Giving adherence intervention programs their due

Four decades of medication adherence research has yielded little translatable knowledge, and is beginning to look like nothing but a mirage on the healthcare landscape. In fact, if the need to boost adherence to medications were not essential for treatment success, continued funding would be difficult to justify. Despite years of targeted efforts, a successful intervention approach has yet to emerge as effective across diseases and medications, especially the common chronic conditions such as hyperlipidemia, hypertension, diabetes, and asthma. A systematic review of adherence interventions by Conn et al.¹ only showed modest effect sizes with the current interventions. Medication adherence is a problem beyond the US borders, considering that up to half of the worldwide population is not following optimal patterns of mediation use for their health conditions².

A vast array of factors contribute to sub-optimal medication adherence. These range from forgetfulness or poor planning to personal health beliefs, side-effects, or problems in the healthcare system as a whole. Solutions need to match the specific factors impacting adherence, which can be complex to sort out and costly to address. The problem is further complicated in cases where the barriers to adherence differ by drug within the same individual. For example, a patient may stop taking statins for only a few days each month due to side-effects, may go off methotrexate for 3 months because it costs too much, and never even choose to take their levothyroxine due to a lack of necessity belief in that medicine. Think this example is rare? Think again: the Center for Disease Control and Prevention reports that nearly half of all US adults have at least one chronic disease, and 22% are prescribed three or more drugs to control these diseases³. One additional point—adherence to medications for chronic conditions requires long-term adherence by individuals with very dynamic lives. Adherence barriers can change over time, resulting in variable levels of adherence that include periods of high adherence. Stressful life situations such as the death of loved ones, loss of employment, and family illness are examples of events that can disrupt patterns of medication adherence. Thus, with more people on multiple medications, it becomes a complex task for researchers and providers to pinpont the exact rates and reasons for non-adherence with each medication.

It is ironic that, with such a complex issue, so many are demanding simple solutions. Comments often heard from clinicians and funding agencies alike are “Will the intervention take more than a few minutes to implement?” or “Will it cause a disruption in the work flow?” Why are we restricting our interventions based on such short-sighted criteria? As established by Donovan and Blake⁴ in 1992, patients are not passive in their medicine-taking decision. They conduct their own, internal cost-benefit analysis for taking medicines, especially the ones for chronic conditions that need to be taken for the rest of their lives, and make a decision whether to adhere or not. Healthcare providers are in a unique and powerful position to help patients in this decision-making process, and should devote as much or more time to this activity as to any other part of the patient visit. According to the WHO, “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”². Knowing there are a multitude of reasons for non-adherence and knowing the costs in terms of money and non-optimal outcomes that are associated with non-adherence, our focus should be on delivering the right intervention to the right patient at the right time, even if it means some degree of disruption to business-as-usual.

Synonymous with prescribing the proper medication for the correct diagnosis, interventions targeting medication non-adherence must be matched to each patient’s situation. This may require the use of a comprehensive assessment tool, an in-depth interview, or a combination of both. Once the threats to medication adherence are identified, targeted strategies can be implemented to minimize each threat that fits within the context of the patient’s life. Often, patients spend a minimum 10–15 min in the waiting room before being seen by a physician. If properly utilized, this time might be used to collect information about their medicine-taking behavior and the barriers they face. The use of a comprehensive adherence tool to collect information about medication adherence should be a part of the patient’s chronic disease management visits, and this information should be used in engaging in meaningful conversations with patients, which can make them feel like “co-authors” of the treatment process, as so aptly described by Oldfield and Duvall⁵ in 2016, and correspond to further improvements in adherence. One reason for the lack of “adherence talk” at every visit might be the lack of workforce. Thus, improving adherence should not be the job of any one healthcare provider, such as a physician, rather a team-based approach with physicians, nurses, social workers, pharmacists, and/or psychologists, all working together and supporting the patients as they work to integrate the tasks of taking medication into their daily routine. Another reason for the lack of “adherence talk” might be the lack of communication skills. Healthcare providers are often not trained in communicating effectively with patients related to adherence, especially when non-adherence is due to misbeliefs or misperceptions about their medicines or illnesses. The communication often focuses on the diagnosis and the subsequent logical step of taking evidence-based medicines. A patient admitting non-adherence due to lack of belief in diagnosis can pose a communication challenge for the clinician. Thus, using tools to understand a patient’s medication adherence, and other psychosocial factors such as beliefs and self-efficacy, can potentially empower the clinicians to bridge the adherence gap, even though it is time-consuming. New avenues such as mHealth and technology interventions are trying to fill the gap left by lack of time and skills needed in adherence interventions. However, the first step in this direction will be to change the predominant mindset that adherence interventions should be minimal and marginal in nature. For as long as that mindset prevails, medication interventions can be expected to be minimal and marginal in impact.

Elizabeth J. Unni Roseman University of Health Sciences College of Pharmacy South Jordan, UT, USA Lisa K. Sharp Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago Chicago, IL, USA

Transparency

Declaration of funding

This editorial received no funding.

Declaration of financial/other relationships

The authors have no financial/other relationships to disclose. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgement

The authors acknowledge Dr. Tyler Rose for his valuable insight in this editorial.