Issue had fewer comorbidities.7 Problems with health literacy affect The National Council on Patient Although age is not a risk factor for millions of people in the United States, Information and Education (NCPIE) medication nonadherence, older adults including older adults. More than 77 is a coalition of 125 organizations are more likely to have chronic illnesses > million adults in the United States whose mission is to stimulate and and to take more prescription medi- have basic or below-basic health lit- improve communication of infor- 15 cines. Forty percent of older adults take eracy skills. mation on appropriate medicine five or more prescription medications a Many patients consciously choose day. 8 Additionally, the number of older use to consumers and health care not to fill a prescription, not to take adults in the United States is increas- professionals. their medicine as prescribed, or to ing at a rapid rate. In 2007, people In August 2007, NCPIE published discontinue therapy.13 These choices “Enhancing Prescription Medication > 65 years of age comprised 12.6% of are influenced by a number of factors the U.S. population. The U.S. Census Adherence: A National Action Plan,” related to patients’ experiences, per- which can be accessed online at www. Bureau estimates that number will ceptions, and understanding about talkaboutrx.org. The 36-page action increase to 20% by 2030.9 their disease and can include:13,16 plan was written by a group of 11 • Perceptions about the nature and advisors from leading professional Benefits of Medication Adherence severity of their illness societies, voluntary health organiza- in People With Diabetes • Denial of illness and the need to tions, and patient advocacy groups. Those who care for people with diabe- take medicines It assesses the extent and nature of tes are well acquainted with the value • The assumption that once the of medications in the treatment of poor medication adherence, its health and economic costs, and its underly- symptoms improve or people feel hyperglycemia, hypertension, hyper- better, they can discontinue use of lipidemia, and other comorbidities and ing factors, as well as the status of the medication complications associated with diabe- research funding. This action plan • Limited appreciation about the tes. A study published by Pladevall et lists 10 recommendations for improv- value of medicines when properly al.10 found that nonadherent people ing medication adherence (Table 3).13 used with diabetes had significantly worse All health care professionals should be clinical outcomes than those who were aware of this action plan and be work- • Beliefs about the effectiveness of more adherent. ing to improve medication adherence the treatment in their patients. • Acceptance of taking medica- Consequences of Nonadherence in tions for preventive purposes and People With Diabetes Common Factors Contributing for symptomless conditions (e.g., Table 2 lists some of the consequences to Medication Adherence statins to lower blood cholesterol that can occur when people do not Research on medication adherence has levels) take their medications.11 We know that focused mainly on uncovering the bar- • Worries about the social stigma poor medication adherence reduces the riers to adherence. Table 4 lists some associated with taking medicines likelihood of patients achieving clinical common factors that affect medica- • Fear of side effects or concern targets. In people with diabetes, this is tion adherence.14 The NCPIE action about becoming drug dependent Diabetes Spectrum Volume 22, Number 2, 2009 81 Table 2. The Impact of Nonadherence to Medication Regimens11 Concern about medication side effects is another barrier. A 2005 sur- Medication nonaherence is responsible for: vey of 2,507 adults found that 45% of • 33–69% of medication-related hospital admissions the respondents did not take a medi- • 23% of all nursing home admissions cation because of concerns about side • $100 billion in direct and indirect costs effects.13 • Increased use of expensive, specialized medical resources • Unneeded medication changes Prescriber-related factors • Unexplained treatment failures In looking at medication nonadher- • Repeat office visits ence, the most significant factors Table 3. Recommendations for Improving Medication Adherence related to the prescriber are lack of from the NCPIE Action Plan13 time and poor communication skills. A search of the literature regarding 1. Elevate patient adherence as a critical health care issue. communication between prescribers 2. Agree on a common adherence terminology that will unite all and patients regarding medication use stakeholders. reveals some interesting information. 3. Create a public/private partnership to mount a unified national educa- One study examined the concerns tion campaign to make patient adherence a national health priority. of older adults with diabetes about 4. Establish a multidisciplinary approach to adherence education and the complexity of their medication management. regimen and whether they discussed 5. Immediately implement professional training and increase the funding medication-related concerns with their for professional education on patient medication adherence. physician. One of the findings was that 6. Address the barriers to patient adherence for patients with low health many older adults did not think it was literacy. appropriate to discuss their concerns 7. Create the means to share information about best practices in adherence about medication costs with their phy- education and management. sician or doubted that chronic illness 8. Develop a curriculum on medication adherence for use in medical medications were necessary at all.19 schools and allied health care institutions. Another study of medication 9. Seek regulatory changes to remove roadblocks for adherence assistance adherence in the senior population programs. reported that up to 40% of the 17,000 10. Increase the federal budget and stimulate rigorous research on medica- patients surveyed reported some type tion adherence. of medication nonadherence, and 35% Table 4. Common Factors Affecting Medication Adherence6,14 reported cost as a reason. Many who • Regimen complexity decided to skip doses or stop taking • Dosing frequency greater than twice a day their medicine as a result of cost did • Remembering doses and refills not tell their prescriber. However, • Depression researchers found that patients who • Adverse effects or fear of them talked with their physician about cost- • Lack of belief that the medication will help related concerns were more likely to be switched to a lower-cost medica- • Fear of needles and the need for decrease in medication nonadherence tion.20 Piette et al.21 found that reasons self-injections related to cost. patients give for not discussing medica- • Lack of confidence in the ability to A recently published meta-analysis tion-related issues with their provider follow the medication regimen on depression and diabetes treatment include patient embarrassment, not • Media influence regarding safety nonadherence found, not surprisingly, thinking the topic was important or risk issues associated with par- a significant association between enough, lack of trust, and lack of time ticular medicines depression and treatment nonadher- during the clinical encounter. • Lack of positive motivations and ence in people with diabetes.18 In their article titled, “The incentives to make necessary Language of Medication Taking,”4 changes in behavior Medication-related factors Steiner and Earnst write that, Complex medication regimens are a “Medication-taking is a prototype for Another key factor affecting medi- significant barrier to medication adher- many behavioral issues in medicine, cation adherence, especially for older ence. The use of multiple medications such as dietary modification, smoking adults, is cost-related issues. Studies (polypharmacy) is often required and cessation, and exercise prescription. have shown that older adults skip Terms like compliance and adherence beneficial in helping patients with dia- doses, reduce doses, or do not get are too facile to describe these complex prescriptions filled because they can- betes achieve optimal blood glucose, behaviors. They should be replaced not afford to pay for medications.17 blood pressure, and lipid control and with a language that is less succinct but Madden et al.17 recently examined manage other diabetes-related com- richer in its description and analysis of the changes in cost-related medication plications and comorbidities. It is not human behavior. We must assess what nonadherence after implementation of uncommon for a patient with diabetes our patients are doing and understand the Medicare prescription drug ben- to be appropriately prescribed five or why they do it if we wish to help them efit and found a small but significant more medications. change. In this effort, our language is 82 Diabetes Spectrum Volume 22, Number 2, 2009 Table 5. Strategies to Improve Medication Adherence3,13 From Research to Practice/Pharmacological Management of Type 2 Diabetes Barriers Possible Strategies to Overcome

