Monthly Archives: September 2013

Interesting New Study on Classifying Non-adherence

News & Comment about medication adherence

New ways of describing adherence behavior types may allow better prediction and management of non-adherence.

Commitments to Reduce Non-adherence

CVS Caremark is probably best known as one of the largest U.S. pharmacy groups. What may be less well-known are its strong commitments to improve medication adherence. Commitments that include research partnerships with leading academic and hospital centers, like Harvard, Brigham and Women’s Hospital, and University of Pennsylvania.

A list of 29 adherence-related publications from these partnerships can be found here. Of particular interest for this post, a 30th paper from these research efforts was published earlier this month.

New Insights into Non-adherence Patient Types

The new publication in question can be found here.

To date, descriptions of adherence-related behavior types have been inexact. This is largely because the most common adherence measure – proportion of days covered (PDC) – is unable to distinguish between different patient situations. For instance, the same PDC value may apply to three patients who – over the same period of time – have very different behaviors, eg:

  • Patient #1 adheres early, but later shows non-adherence
  • Patient #2 is non-adherent early, but later shows adherence
  • Patient #3 shows ‘on/off’ adherence and non-adherence over the period

This latest study uses new methods to help identify different adherence behavior types. Defining these behaviors is important as different solutions to overcome non-adherence may apply to each behavior type.

In the study, nearly 265,000 patients receiving statin medications were followed for 15 months. Results from the study described six distinct behaviors. These are listed below, together with the percentage of patients that fell into each category.

  1. Patients that were nearly always adherent (23.4%)
  2. Patients that showed non-adherence early, then adhered later (11.4%)
  3. Patients whose adherence declined slowly over the study period (11.3%)
  4. Patients who only took the medication occasionally throughout (15.0%)
  5. Patients whose adherence declined rapidly right from the start (19.3%)
  6. Patients that had no refills after the initial prescription (23.4%)


Up to now a general figure of ‘50% non-adherence’ to chronic medications has commonly been used. These new data give deeper insights into the issue of non-adherence, suggesting multiple distinct patient behaviors types.

There are marked differences between the six identified behaviors. So it’s not unreasonable to think these behaviors may be driven by equally different underlying reasons for non-adherence. And if there are different underlying reasons, it’s also not unreasonable to imagine that separate interventions will be needed to address these different reasons.

Key steps to improve medication adherence.

Suggested key steps to improve medication adherence.

While the study provides interesting new insights, it sheds light on only a part of the overall problem. Identifying and classifying non-adherence is a critical first step. Beyond that, it will be just as important to investigate and understand the reasons why patients show these behaviors. And lastly, healthcare professionals need effective solutions that specifically align with each reason; plus the time to implement these solutions properly.

What are your thoughts on these new findings?

Who Will Lead Initiatives to Improve Adherence?

To improve adherence will require healthcare organizations to change the way they work. Such a change may be slow to occur, or may be stalled, when individuals don’t adopt the behavioral shifts needed to make the new approach successful.

How important is the role of leadership in making such healthcare changes happen? A recent study suggests the answer is “very important”!

Behavioral change is critical to improve adherence to medications.

Importance of Change Leadership

The study explored how three factors affected physicians support for a major change within a large healthcare organization. The new approach required changes to the nature of the interactions between patients and their physicians. The three factors were:

  • Team members’ agreement with the new approach
  • Team leadership and their support for the change
  • Team members’ readiness to adopt change

The authors concluded that leadership plays a major role. Indeed, in most situations where a significant change to everyday practices is undertaken, the strength of leadership will have a significant impact on its success or failure.

In this study, the team leaders were physicians. To improve adherence however, who will be the leaders? Who drive adoption of new practices and help ensure these practices are effectively implemented? Who will set examples that will influence others to follow?

Setting examples has strong leadership influence on others.

Leadership of Initiatives to Improve Adherence

Non-adherence to prescribed medication affects many aspects of healthcare systems. However, the fragmented nature of U.S. healthcare complicates the leadership question. For example healthcare professionals within the same system or institution may serve different masters.

