To speed up improvements in adherence, we need to focus on factors that most impact progress. But which are those factors? This post considers five potential blocks to improvement and assesses their relative effects.
Barriers to Improving Adherence
A previous post (see here) suggested five factors that may be slowing advances in medication adherence. These are:
- Maybe some key adherence information pieces are still missing?
- Perhaps there’s poor understanding among key healthcare providers (HCPs) of what they can do improve adherence?
- It could be a shortage of commitment or of training among HCPs?
- Or possibly insufficient commitment or support from healthcare systems?
- Or difficulties including adherence efforts and actions into the everyday practice of medicine?
Below we assess the extent to which these factors contribute to delayed adherence progress.
Lack of Adherence Information?
Assessment of this factor is relatively simple. We know the predictors of non-adherence. We have good insights into why patients don’t adhere. We have a number of interventions that have been successful in improving adherence. We even have suggestions for how interventions can be matched up with specific reasons for non-adherence; across nine chronic condition types. And based on the WHO 2003 Report (see here), we’ve had all this for 10 years or more.
Poor HCP Understanding of What They Can Do About Improving Adherence?
This seems to differ between the three main HCP groups.
Pharmacists have a clear role to be “responsible for providing patient care that ensures optimal medication therapy outcomes” (see here). Including adherence into medication management is a natural step. Pharmacists are also well-placed to recognize non-adherence (through refill information) and to counsel patients on adherence issues.
Payers understand their role in improving value of care (see here). They also recognize that better adherence improves patients’ health status. Plus, they have launched programs to enhance patient adherence (see here).
Physicians in ACOs or PCMHs probably place a higher priority on adherence, as it’s built into their quality measures. In general however, physicians don’t appear to place much emphasis on adherence (see here). This may reflect a less than full understanding of what they could (or should!) be doing.
Lack of Adherence Commitment or Training among HCPs?
Again, this varies by HCP group.
Pharmacists’ commitment to improving adherence is led by major pharmacy and PBM groups (eg, CVS Caremark, Walgreens, Express Scripts). Commitment to adherence is also strongly advocated by professional pharmacy associations (eg, NCPA, APhA, AACP, NACDS, NAPB). Pharmacist tools and training on medication management and adherence are available (eg, APhA certificate training), and several third-party companies provide adherence support to pharmacies.
Payers are committed to improving value of care, including better adherence. For example, many payers now offer value-based insurance design (VBID) (see here). VBID enables drug costs for patients to be reduced or eliminated as an incentive to improve adherence. Payers are also introducing payment-for-performance for hospitals and for physicians to increase the focus on better outcomes (see here).
Physicians – compared to pharmacists and payers, physicians have a low commitment to adherence. Physicians report a low sense of responsibility for adherence; seeing it as a patient problem (see here). Physicians also score poorly for key adherence-supportive behaviors; such as quality of communications (see here) and shared decision-making (see here). Physicians are poor at identifying non-adherence (see here). They generally have limited or no training on adherence-related topics (see here) and have few tools available to them.
Advocacy for adherence from professional physician organizations (eg, ACC, AHA, ADA) is either absent or only limited. Plus, physicians have made no clear attempts to ‘own’ elements of the adherence problem.
This sentence from a 2011 article in Mayo Clinic Proceedings sums things up:
Not only do physicians often fail to recognize medication non-adherence in their patients, they may also contribute to it by prescribing complex drug regimens, failing to explain the benefits and adverse effects of a medication effectively, and inadequately considering the financial burden to the patient.
Lack of Adherence Commitment or Support from the Healthcare System?
Once again this varies across HCP groups.
Pharmacy groups and professional organizations provide significant support and training for employees and members. Pharmacists are also reimbursed for carrying out medication management reviews with patients.
Payers are their own masters. They are testing new approaches (eg, ACOs, VBID, ‘gaming’) and quantifying impacts on adherence, value, and costs. Through these new approaches, payers are also directly influencing both physicians and pharmacists (eg, pay-for-performance programs).
Physicians on the other hand are largely left to fend for themselves. To support physicians, healthcare systems need to:
- Allow physicians the time to effectively engage patients on adherence topics (see here)
- Provide appropriate incentives for HCPs to adopt new behaviors (see here)
- Provide HCPs with appropriate adherence support and training (see here)
Sadly, the proposals below from the WHO Report in 2003 still hold true today:
Health providers can have a significant impact by assessing risk of non-adherence and delivering interventions to optimize adherence. To make this practice a reality, practitioners must have access to specific training in adherence management, and the systems in which they work must design and support delivery systems that respect this objective.
Difficulties Including Adherence Efforts into the Daily Practice of Medicine?
This is a likely physician sticking point for a number of reasons. For instance:
- There’s no single clear area for physicians to focus on where they can quickly improve adherence (unlike pharmacists and medication management)
- Improving adherence will require physicians to sharpen up their skills (eg, communication, engagement, shared decision-making)
- Physicians will need to create additional patient-facing time (eg, using nurses/NPs/PAs)
- There’s no simple plan available for how physicians should incorporate adherence into their daily practice routine
Maybe a ‘blueprint’ for successfully introducing better adherence management into physician practices might look something like this.
What do you think?