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The American Journal of Accountable Care December 2018
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The Cost of Not Taking Our Medicine: The Complex Causes and Effects of Low Medication Adherence
Ellen Harrison, MBA, RN, vice president, HMS
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The Cost of Not Taking Our Medicine: The Complex Causes and Effects of Low Medication Adherence

Ellen Harrison, MBA, RN, vice president, HMS
Actions by providers, health plans, and healthcare consumers can substantially improve surprisingly low medication adherence rates in the United States and overall population health.
The American Journal of Accountable Care. 2018;6(4):e11-e13
Whether it is for a short-term illness or to manage a chronic condition, taking the medicine we have been prescribed seems like a straightforward course of action to improve or manage our health. Yet, medication adherence in the United States is surprisingly low. One study confirms that up to half of all prescribed medications are not taken as prescribed and some 20% to 30% of all persistent medication prescriptions are never filled.1

Fortunately, there are actions the healthcare industry can take to substantially improve medication adherence rates and, consequently, the health of the population. Providers, health plans, and healthcare consumers all play a role.

Clinical and research communities agree that improved adherence to medication regimens would reduce the progression of chronic disease and decrease unnecessary hospitalizations.2,3 These benefits (as shown in Figure 14-8) also translate into a reduction in the cost of healthcare to those with chronic diseases. Poor adherence, on the other hand, puts patients with chronic disease at serious risk of disastrous and sometimes irreparable health decline.

What’s Driving the Problem? The Complexity of Medication Adherence

It is very common to explain nonadherence by putting it down to forgetfulness. It seems logical that someone who is ill may also experience related confusion and memory impairment or have other health issues that affect memory and judgment. However, simple forgetfulness explains just a portion of the actual occurrence of low adherence and nonadherence. In reality, the multitude of factors affecting a patient’s ability and desire to take their medications cover a wide gamut, including health status, social and economic factors, and health literacy. The presence of 1 or any combination of these factors can create a disruption in care and treatment.

Unraveling the Web of Causes and Drivers

Unfortunately, improving medication adherence is not as simple as ensuring certain basic factors are met, including health insurance coverage, a convenient network of pharmacies, regular refill reminders, and provider medication reviews. As shown in Figure 2, many of the influences that drive medication adherence are related to care pathways for disease management and coordination of care across multiple healthcare providers. The essential first step in a comprehensive medication adherence improvement program is understanding patient perspectives around poor adherence.

“Do I need this medication?” The adverse effects of medication, real or perceived, can often result in early termination of treatment. In some instances, diseases exhibit few symptoms or symptoms are alleviated at the initiation of treatment; thus, patients might assume that they are better and no longer need the medication. Patient polls conducted by the National Community Pharmacists Association reveal that other common reasons for self-termination of treatment include lack of patient understanding of the therapy or their health condition and a lack of connection with their healthcare provider. Patients who report seeing the same provider consistently report a higher likelihood of continued use of prescribed medications, which is perhaps a measure of trust.9

“It’s beyond my control.” Involuntary nonadherence or termination of treatment often results when barriers occur, including cognition issues, health deterioration, medication therapy changes, and, in some instances, conflicting posthospitalization discharge instructions.

Several drivers affect patient access to medication and treatment, including lack of social support, affordability of prescription medication, and the patient’s perceived need for treatment. Many at-risk patients with multiple chronic comorbidities require multiple prescriptions and complicated treatment regimens. Adherence challenges can result from fragmented care, poor care coordination, and lack of communication by patients and among healthcare providers.

Low health literacy. A major deterrent to medication adherence is a lack of health literacy. About 8 of 10 patients have below-average health literacy, meaning they have limited understanding of common health terms, a poor understanding of the potential complications of their health conditions, and a limited capacity to discuss care and treatments with providers. Patients with low health literacy have been linked to poor health outcomes and higher rates of hospitalization, and they are less likely to seek preventive services.10

Low health literacy can also mean an inability to read and comprehend prescription dosing instructions. Reading a prescription label can be challenging and stressful. Medication labeling is inconsistent and further complicates patient understanding. For example, prescription labeling can vary widely: “take with food,” “take before eating,” “take with meals,” and “take on a full stomach” all mean the same thing, but does the layperson comprehend these variations? Patients of lower socioeconomic status and the elderly are more likely to exhibit lower health literacy. These same populations often have a higher prevalence of chronic conditions requiring persistent medications.

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