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Patient Non-Compliance With Medications. 3 rd Year Research Project Class of 2007. Introduction. Medication non-compliance …..the world’s “ other drug problem” 4. Medication Non-Compliance. As dangerous and costly as many illnesses

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patient non compliance with medications

Patient Non-Compliance With Medications

3rd Year Research Project

Class of 2007

introduction
Introduction
  • Medication non-compliance

…..the world’s “other drug problem”4

medication non compliance
Medication Non-Compliance
  • As dangerous and costly as many illnesses
  • Increases the cost of healthcare as a result of adverse outcomes4

(i.e. hospitalizations, development of additional illnesses/complications, exacerbation of the disease or disease progression, premature disability, or death)

medication non compliance4
Medication Non-Compliance
  • In the United States, 50-70% of patients do not properly take their medications5
  • Costs of patient non-compliance are estimated at over $100 billion annually5
definition
Definition

Compliance, simply defined as “agreement.” With regard to medicine, compliance means agreeing to take medicine(s) as directed, and then following through with that agreement…..accepting the responsibility of taking medicine(s) as agreed8

definition6
Definition

Adherence is defined as the extent to which a patient’s health behavior coincides with their physician’s recommendations, whether taking medications or following advice for some type of behavioral change

adherence vs compliance
Adherence vs. Compliance
  • Adherence is a more accurate term than compliance
  • Compliance suggests a process in which dutiful patients passively follow the advice of their physicians
  • Adherence, in contrast, better fits how most patients actively participate in their care and decide for themselves when and whether to follow their doctor’s advice
background research
Background Research
  • Multiple studies done looking at adherence to medication and recommended interventions to improve compliance
  • Typical adherence rates for prescribed medications are about 50% with a range from 0% to 100%1
  • Adherence greater during first 6 months of follow up and drops thereafter1
  • Chronic and asymptomatic disease have lower adherence rates than acute ones1
recent studies
Recent Studies
  • Primary Medication Adherence in a Rural Population:

The Role of the Patient-Physician Relationship and Satisfaction with Care

(Thomas H. Wroth, MD, MPH and Donald E. Pathman, MD, MPH )

– Prescription primary non-adherence is prevalent in the rural South. Adherence may be improved by remedying patient dissatisfaction and lack of confidence in their physicians as well as addressing transportation barriers

recent studies10
Recent Studies
  • Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure, and Low-Density Lipoprotein Cholesterol

– A pharmacy care program led to increasesin medication adherence, medication persistence, andclinically meaningful reductions in BP, whereasdiscontinuation of the program was associated withdecreased medication adherence and persistence

background research11
Background Research
  • Although correlates of overall medication adherence have been studied, little is known about primary medication non-adherence and whether it relates to how patients view their physician, satisfaction with their care, and how easy or difficult it is for them to travel for care
hypothesis
Hypothesis
  • Patient non-adherence with medications can be attributed to 4 key reasons:
    • Language Barrier
    • Low Education Level
    • Poor doctor-patient interaction
    • System related obstacles
objectives
Objectives
  • To evaluate if language barriers interfere with patient adherence with medications
  • To discover if low literacy has an impact on patient adherence
  • To assess if doctor-patient interaction has an effect on patient adherence
  • To find if there are system-based factors that interfere with patient adherence
purpose of our study
Purpose Of Our Study

To identify the factors that contribute to patient non-adherence with medications in an effort to optimize patient care and reduce morbidity and mortality

methods
Methods
  • 3-page survey constructed with questions written at 8th grade level in both English and Spanish
  • Questionnaires written in Spanish were reviewed by certified interpreters to check for accuracy
  • Each Resident was assigned with the task of completing a minimum of 30 surveys
methods16
Methods
  • Questionnaires were given to “eligible” patients upon registration for a clinic visit
  • Some Residents surveyed their assigned patients once they entered the patient’s room
  • Eligibility determined by inclusion and exclusion criteria*
inclusion exclusion criteria
Inclusion

Both genders

All Ethnicities

Age 18 years old

Taking  1 prescription medication not under the exclusion criteria*

Registered as FCC patient for > 1 year

Last visit to FCC w/in 6 months

*special inclusion for ASA for cardiovascular risk prevention and calcium with vitamin D for postmenopausal women not on HRT

Exclusion

Age < 18 years old

Pts. with dementia or cognitive impairment requiring assistance or special needs

FCC patient for < 1 yr.

Last visit to FCC > 6 m.

