Adherence as a Health Care Priority - Virginia Perspectives

6 March 2009

The expanding burden of disease in the US, as in other developed countries, has shifted from episodic care to the management of chronic illness. Successful patient management depends on adherence to a prescribed regimen, including both lifestyle considerations and pharmacotherapy. In chronic medical conditions, failure to take medication appropriately or consistently ultimately leads to poor health outcomes and increased healthcare expenditures. Subsequently, the challenge of developing strategies to improve medication regimen adherence is critical.

A roundtable of clinicians involved in epidemiology, cardiology, family medicine, public health, surgery, pharmacy, and research recently convened in Richmond, Virginia to share their experiences and insights on the “adherence challenge” – with an objective of identifying strategies for improvement. Their observations will be used to guide the MSV Foundation in determining how it can be most effective in equipping Virginia’s physicians to improve their patients’ adherence to recommended treatment.

Medication Adherence – Basic Concepts and Barriers
With the increased reliance on pharmacotherapy to address chronic illness, patient non-adherence to prescribed medication is an emerging challenge for health care providers. Defined as the extent to which patients take medications as prescribed by their healthcare providers, individual adherence is inherently difficult to measure, monitor, and improve. In 2001, the World Health Organization call to action report recognized the importance of patient adherence and the impact of poor adherence to health. The WHO encouraged global efforts to improve the patients’ role in treatment decisions to support their use of life-saving medication.
In this paper, we take a broader, clinically focused perspective and consider not only medication per se,, but health behaviors and preventive initiatives that complement and fundamentally interact with any regimen of prescription medicine

Adherence is a means to an end – the improvement or maintenance of health and management of symptoms. The challenge is how to achieve optimal adherence in a complex environment. Adherence includes many aspects of health care, ranging from seeking medical attention when problems arise, collaboration it the diagnostic process and laboratory monitoring, patient counseling, filling prescriptions, taking medications appropriately, keeping follow-up appointments, and adopting behavioral interventions that impact health. With so many factors to consider, it is understandable that patients may stumble along the way. Even if patients do not display any of the many predictors of poor adherence, physicians should suspect non-adherence in any patient whose condition is not responding to therapy.

Adherence as a Quality Indicator
It’s quite clear that if patients don’t adhere to their medical regimen, then the outcomes of clinical trials cannot be reproduced in clinical practice. It’s not unreasonable then to consider improved adherence as a measure of successful patient management. Currently we evaluate a wide range of indicators of care, such as attainment of LDL-c and blood pressure goals, to support the assessment of quality. In order to make these changes we systematically learned key content, developed appropriate guidelines, implemented processes and measured incremental success. This quality improvement process is critical to not only improve patient care, but to further document the value of a wide range of clinical services. This justification for reimbursement is the core for the recent emergence of pay for performance projects conducted by managed care organizations, the government and others who pay for care.

Adherence Insights and Suggested Next Steps from the Virginia Physician and Pharmacist Roundtable

• Non-adherence is a "hidden" problem and will likely remain obscured until there is an effective data feedback mechanism that links all members of the health system (physician practices, hospitals, pharmacies, et al.) with information on patient follow up with treatment recommendations. This would include an interface with the payer. Properly designed, Electronic Health Records will help with this problem, but not solve it completely. Interoperability issues and design features that provide support for tracking adherence remain a challenge.
• There are very different adherence issues for preventive care versus the care of a primary diagnosis, and these differences across the spectrum of acute and chronic health conditions.
• Adherence in the setting of common scenario of multiple chronic conditions is one of the most important emerging challenges for our medical system and requires special attention. Appreciation of the complex issues involved is essential for development of successful strategies to optimize adherence.
• Physicians will continue to benefit from considering a team approach to the problem within their practices. Physicians should leverage the time and opportunity present in their clinical and administrative staff to support adherence of the patients.
• Financial incentives for performance measurement (aka Pay-for-Performance) will change the "ownership" of the adherence paradigm - and physicians and the healthcare system will have a greater sense of urgency to take action to improve the adherence of their patients. It might also be beneficial to begin to better educate physicians on the dynamics of various pay-for-performance systems and how patient adherence will affect them and their reimbursement.
• Employers are recognizing the financial incentives to share in the ownership of the problem. Some larger employers are beginning to waive prescription co-pays when prescriptions are filled regularly. Health plans now offer support for patients as well.
• Patient failure to adhere to a treatment regime is a societal problem with effects at many levels. Currently there is little collective or collaborative "ownership" of this problem. It would be beneficial to consider an educational campaign for the general public. We need simple tools in provider offices which would allow the patient to express their challenges in adherence to a treatment plan. These tools should be cultural and community specific tools which would enable providers to assess which patients are at risk for non-adherence.

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Adherence as a Health Care Priority:  Virginia Perspectives (PDF)