How to Increase Medication Adherence

by Jim Mizner, MBA, BS, RPh

Have you ever received a refill request from a patient for a refill for a maintenance medication for a chronic condition such as hypertension, diabetes, or hypothyroidism?

When you check the patient’s refill history, you observe they are 30 days past due for the refill, and it isn’t just for one medication but multiple medications. As a pharmacist working in a clinic in the Washington, DC metropolitan area, there is hardly a day that goes by where I don’t encounter numerous refill requests whereby the patient appears not to be taking their medication as prescribed by their physician or healthcare provider. Do you experience this in your pharmacy?

Before we discuss the factors affecting an individual’s adherence to their medication regimen and what we can do to improve their adherence, we must define medication adherence. Adherence is the extent to which a patient’s behavior follows clinical findings jointly agreed upon by the patient and provider. The American Medical Association (AMA) considers a patient as being adherent if they take 80 percent of their prescribed medicine(s) while taking less than 80 percent of their prescribed medication(s), classifies them as being nonadherent. There are four types of non-adherence: primary non-adherence, secondary non-adherence, intentional non-adherence, and unintentional non-adherence:

• Primary non-adherence occurs when a new medication is prescribed for a patient. Still, the patient does not get the medication for a reasonable time after it was prescribed.
• Secondary non-adherence happens when a patient fills a prescription but does not take the medication as it was prescribed.
• Intentional non-adherence occurs when the patient decides to deviate from the treatment regimen.
• Unintentional non-adherence happens when the patient may be forgetful or careless about following their medication regimen.

As pharmacy technicians and pharmacists, we see the high prices associated with prescription medications. For example, the price of Jardiance 10 mg, which is indicated for diabetes mellitus type 2 and heart failure. According to GoodRx, the price is $569/month.  Although many patients have prescription drug coverage, some plans may charge a higher co-pay for this medication. However, many patients lack prescription drug insurance and are faced with a dilemma. When a patient does not have drug coverage, the patient may opt not to purchase their prescription or administer it differently than was prescribed. So how would you assist this patient? Several options are available, and they include:

• Contact the doctor to see if a generic exists. In the case of Jardiance, a generic is not currently available.
• Call the doctor to see if a less expensive medication could be prescribed.
• Determine if a drug coupon or drug savings card is available from the drug manufacturer. In the case of Jardiance, a drug savings card is available and can be used with prescription drug insurance.
•   Determine if the patient qualifies for a patient assistance program (PAP). A PAP is a program to help people with no health insurance and those who are underinsured afford medications. A PAP is managed by pharmaceutical companies, nonprofits, and government agencies. PAPs may cover the full cost of medications or provide a discount. In the example provided, a PAP covers Jardiance.

As healthcare providers, we encounter a variety of patients from many different backgrounds every day. Many of our patients possess low health literacy, which refers to the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Health literacy requires a patient to be able to read, listen, communicate and comprehend to follow their medication regimen. Patients with low health literacy skills may lack the ability to learn about their illness, impacting their adherence. How often have you asked a patient to fill out forms, and they have not filled them out completely? Or they refer to their medication by its shape or color (e.g., it’s a little white pill). Or they bring their child with them to pick to interpret what you are saying to them. These actions may indicate the patient’s lack of health literacy. How would you help a patient with low health literacy? You could:

• Speak with patients using plain language (e.g., no medical jargon)
• Employ individuals who are multilingual who can translate when you are counseling the patient
• Using pictograms on the prescription bottle
• Allow the patient to ask question

Polypharmacy can affect a patient’s medication adherence. Polypharmacy is defined as the regular use of at least five medications. It is common in older adults and at-risk populations. Risk factors associated with polypharmacy include:

• Patient’s age
• Multiple medical conditions are being managed, and my multiple physicians
• Having chronic mental health conditions
• Filling prescriptions at multiple pharmacies
  
  

Polypharmacy may increase adverse drug effects and drug interactions. Additional medications may be prescribed to treat these adverse drug effects. As pharmacy healthcare providers, we should:Perform medication reconciliation for each patient

• Inquire about over-the-counter-medications and herbal supplements they are taking
• Identify drug interactions
• Educate the patient and caregiver regarding safe medication
• Encourage the patient to fill all their prescriptions at one pharmacy
• Discourage the use of self-medicating with nonprescription/herbal supplements without their physician’s advice

As part of the pharmacy team, you have the opportunity to assist the patient in adhering to their medication regimen. This can be accomplished by educating the patient on taking their medication as prescribed and providing them with the appropriate resources to adhere to their medication regimen.