Patient-related issues

• Forgetting due to busy schedule • Using pill boxes or reminder packaging • Difficulty taking multiple medications • Encouraging patients to relate pill taking to daily activities • Misunderstanding or denial of disease • Reducing the number of medications. Use combination prod- • Failure to see treatment as necessary, ucts or omit medications with a low benefit/risk ratio. especially if asymptomatic • Reminding patients that they have a lifelong condition that • Low expectations about treatment requires their involvement • Financial barriers • Using health coaching techniques such as reflective listening to • Physical barriers encourage behavior change • Tailoring medication regimens to patients’ health care goals and life expectancy • Using monitoring (blood glucose, blood pressure, cholesterol) to motivate and educate • Helping patients find free or low-cost medications • Helping patients find devices to overcome their physical limitations

Medication-related issues

• Complex medication regimens • Reviewing medications at each visit and eliminating medica- • Concerns about side effects tions that are not needed • Simplifying dosing regimens. Adherence is best with once-daily dosing. • Reducing the number of medications. Use combination prod- ucts or omit medications with a low benefit/risk ratio. • Discussing side effects in the context of medication benefits • Using “positive framing” when discussing the potential for side effects (e.g., “If 1 in 100 patients experiences a side effect, then this means that 99 in 100 patients do not.”)

