Improving Medication Compliance Among College Students

1. Improving Medication Compliance Among College Students Presented to the American College Health Association May 31, 2012 by Benjamin F. Banahan III, Ph.D., Director

2. Conflict of interest disclosure Improving Medication Compliance Among College Students 2 I have NO actual or potential conflict of interest in relation to this educational activity or presentation.

3. Educational objectives Powers et al 2008. Complex chronic care: patient, provider and organizational issues. J of Management and Marketing in Healthcare, 1(2): 179-190 Improving Medication Compliance Among College Students 3 • Describe the medication compliance problem. • Identify major factors contributing to poor compliance. • Identify special situations for college health pharmacies. • Discuss strategies and tools for improving compliance.

4. Medication adherence = How well patients manage their medications Improving Medication Compliance Among College Students 4 In order for prescription medications to be effective at treating illnesses, patients must: • Fill the prescription given to them by the physician • Routinely takethe medication as directed by the physician: • Quantityof medication to be taken • Number of times per day medication is to be taken • Time(s) of day medication is to be taken • Refill the medicationas needed in order to take the medication as long as recommended by the physician. If a patient fails to do any of these – medication adherence is less than perfect.

5. Adherence: Medication adherence includes two related components Medication compliance refers to the act of conforming to the recommendations made by the provider with respect to timing, dosage, and frequency of medication taking. Medication Possession Ratio (MPR) = 120 days supply / 140 days covered = 86% 30 days to refill 35 days to refill 30 days to refill 45 days to refill 30 days supply 30 days supply 30 days supply 30 days supply Medication persistency = 140 days Medication persistenceis defined as the duration of time from initiation to discontinuation of therapy. Improving Medication Compliance Among College Students 5

6. Adherence: What is acceptable? • Medication compliance is often considered appropriate if MPR is >= 80%. • Some medications such as HIV meds, antisiezure meds, antipsychotics may need higher MPR to be clinically successful. 30 days to refill 35 days to refill 30 days to refill 45 days to refill 30 days supply 30 days supply 30 days supply 30 days supply • Medication persistenceis considered to be acceptable if medication is taken as “long as needed” • Antibiotic taken for 5 days with 10 day course of therapy can be a problem. • Stopping medication against or without advice of physician can be problem. Improving Medication Compliance Among College Students 6

7. Background: Why is adherence getting so much attention? Improving Medication Compliance Among College Students 7 • Increased availability of chronic medications that can manage symptoms or prevent progression of serious illnesses. • Poor adherence can increase total health care costs. • Poor adherence can make a potentially effective medication a useless health care expenditure.

8. Background: Chronic diseases are managed with “maintenance medications” Improving Medication Compliance Among College Students 8 Maintenance medications are prescription medications taken regularly to help prevent or manage chronic diseases. Most patients with chronic diseases will need to take maintenance medications the rest of their life. Most patients with complex chronic conditions require multiple daily medications for adequate control. Many patients struggle with self-management of their maintenance medications.

9. Background: Health care increasingly is focused on managing chronic diseases Powers et al 2008. Complex chronic care: patient, provider and organizational issues. J of Management and Marketing in Healthcare, 1(2): 179-190 Improving Medication Compliance Among College Students 9 82% of adults 65 years old and older have at least 1 chronic condition. 24% of older adults have four or more chronic conditions. Even among the non-elderly, managing chronic diseases is increasingly the largest use of pharmaceutical products.

10. Adherence: Adherence is the # 1 problem in treating chronic conditions today As many as half of all patients fail to take their medications as directed . . . National Association of Chain Drug Stores, 2004. Improving Medication Compliance Among College Students 10

11. Adherence: Adherence is the # 1 problem in treating chronic conditions today . . . and that failure has very costly implications. National Association of Chain Drug Stores, 2004. Improving Medication Compliance Among College Students 11

12. Adherence: Many factors contribute to medication non-adherence Improving Medication Compliance Among College Students 12 • Patient attitudes, knowledge and behaviors • Forgetfulness • Not understanding the instructions for when/how to take the medication • Lack of knowledge about disease being treated • “Feeling better” and deciding to quit the medication • Poor disease management • Failure to appropriately manage transient side effects when starting new medications • Failure to maintain effective therapeutic levels • Cost factors • Co-pay and co-insurance levels • Transportation problems

