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Jan D. Hirsch, BSPharm, PhD, and Candis M. Morello, PharmD, CDE
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Strategies for Addressing the Cost of Nonadherence in Diabetes
Candis M. Morello, PharmD, CDE, and Jan D. Hirsch, BSPharm, PhD
Utilizing Advances in Diabetes and Targeting Medication Adherence to Enhance Clinical Outcomes and Manage Costs for Type 2 Diabetes Posttest

Strategies for Addressing the Cost of Nonadherence in Diabetes

Candis M. Morello, PharmD, CDE, and Jan D. Hirsch, BSPharm, PhD
Overcoming Barriers to Adherence
In most cases, nonadherence results from a culmination of factors rather than 1 isolated barrier or behavior. However, patient-related barriers are the most common causes of nonadherence. A recent meta-analysis of systematic reviews showed that a patient’s level of education tends to be related to the patient’s beliefs about their condition and treatment.10 Lack of knowledge about the disease and treatment was shown to be associated with poor patient motivation, which was linked with poor medication adherence. Similarly, the number of comorbidities tends to increase with age.10 Nonadherence has many possible determinants and barriers, such that eliminating a single barrier may not have a significant impact on adherence.2 Therefore, improvement in adherence may require multiple points of action combined to create programs based on individual need.

One of the most significant barriers to medication access for patients is cost. One method to improve the affordability of medications is to reduce co-payments for expensive diabetes medications that are proven to improve clinical outcomes and patient adherence. One study evaluating the impact of value-based benefit design on adherence to diabetes medications found that a 36.1% reduction in co-pay reduced the number of nonadherent patients by 30%.22 Although this would shift the cost of medications from the patient to the managed care organization (MCO), the MCO can benefit from reduced hospitalization costs.

Data from a 2013 National Health Interview Survey found that 14% of adults with diabetes who participated in the survey reported cost-related nonadherence (CRN).23 The likelihood of CRN increased with greater perceived financial stress and financial insecurity with healthcare. Proactively discussing the cost of treatment and offering lower-cost options may be 1 way that prescribers and pharmacists can improve adherence to treatment. Prescriber and patient awareness of each patient’s formulary coverage for medications is critical to optimize the cost of a patient’s medication regimen. Recognizing that diabetes medications often represent only a portion of the patient’s total medication regimen is also important. A study comparing medication regimen complexity of 4 common chronic disease cohorts found the diabetes cohort was using a mean of 10.4 total medications per patient, with only a mean of 1.9 medications being for diabetes; almost half of the cohort was using more than 11 total medications.24 Offering assistance with preapprovals, prior authorizations, or enrollment in savings programs offered by pharmaceutical companies may also help patients limit their out-of-pocket expenses.

Patient Education
Educating patients about their medical condition and treatment are key to changing attitudes toward adherence. Patient education, including comprehensive medication reviews as part of MTM, can empower patients and improve treatment adherence.

During the patient education process, clinicians should identify and address underlying psychological issues that pose potential barriers to adherence. These can include anxiety, depression, and eating disorders, which have all been shown to lower rates of treatment adherence.25 Referrals to appropriate programs or clinicians for more in-depth education for problem areas can be key. The goal of a patient education program should be to alter patient behavior in a manner that promotes healthy lifestyle choices, disease self-management, and prevention of diabetes complications. Part of the program should be identification of self-management problems, and subsequent development of strategies to solve those problems.3

Patient beliefs and attitudes toward their diabetes and its treatments also influence adherence rates.26 A positive perception of the benefits of medications is positively and strongly associated with the intention of treatment adherence.15 A recent study of older adults found that 41% of the adults reported at least 1 nonadherence behavior, with a strong relationship between low perceived benefit of medications and nonadherence.27 A survey of patients with diabetes and caregivers attending a large diabetes education conference revealed that the most frequently reported helpful methods for improving medication adherence were taking medications as part of a daily routine and using pill boxes.28 The most commonly identified motivating factors to improve adherence were knowing that diabetes medications work effectively to lower blood glucose, knowing how to manage adverse effects from medication, and understanding medication benefits.28

While many patient barriers to treatment, such as socioeconomic status or age, cannot be easily addressed by healthcare professionals, interventions designed to improve adherence must have a patient-centered approach that focuses on individual barriers to adherence. Open communication and increased patient knowledge may help overcome barriers, such as cultural beliefs or perceived treatment risk/benefit, and improve self-management behaviors.25

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