Any medication(s) not taken on a scheduled basis

OTC meds

NSAIDs

Narcotics

Inclusion/Exclusion Criteria
methods18
Methods
  • Patients allowed as much time as needed to complete surveys, and able to use medication bottles/lists for assistance
  • Physicians reviewed surveys upon completion to verify accuracy and make any necessary clarifications during patient interview
  • Questionnaires valid once signed by physician
methods19
Methods
  • Data compiled to see:
    • What percentage of patients know the medications they are taking and for what reason
    • What patients do when they run out of their medication
    • What reason(s) patients give for not taking their medication as prescribed
methods20
Methods
  • Data collected used to identify the specific individual-based obstacles as well as system-based obstacles involved in medication adherence
methods21
Methods
  • Identify problematic areas as defined by our patient population
  • Implement strategies in FCC to improve medication adherence and standard of care
survey
Survey

1. Circle your gender:

Female Male

2. Circle your ethnicity (optional)

Caucasian Hispanic Africanamerican Asian Philipino American-Indian Other

3. Circle the language or languages that you speak:

English Spanish English and Spanish other

4. How old are you? (Circle the one that apply)

18-30 31-45 46-65 65 or more

survey23
Survey

5. How long have you been a patient in Family Care Clinic?

1-3 years 3-6 years more than 6 years

6. What is your education level? (Circle the one that applies better to you)

A. Don’t know how to read

B. Can read with difficulty

C. Can read very well

D. Finish elementary school

E. Finish High school

F. More than high school

survey24
Survey

7. What kind of insurance do you have?

MISP MEDICAL MEDICARE IEHP Exclusive Care MOLINA Self Paid Pending

8. Do you know the medications you are taking? Yes No

9. Do you have the mediations with you?

Yes No

10. Can you name them? Yes No

11. Do you know what the medications you are taking are for? Yes No

12. How many medications are you taking?

13. How many times a day do you have take your medicines?

survey25
Survey

14. Where do you get your medications?

RCRMC Other Pharmacy

15.What do you do when you run out of medication? (Circle what happens most often)

A. Call the pharmacy

B. Call the doctor’s office

C. Call the special line to refill medications

D. Go to the emergency room

E. Stop taking the medication

survey26
Survey

16.What are the reason(s) that you run out of medication? (you can choose more than one)

[If you choose more than one, please put* next to the most common reason]

  • A.     Pharmacy lost the prescription
  • B.     Language problem in communication with Pharmacy . If yes was an interpreter available Yes No
  • C.     Medications needs TAR form to be filled by the doctor
  • D.     Didn’t have the copayment to pay medications
  • E.      Pharmacy was closed when trying to get prescriptions
  • F.      Pharmacy was to slow and left without getting the prescriptions
  • G.     Didn’t have doctor’s license number in prescription when trying to get prescriptions outside the hospital
  • H.     Hard time getting transportation to pharmacy
  • I.        Finish medications earlier than the next doctor’s appointment
  • J.       Waiting for doctor’s office to refill medication
survey27
Survey

17. Did you know there is a special phone line to refill your prescriptions over the phone

Yes No

18. If yes Have you ever use it? Yes No

If yes, were you able to refill your medications through it? Yes No

If Not, you couldn’t do it because:

A. Didn’t understand how to use it?

B. Line was too busy most of the time and couldn’t get through it

C. Unable to spell the name of your medication

D. Left message over the phone but didn’t get a call from the Dr. telling you that your prescriptions were ready.

survey28
Survey

19. Reasons why you don’t take your medications as prescribed: (Circle all the reasons that apply to you)

  • A. Forget to take it
  • B. Confusion as to what medication to take and when
  • C.  Fear of side effects
  • D. Don’t know what the medications you are taking are for
  • E. Feel depressed or sad and don’t feel like taking the medicines
  • F. Disorganization, lose medications can’t find where are they
survey29
Survey

20. What motivates you the most to take your medications? (Circle all that apply)

Put * next to the main reason

  • A. The doctor during the visit
  • B. The nurses
  • C. Myself
  • D. My family
  • E.  Friends

F.  Other

21. Please write down any suggestions to improve your own compliance with your medications

answer rate
Answer Rate

-TOTAL OF PATIENTS INTERVIEWED→ 296

-NOT ALL PATIENTS ANSWERED ALL THE QUESTIONS

-OF 21 QUESTIONS 13 (62%), WERE ANSWERED BY MORE THAN 290 PATIENTS

-6 (23%) QUESTIONS WERE ANSWERED FOR AT LEAST MORE THAN 250 PATIENTS, MOST OF THESE QUESTIONS WERE REGARDING

KNOWLEDGE OF MEDICATIONS BEING TAKEN

conclusion
Conclusion

Medication Non-Adherence isMultifactorial

prerequisites to adherence 6
Prerequisites to Adherence6
  • Demographics
  • Psychosocial & Behavioral Characteristics
  • Medication Characteristics
  • Healthcare Delivery System Characteristics
demographic variables
Demographic Variables
  • Age
  • Socio-economic status of the patients
    • e.g. unstable living quarters, limited access to healthcare facilities, burdensome schedules, language barrier, limited level of education, lack of financial resources to pay for medications
psychosocial behavioral characteristics
Psychosocial & Behavioral Characteristics
  • Patients’ medication-taking behavior
  • Patients’ beliefs about and attitudes towards their disease
    • More likely to be compliant if they feel threatened by their disease, or if they believe their medication will actually cure or control the disease
medication characteristics
Medication Characteristics
  • Complexity of the regimen
  • Effects of the regimen
characteristics associated with decreased compliance 7
Characteristics Associated with Decreased Compliance7
  • >4 meds
  • More frequent daily doses
  • Patient confusion re: med regimen
  • Patients’ belief that they cannot follow the regimen
  • Fear of side effects
healthcare delivery system characteristics
Healthcare Delivery System Characteristics
  • System-related obstacles
    • Pharmacy waiting time, difficulty obtaining medication refills, insurance complications
  • Lack of knowledge and understanding of their disease state and regimen
    • Relationship between the patient and the healthcare provider
system related obstacles
System-Related Obstacles
  • #1 concern: Pharmacy
  • Only 2.3% of those surveyed, claimed to have never run out of medications!

