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Jan D. Hirsch, BSPharm, PhD, and Candis M. Morello, PharmD, CDE
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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
Provider-Based Support
Healthcare professionals can help improve patient adherence by reducing barriers to medication access, counseling patients on the importance of pharmacologic therapy, and directing patients toward tools to reduce forgetfulness. Many of the strategies aimed at improving treatment adherence in diabetes focus on using a multidisciplinary care team incorporated within the Chronic Care Model (Table 23).3,26

This approach may include individualized counseling sessions conducted by pharmacists or nurses.26 These models offer greater opportunity to provide patients with education regarding their condition and their treatment, as well as occasions for patients to ask questions and have their concerns heard. An online survey of 807 adults with diabetes found that adherent patients were more likely to have received information about their condition and/or treatment from their healthcare provider.29

Point-of-service counseling coupled with follow-up communication by an appointed healthcare professional may help improve adherence to treatment and ensure timely treatment initiation.30 In an intervention study, adherence and physician initiation of treatment increased (2.1% and 38%, respectively, compared with a control group) when patients received in-person counseling by a pharmacist.31 The pharmacist-led counseling included a follow-up call after each refill, a counseling session at the time of first treatment fill, information about treatment of known comorbid conditions, and an offer to discuss initiation of treatments needed with the patient’s physician. Furthermore, the interventions had a return on investment of approximately $3 for every $1 spent.31

Promotion of a more coordinated and systematic approach to medication management across providers and health systems has the potential to improve patient adherence and clinical outcomes on a wide scale. MTM programs provided through Medicare Part D plans, or broader comprehensive medication management programs that include elements of collaborative care and long-term follow-up, have been shown to improve adherence.32 A systematic review of MTM literature found medication appropriateness, adherence (measured either by doses taken or achieving a threshold percent adherence level that is disease-appropriate), and reduced medication dosing (reduced number of doses per day) were all significantly improved via MTM intervention in the studies included.33

Medication Support
Overcoming medication-related barriers to treatment includes helping patients remember to take medications, making treatment administration easier, reducing medication regimen complexity, and improving delivery systems.

Patients are very likely to forget to take medications or not follow instructions carefully. Various simple tools are available to help overcome the barrier of medication forgetfulness. These tools can include setting reminders for taking medications, using pill organizers or boxes, or encouraging manufacturers to place pills in blister packs. Many support programs offered by drug manufacturers and pharmacies include phone calls or text messages to remind patients to take their medications. Patients should also be encouraged to download apps for their smartphones that function as medication reminders.

An effective method for improving patient adherence is to encourage use of therapies that can reduce the complexity of a medication regimen, such as using combination agents or insulin pumps. Usage of insulin pens, or devices that help ease the burden or pain associated with insulin injections, may improve adherence in some patients.3,34-36

Insulin delivery systems have come a long way from the vial-and-syringe method of insulin delivery. They now include pens, pumps, inhaled devices, continuous glucose monitors, and closed-loop systems. Insulin pens not only result in greater patient satisfaction and adherence, but they allow patients to have greater independence in their overall lifestyle, are easier and more convenient to use, have superior accuracy, and are more socially acceptable than insulin vials and syringes.37 However, it is important for healthcare providers to educate patients on proper injection techniques to prevent dosing errors. Recent combination treatment pens allow for fewer injections and may help reduce regimen complexity.37

Insulin pumps are small electronic devices that can deliver insulin in bolus doses or continuous doses.38 They are much more commonly used in type 1 diabetes, but can improve outcomes in patients with T2D who require multiple daily injections and whose disease is poorly controlled.39 Use of insulin pumps may help improve predictability of insulin levels and glucose levels, resulting in increased adherence and fewer injections.38 However, insulin pumps are usually expensive and may not be appropriate for all patients.38

The connection between combination therapies and adherence may not be quite as clearly defined. Combination therapies are often seen as the solution to issues with complexity of dosing and treatment regimens. Patients tend to be less compliant with complex regimens, and more adherent to simpler regimens and those with fixed-dose combinations.40-42 Fixed-dose combination therapy with metformin has repeatedly been shown to have higher treatment adherence than loose-pill combinations.40,41 Simplicity of the dosing regimen and the frequency and timing of dosing are also important indicators of potential adherence—once-daily dosing is associated with higher rates of adherence than twice-daily dosing.41 However, it cannot be assumed that a combination treatment will increase adherence. For example, newer insulin pens come with fixed-dose combinations of a basal insulin and a glucagon-like peptide-1 receptor agonist, thus reducing the number of injections and simplifying the dosing schedule. However, because they are recent approvals, these pens also cost more than the combined price of the individual drugs. Cost is a major factor in treatment adherence and compliance and cannot be ignored. Diabetes is a disease that requires long-term treatment. As such, it is important to ensure that patients are aware of all their treatment options so that the factors important to them can be used to determine the treatment regimen they are most likely to adhere to over the long term.43

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