At the moment, there’s no immediate, clear-cut answer to the question of who will drive initiatives to improve adherence. At first pass, four groups stand out as candidates for the role – either individually or collectively:

  1. Physicians are trusted by patients. They have regular contact with patients treated for chronic illnesses and have responsibility for appropriateness and quality of care. Expected treatment outcomes can only occur when medications are taken as instructed. So physicians should have a strong vested interest in improving adherence.
  2. Pharmacists also have regular contact with many patients and are a trusted source of advice. They have a clear role in assessing a patient’s medication management; to ensure safe and effective use. Assessment of adherence can readily be a part of this assessment. Pharmacists’ role in promoting medication adherence is strongly advocated by professional pharmacy bodies.
  3. Payers and Provider Groups both have leadership roles in ensuring that physicians and pharmacists are appropriately incentivized to address medication adherence challenges. Evidence for the relationships between improved adherence, reduced healthcare use, and better outcomes is strong. By investing a portion of projected savings to motivate physicians to more actively address the topic, medication adherence can be significantly improved.
  4. Government has a leadership role on adherence too. Around 40% of National Health Consumption Expenditure costs are accounted for by Medicare or Medicaid, so it has direct interests in improving adherence. For 2013, five of the 18 individual measures in the Part D CMS star rating process are related to adherence; with 3%-to-5% ‘quality bonus payments’ paid to participating provider groups aligned with star ratings received (3-to-5).

Who Should Lead Adherence Changes?

Who, in your opinion, should step up and take leadership roles to improve adherence to medications?

If, as seems likely, system-wide solutions to improve adherence will need combined efforts between all these players; then what’s the forum that gets all these parties on the same page?

What are your thoughts on these questions?

Solutions to Medication Adherence Are Within Reach

Adherence360 strives to improve medication adherence by promoting broad-based, multidisciplinary thinking and discussion; based on 360-degree viewpoints.

Medication Adherence Is a Vital Healthcare Issue.

The bottom line for patients who do not take their medications as prescribed is clear. It results in poorer health, more visits to emergency departments, and more admissions to hospital. Use of these extra healthcare services also adds to costs. A recent estimate  puts those added costs at around $300 billion a year. That’s about 12% of current annual U.S. healthcare spend. These extra costs could be avoided with better medication adherence.

As a nation and as individuals we cannot ignore this. Significant improvements in adherence will help improve patient outcomes, help control rising healthcare spend, and help protect everyone’s wallets.

Improving medication adherence: scattered jigsaw pieces.Current Activities to Address the Problem Are Fragmented.

Improving adherence to medications is not a simple task. There are many different parts to the problem; many different interested parties; and many different possible answers. Throwing all this together, you currently get a messy, jumbled-up picture – just like the jigsaw pieces in the image to the left.

Here are a few examples to illustrate this point:

Information on adherence is scattered and disconnected The volume of information on medication adherence is truly impressive. However, it’s widely scattered and is often presented as individual, disconnected ‘nuggets’. This makes it difficult to pull together answers to key questions such as: which interventions work, and in what situations?

Many different reasons for non-adherence – Patients don’t take their medications as instructed for a large variety of reasons. Also individual patients’ reasons for non-adherence differ widely from one person to the next. There’s no simple ‘one-size-fits-all’ solution to improving adherence. To address each individual patient’s need will most likely require a mix of different answers.

Many different individual solutions – A variety of approaches to improving adherence have been studied. However, most have only been tested as individual, standalone solutions. It’s not clear how these individual answers will fit into the multi-component solutions that are needed.

Key healthcare professional groups aren’t thinking together about solutions – Different healthcare professional groups (eg, physicians, pharmacists, or payers) may provide different parts of multi-component solutions to medication adherence. These groups will therefore need to work together closely to create these integrated solutions. For the moment however, these groups appear to be operating independently, with only limited cross-group thinking.

Absence of leadership – There are no clear leaders of efforts to improve adherence. This lack of leadership and coordination contributes to fragmentation and inefficiencies.

Improving Medication Adherence_complete_08-25-13Adherence360 Advocates a Different Approach.

The idea for Adherence360 arose out of the need for more integrated approaches to solving medication adherence – like putting all the jigsaw pieces together to get a better picture.

Adherence360 aims to draw important strands together and help expedite creation of cohesive, comprehensive solutions. Through this approach readers will hopefully gain better insights into how the various moving parts can best be linked together to produce multi-component solutions. Solutions that both improve adherence and are customized to specific patient needs.

To achieve this, we’ll work to:

                  1. Look at the adherence problem from all sides, drawing on 360-degree viewpoints
                  2. Better link together the available ‘nuggets’ of information on adherence
                  3. Encourage collaborative, interdisciplinary thinking and discussion
                  4. Facilitate fresh ideas about how practical, multi-component solutions can be put together

Please join in! I very much welcome your inputs, comments, or suggestions on the general approach and on content.

If you would like to contribute a guest blog, that’s also very welcomed. Just contact me at