Prescriber-related issues

• Limited time to provide information at • Practicing effective communication office visits • Assessing what patients need to know. Providing information • Failure to provide information in a way on the drug’s mechanism of action may not always be needed patients can understand for adherence. • Authoritarian approach instead of patient • Providing clear, written instructions empowerment approach • Assessing understanding of instructions • Asking about medication adherence at every visit. Make it important. • Encouraging patients to make a list of medications and to keep the list current • Having indications on the prescription and label, if possible • Helping patients find free or low-cost medications (e.g., popular websites include www.needymeds.org and www.rxassist.org) as powerful a tool as the medications in increasing medication adherence. Improving Medication Adherence in we prescribe.” This study followed 200 patients > 65 Patients What we say to patients and how years of age who were taking at least Although medication adherence has we say it can really make a difference. four medications. Medication adher- been well studied, there are few data ence, blood pressure, and cholesterol on what specific interventions work Pharmacy-related factors were improved in patients who partici- to improve medication adherence.12 Many pharmacists are in an ideal pated in a comprehensive pharmacy Table 5 lists various strategies that can position to promote medication adher- care program. Despite this potential be used to help overcome some of the ence because of their frequent contact for success, many pharmacists face barriers to medication adherence. For with patients. One study in particu- barriers such as space limitations, many health care providers, the first lar, the Federal Study of Adherence to lack of time and resources, and lack step in addressing this problem may be Medications in the Elderly,22 demon- of management support to counsel to change how they think about and strated the effectiveness of pharmacists patients on medication adherence. discuss medications with patients. An Diabetes Spectrum Volume 22, Number 2, 2009 83 12Odegard PS, Gray SL: Barriers to medica- Table 6. Online Resources for Improving Patient Knowledge tion adherence in poorly controlled diabetes About Medication Use mellitus. Diabetes Educ 34:692–697, 2008 13National Counsel on Patient Information • ASK (Adherence Starts with Knowledge): www.takingmeds.com and Education: Enhancing prescription • MUST for Seniors: www.mustforseniors.org medicine adherence: a national action plan • “Be An Active Member of Your Health Care Team”: www.fda.gov/cder/ [article online]. Available from http://www. consumerinfo/active12panelEng.htm talkaboutrx.org/documents/enhancing_ • “Check Your Medicines: Tips for Using Medicines Safely”: http://www. prescription_medicine_adherence.pdf. Accessed 20 November 2008 ahrq.gov/consumer/checkmeds.htm • “Your Medicine: Play It Safe”: http://www.ahrq.gov/CONSUMER/safe- 14Grant RW, Devita NG, Singer DE, Meigs JB: Polypharmacy and medication adherence meds/safemeds.pdf in patients with type 2 diabetes. Diabetes Care 26:1408–1412, 2003 imshealth/menuitem.a46c6d4df3db4b3d88f6 open-ended question such as, “How 15U.S. Department of Health & Human many doses of your medication have 11019418c22a/?vgnextoid=936d9df4609e91 Services Office of Disease Prevention and 10VgnVCM10000071812ca2RCRD&vgnext Health Promotion: Health communication you missed over the past week?” fmt=default. Accessed 20 November 2008 instead of “Have you missed any doses activities [article online]. Available from 2 www.health.gov/communication/literacy. of your medication” (a closed-ended Surescripts: E-prescribing statisics [article online]. Available from http://www. Accessed 20 November 2008 question) may provide patients an surescripts.com/e-prescribing-statistics.html. 16Fincham JE: Advancing prescription opportunity to voice a concern. Using Accessed 20 November 2008 medication compliance: new paradigms, new more open-ended questions and a non- 3PharmacistsLetter.com: Medication adher- practices. J Pharmacoepidemiol 3:1–8, 1995 judgmental tone of voice can improve ence [article online]. 