…..so what about the other 97.7% of patients who do run out of medications?

system related obstacles cont d
System-Related Obstacles Cont’d
  • 13% simply stop taking the medication or go to the ER
  • 14% use the Prescription Refill Line
  • 21% call their Doctor
  • 44% call the Pharmacy
slide63

Knowledge of Prescription Refill Line

YES NO

56% 44%

Used ItDidn’t Use

57% 43% Didn’t Know ??????

How ????

4% 96%

pharmacy
Pharmacy
  • Most popular method of refilling medications, and yet:
    • Language problems when communicating w/ Pharmacy staff
    • Medication Tars
    • Pharmacy hours too limited
    • Too long of a wait, patients unable to wait
  • 36% of patients had these specific pharmacy complaints
physician patient relationship
Physician-Patient Relationship
  • Nearly 70% of patients cited themselves as the motivating factor in adhering to medication regimens
  • What does this mean?

Patient education is a must! It’s our duty as physicians to explain medical conditions, treatment options, prognosis in terms that the patient can understand

strengths weaknesses
Strengths

Non-Bias

Willingness of Physicians Involved

Good Sample Size

Thoroughness

Applicable to RCRMC Patient Population

Weaknesses

Human error

Length of Survey

Language Barrier

Selection Bias

Strengths/Weaknesses
recommendations system based obstacles
Recommendations – System Based Obstacles
  • Medication Card
  • Upon registration, the patient will be given a medication card at the front desk (unless the patient has an old card)
  • Patient will first attempt to fill out the card in the waiting room
  • Nurse will review the card and verify the medications by the bottles and note from previous visit
  • Physician will do the final review and completion of the card
recommendations system based obstacles68
Recommendations –System Based Obstacles
  • Write prescription on-line
  • Ex. www.assuredscript.com
  • Medications can be easily reviewed, and medication list can be printed out
  • Cost?
recommendations system based obstacles69
Recommendations –System Based Obstacles
  • Extend open hours for RCRMC Pharmacy
  • New outside county pharmacy for MISP patients
  • Write from the list of Walmart $5 prescription or Costco special price medications
recommendations system based obstacles70
Recommendations –System Based Obstacles
  • Stamp the refill line number on the appointment card
  • Post refill line number on the door inside the room
  • Email address for pharmacy refill
  • Easier access of medication profile inside the hospital computer system
recommendations language barrier
Recommendations –Language Barrier
  • One full time Spanish interpreter for pharmacy
  • Interpreter phone at pharmacy
recommendations doctor patient interaction
Recommendations –Doctor-Patient Interaction

Strategies for increasing adherence3:

  • Provide rationale for tx. in patient’s language
  • Collaborate on tx. plan
  • Frequent follow-up
  • Positive reinforcement
  • Family counseling/therapy
recommendations doctor patient interaction73
Recommendations –Doctor-Patient Interaction
  • Doctor to prescribe more medication refills (ex. 6 refills for chronic meds)
  • Doctor to ask for side effect of medications at the start of the clinic visit
  • Doctor to ask if patient needs medication refill before next appointment
  • Doctor to remind patient at the end of every visit to take medications
recommendation front office patient interaction
Recommendation –Front Office-Patient Interaction
  • When the patient is called to confirm appointment, remind the patient to bring the bottles of their medications
references
References
  • “Interventions to Enhance Patient Adherence to Medication Prescriptions”; Clinician’s Corner
  • Up-To-Date: Adherence to Pharmacologic Therapy
  • “Adherence to Pharmacologic Therapy in Patients with Type 2 Diabetes Mellitus”; American Journal of Medicine; Vol. 118, May 2005
  • Zuger, Abigail. “The ‘Other’ Drug Problem: Forgetting to Take Them,” The New York Times, June 2:Section F, Page 1, Column 2, 1998
  • Santella, T., Wertheimer, A.. “Medication Compliance Research: Still So Far to Go,” The Journal of Applied Research; Vol. 33, 2001
  • Berger, Bruce. “Improving Treatment Adherence: A Motivational Interviewing Approach,” Walgreens.com, 2002
  • Claxton et al., “A Systematic Review of the Associations between Dose Regimens and Medication Compliance,” Clinical Therapeutics, 23 (8): 1296-1310, August 2001.
  • http://www.innoviant.com/members/mempub/WhatisCompliance.pdf