Improving Adherence – What Will It Take to Really Move the Dial?

By | October 25, 2013

Many recommendations for improving adherence focus on ‘policy’. But are these aimed at the healthcare providers (HCPs) who can make a day-to-day difference? Here are some thoughts on practical approaches that could make big advances in adherence.

Need for Practical Approaches to Improving Adherence

Numerous healthcare-related bodies have issued numerous reports on ‘policy recommendations’ for improving adherence. They are great documents and they contain many good ideas. However, I can’t help thinking there’s a burning need for more pragmatic approaches to the problem.

For example, something that suggests how busy HCPs can build better adherence practices into their daily activities. And also underlines why this is an important thing to do.

A document that takes a practical Why? What? Who? When? Where? And How? approach.

Payers and pharmacists are already very committed adherence improvements. So the suggestions below are more targeted towards physicians, where greater work is needed to get improvements in adherence really moving (see here).

To better set the scene though, here’s an extract from a recent article in Health Affairs (see here):

  • On Capitol Hill and among private payers the case can be made that better use of medicines and improved patient adherence are a pathway to better patient outcomes and appropriate cost control
  • Health care providers need to manage medicines well and improve adherence in order to achieve a new standard of performance (Total Medical Expenditure)

These are strong statements. Statements that reinforce the urgent need to get improving adherence moved higher up the healthcare agenda!

Activating Physicians on Adherence

Many of the 600,000+ physicians in the U.S. are currently ‘spectators’ on the issue of adherence. As the second largest group of HCPs (after nurses), this cannot continue. Without physician support, moving the dial on improving adherence will be significantly more difficult.

There's an urgent need for physicians to become more energized about improving adherence. Without strong MD support, advancing adherence will be difficult.There’s an urgent need to activate physicians, so they adopt adherence-supportive behaviors. However, they are currently ill-prepared to take on this challenge (see here). So here are a few ways to get physicians more energized about adherence:

  1. Payers and provider groups must establish improving adherence as a ‘clear-and-necessary’ physician priority. They should also stress that improving adherence is a critical stepping stone to achieve quality (outcomes) and cost-containment performance measures.
  2. Payers and provider groups must further support physicians by allowing them more time to devote to adherence activities. Perhaps reducing physician administrative duties might be a way of achieving this?
  3. Performance-based incentive payments must be a higher percentage of physicians’ remuneration. To emphasize the importance of better quality and better adherence, these incentive percentages have to be meaningful.
  4. Adherence must be a primary focus for physician training programs (particularly CME). Physicians need to be better informed about adherence matters. They also must be better skilled at assessing patient adherence behaviors and at engaging patients to improve these behaviors.
  5. A practical blueprint for ‘How Physicians Can Improve Adherence’ must be developed. This blueprint should set out:
      • Why adherence is an important factor for achieving quality and cost-containment performance goals
      • Clear, practical steps for integrating good adherence behaviors into physician practices
      • The roles that various practice staff can play to help introduce these adherence-supportive behaviors
      • Measures that can track progress towards inclusion of these new adherence-supportive behaviors into daily practice routines
      • A list of tools and resources that are available to support the blueprint
  6. Physician associations must show leadership and must more strongly advocate the need for a stronger focus on adherence. Currently such leadership is largely absent.
  7. Adherence training must be included into residency programs. This will further underline the importance of adherence to quality care. It will also provide a future flow of “adherence-enabled” physicians into the workplace to drive implementation of local actions.
  8. Lastly, but by no means least, there must be better care coordination and information sharing between physicians and other HCP groups. Through communication and shared information, different HCPs treating the same patient will be better informed. They can then better support that patient’s adherence plans and behaviors.

Implementation Anyone?

Hopefully there are a few decent thoughts here. But they’re still a long step away from moving any dial.

So what are the best routes to put these thoughts into action? Ideas anyone?

3 thoughts on “Improving Adherence – What Will It Take to Really Move the Dial?

  1. AudibleRx

    I just recently found your blog and I find it a fantastic inspiration! Thanks for taking the time to bring all of the avenues for adherence into one location. You bring a very “hands on” practical approach to the situation.

    Yes, physicians participating in the adherence equation will definitely help. As a practicing community pharmacist, I encounter quite a few physicians (especially psychiatrists) who are intimately involved with how frequently patients are receiving their refills. Regularly the physician will only provide 2 or 3 months’ worth of refills so that they may be reminded when the patient needs a refill. This prompts them to check their records and make sure the patient is on time. If there is a discrepancy, the physician then requires an office visit. The physician may not even realize it; however, they are actively participating in a medication adherence program.

    I have chosen to participate in the area of Health Literacy as my niche of helping to increase adherence. With over 72% of all patients taking prescription medications having some sort of health literacy limitation, there is definitely a need for greater education. Patients who understand their medication therapy are more likely to participate in their pharmaceutical care.

    The process of health literacy and #meded begins when the patient sees their physician. This process then continues through to the pharmacy when the patient picks up their prescriptions and HOPEFULLY receives a full consultation with their community pharmacist. When the patient gets home and has their medication in front of them is where “the rubber meets the road”. Patients then need some sort of follow up form of medication education to enhance their Health Literacy and enable them to call their health care providers with educated questions about their therapy.

    There are multiple ways to receive medication education.
    Medication education requires a full team approach, including the physician, pharmacist, family, caregiver and patient. Everyone needs to take some of the responsibility.

    Thanks for all your great articles!
    Steve Leuck, Pharm.D.

    1. Steve Morris Post author

      Hi Steve, Thanks for the encouragement! Bringing all the adherence threads together in a practical way is exactly the vision that motivated me to start Adherence360. So it’s good to get your reinforcement.

      Interested in your comment that doctors follow up on refill frequency. This again seems a very ‘practical’ thing to do. Do other pharmacist colleagues find the same thing? I guess too that psychiatrists are more conditioned to think about adherence as depression and psychotic disorders are factors for nonadherence?

      1. AudibleRx

        Steve, I am not quite sure how it happens at the Big Box store level; however, I am in a small clinic pharmacy so I am regualrly involved in the refill process. When patients are just starting out on new medications I find it fairly regular that physicians will only prescribe 2 or 3 refills, with the idea that the pharmacy will need to call for refill authorization in a couple months. After multiple discussions with physicians, this is one way to assure that the patient is actually taking their medications. And yes, psychiatrists, in my community, are much more aware of their patients adherence than any other specialty.
        Keep up the good work.

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