Innovative Strategies for Boosting Medication Adherence in the Real World
At a session during the National Association of Managed Care Physicians Fall Managed Care Forum 2017, speakers discussed how new approaches to encouraging medication adherence can help improve outcomes in patients with chronic diseases.
First, Steven Edelman, MD, professor of medicine, University of California, San Diego, gave an overview of the barriers to adherence, which he called the “single most important topic there is” in type 2 diabetes (T2D). In recent years, over 40 new medications have been approved, but nationwide glycated hemoglobin (A1C) rates have not improved. Instead of developing even more new drugs, “we need to get the right drug to the right person and help improve adherence,” he said.
Poor adherence is defined by a medication possession ratio or proportion of days covered less than 80%, but these metrics do not account for prescriptions that are never filled or what medications the patient actually takes, so the current definition underestimates this problem, Edelman explained. Rates of adherence vary across different chronic diseases, but it represents a particular challenge for patients with “silent conditions” like T2D that do not produce acute symptoms.
If patients don’t feel any difference between when they take their medications or not, they will “have to be pretty motivated” in order to continue the regimen, he said. Despite the lack of difference perceived by patients, there are clear negative outcomes associated with poor adherence, including higher risk of hospitalization and, in one study, a 39% increased risk of all-cause mortality among patients with poor adherence to their oral hypoglycemic drugs. Patients with low adherence also incur significantly higher costs for preventable hospitalizations compared with those considered adherent.
Edelman highlighted the differences between adherence in randomized controlled trials and in the “real world.” Trial participants receive extra support and monitoring, can focus on taking the therapy for a finite period of time, and may be more motivated due to cash incentives, but real patients do not have these advantages.
In a modeling study comparing the A1C results predicted under trial conditions with actual results, 75% of the gap in outcomes was explained by differing levels of adherence. These findings demonstrate that “achieving outcome improvements requires innovative approaches designed with the real world in mind,” Edelman concluded.
Some of these approaches, both traditional and creative, were outlined by the second speaker, James Gavin, III, MD, PhD, clinical professor of medicine, Emory University School of Medicine and Indiana University School of Medicine. To understand these approaches, Gavin first explained the multifactorial barriers that contribute to poor adherence, which include affordability, tolerability, forgetfulness, lack of motivation, difficulty opening or reading packaging, and inability to swallow or inject the medication itself.
The traditional strategies used to encourage adherence have addressed some of these barriers, but not all. For instance, fixed-dose combinations or long-acting injections have reduced the pill burden on patients, but limitations remain, like the motivation to perform the injection or visit a provider for the administration. To help manage forgetfulness, patients can receive timer bottle caps that ring or flash when it is time to take a dose.
“That’s what my alarm clock does in the morning,” Gavin said, “but that doesn’t stop me from hitting the snooze!”
Because reminders do not affect patients’ underlying motivation, Gavin has found that the most effective interventions to encourage adherence include multiple components, such as patient education, behavioral or social support, and case management. In a review of 83 interventions studied, the only ones that improved adherence or outcomes were multifaceted.
However, he explained, there are also more advanced approaches in development. Some may be perceived as invasive, as they involve pills with tracking chips or camera-based adherence monitoring enabled by facial recognition, so the innovations he finds most exciting are those like implantable delivery systems where providers and patients can “set it and forget it.”
Another promising approach to adherence in diabetes is the development of artificial pancreas or continuous glucose monitoring systems, where sensors evaluate glucose levels and send signals to insulin pumps. These systems alleviate most of the burden on the patients to make decisions and actively dose themselves.
Overall, Gavin predicted that the most successful new solutions are those that take a “broader-based, more holistic approach to managing compliance.”
He also spoke of the need for health plans to invest in medication adherence solutions, as many are not currently covered by managed care organizations.
“If real-world evidence for these approaches is generated, it really is going to be important that payers will play a role in supporting the use of these technologies,” he stated.