23:230811, 2007. 17Madden JM, Graves AJ, Zhang F, Adams communication and allow for more Available from www.pharmacistsletter.com. AS, Briesacher BA, Ross-Degnan D, Gurwitz information to be exchanged. Accessed 20 November 2008 JS, Pierre-Jacques M, Safran DG, Adler Table 6 lists resources that can be 4Steiner JF, Earnest MA: The language of GS, Soumerai SB: Cost-related medication used to help educate patients about medication taking. Ann Intern Med 132:926– nonadherence and spending on basic needs 930, 2000 following implementation of Medicare Part the value of their role as part of their D. JAMA 299:1922–1928, 2008 5American Heart Association: Statistics health care team. GlaxoSmithKline 18 you need to know [article online]. Available Gonzalez JS, Peyrot M, McCarl LA, Collins recently published a 20-question sur- EM, Serpa L, Mimiaga MJ, Safren SA: vey titled “Taking Medicine—What from www.americanheart.org. Accessed 20 November 2008 Depression and diabetes treatment nonad- Gets in the Way?” that can be given herence: a meta-analysis. Diabetes Care to patients to help uncover barriers to 6Odegard PS, Capoccia K: Medication taking 31:2398–2403, 2008 and diabetes: a systematic review of the litera- 19 medication adherence. This survey can ture. Diabetes Educ 33:1014–1029, 2007 Tjia J, Givens JL, Karlawish JH, Okoli- be accessed online at www.taking- Umeweni A, Barg FK: Beneath the surface: 7 meds.com. Because health literacy has Jo PM: Effect of medication nonadherence discovering the unvoiced concerns of older on hospitalization and mortality among adults with type 2 diabetes mellitus. Health been identified as an issue for many patients with diabetes mellitus. Arch Intern Ed Res 23:40–52, 2008 people, it may be helpful to review an Med 166:1836–1841, 2006 20National Council on Patient Information online summary of best practices in 8Wilson IR, Schoen C, Neuman P, Strollo and Education: Medication use safety train- health communication at http://www. MK, Rogers WH, Chang H, Safran DG: ing for seniors [article online]. Available health.gov/communication/literacy/ Physician-patient communication about from www.mustforseniors.org. Accessed 20 quickguide/healthinfo.htm. prescription medication nonadherence: a November 2008 Ultimately, patients decide when 50-state study of America’s seniors. J Gen 21Piette JD, Heisler M, Wagner TH: Cost- Intern Med 22:6–12, 2007 and how they take their medications. related medication underuse: do patients Health care providers can reduce or 9U.S. Census Bureau: Statistical brief: Sixty- with chronic illnesses tell their doctors? Arch Intern Med 164:1749–1755, 2004 help remove some of the barriers to Five Plus in the United States [article online]. Available from www.census.gov/population/ 22 adherence through appropriate edu- Lee JK, Grace KA, Taylor AJ: Effect of socdemo/statbriefs/agebrief.html. Accessed 10 a pharmacy care program on medication cation, medication, cost reduction December 2008 adherence and persistence, blood pressure, when possible, and open conversa- 10Pladevall M, Williams LK, Potts LA, Divine and low-density lipoprotein cholesterol: tions that allow patients to express G, Xi H, Lafata JE: Clinical outcomes and a randomized, controlled trial. JAMA their concerns. adherence to medications measured by claims 296:2563–2571, 2006 data in patients with diabetes. Diabetes Care 27:2800–2805, 2004 Barbara Kocurek, BS, PharmD, References 11GlaxoSmithKline: Taking medicines: what 1IMS Health: 2007 U.S. sales and prescrip- gets in the way? [article online] Available BCPS, CDE, is the diabetes educa- tion information [article online]. Available from www.takingmeds.com. Accessed 10 tion coordinator at Baylor Health from www.imshealth.com/portal/site/ December 2008 Care System, in Irving, Texas.

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