13. Adherence: Cost issues limit access to care % saying they or a family member have done the following in the past year because of cost. Among those who did each: % saying their condition got worse as a result Kaiser Family Foundation. Economic Problems Facing Families. April, 2008. Improving Medication Compliance Among College Students 13

14. Adherence: Adherence can vary by physician Physician Distribution Based on Average Patient Compliance Lipid Market (n = 23,812) LOW HIGH Some practices do very poorly While others do very well Source: Verispan patient data for the cholesterol market + ZS analysis. Improving Medication Compliance Among College Students 14

15. Adherence: Adherence can vary by pharmacy Performance scores for pharmacies meeting PQA criteria by measure type – 2004 – Proportion of Days Covered Note: Patients attributed to the pharmacy that dispensed majority of the medications related to the measure. There were no major differences when modified attribution strategies were used. Improving Medication Compliance Among College Students 15

16. Co-pay Levels Also Affect Medication Use Persistence With Statin Therapy by Co-Pay Level Improving Medication Compliance Among College Students 16

17. Adherence: Medication adherence rates are related to health care costs and lowers overall health care costs. Improving Medication Compliance Among College Students 17 Better adherence results in: higher prescription costs.

18. Adherence: So what can we do about this problem? Improving Medication Compliance Among College Students 18 Informational interventions through educational processes • Written and oral education material. • Disease management education.

19. Adherence: So what can we do about this problem? Improving Medication Compliance Among College Students 19 Therapy modification interventions • Simplification of dosage regimens • Switching medications to avoid adverse events • Switching medications to avoid higher out-of-pocket costs

20. Adherence: So what can we do about this problem? Improving Medication Compliance Among College Students 20 Behavioral interventions • Increased patient involvement in care • Use of compliance aids (i.e., pill organizers, special packaging) • Reminder systems to combat forgetfulness • Refill reminder systems

21. Adherence: Collaborative care models – providers and patients working TOGETHER Von Korff et al. 1997. Collaborative Management of Chronic Illness. Annals of Internal Medicine, 127(12): 1097-1102 Improving Medication Compliance Among College Students 21 • Collaborative care models encourage patients and providers to work more closely together in order to strengthen and support self-care in chronic illness. • Collaborative care occurs when patients and care providers have: • Shared goals for managing the disease • A sustained working relationship • Mutual understanding of roles and responsibilities • The skills required for carrying out their roles • Pharmacists have regular contact with patients and can develop effective collaborative care services that can improve adherence and outcomes.

22. Adherence: Pharmacy based programs have been shown to reduce costs $7,082 $5,882 $5,210 $4,651 Cranor and Christensen. 2003. The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc, 43(2): 149-159. Improving Medication Compliance Among College Students 22 • Patient care services provided by community-based pharmacies to diabetes patients in Asheville, NC demonstrated: • Improved control of the patients’ diabetes • Improved compliance – resulting in increased use and expenditures for medications • Lower overall health care expenditures.

23. Adherence: Pharmacy care services also reduced sick days • Patient care services for the group of Asheville city employees resulted in a significant reduction in sick days used every year. • The employer estimated that the value of increased productivity was $18,000 per year. Cranor and Christensen. 2003. The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc, 43(2): 149-159. Improving Medication Compliance Among College Students 23

24. CPMM: The RxSync™ program helps community pharmacies with adherence Improving Medication Compliance Among College Students 24 The RxSync ServiceSM is a community pharmacy practice model that improves adherence and outcomes by: • Simplifying the refill process to make it easier to avoid running out of an important medication. • Providing a timely reminder to the patient for refills needed each month. • Monitoring medication problems that might lead to medication noncompliance or other health problems. • Working with the patient and physician to appropriately address medication problems that are identified.

25. What should you focus on? • What medications / diseases do you focus on most often in college health pharmacy? • Chronic / maintenance • Acute • What conditions have the greatest consequences if students are not compliant / persistent? • Chronic • Acute

26. What can you do to improve adherence? • Collaborative actions with other services or academic programs. • Health center providers • Health educators • Health professional students • Use of technology • Your pharmacy management software system • Computer generated voice / text / e-mail messages

27. Questions? Discussion Contact Information: Benjamin F. Banahan III, PhD Center for Pharmaceutical Marketing and Management (phone) 662-915-5352 (e-mail) benb3@olemiss.edu