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Σάββατο 2 Φεβρουαρίου 2019

How Pharmacists Can Help Ensure That Patients Take Their Medicines




Source: Harvard Business Review, January 31, 2019

By Humaira Ameer* & Sachin H. Jain*


What if there was a way to significantly improve health outcomes, reduce hospital and nursing home admissions, and save $105 billion in health spending? There is one such compelling opportunity: a greater systemic focus on medication adherence. When health care professionals use the term “medication adherence,” what we’re really referencing is whether or not patients take their medicines as prescribed. Shockingly, about half the time, they don’t. And the consequences of non-adherence are great.
One of the leading studies of the topic found that “approximately 125,000 deaths per year in the United States are due to medication non-adherence.” No wonder, then, the World Health Organization (WHO) has determined that “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.”
Medicare and Medicaid patients with multiple chronic conditions who tend to take multiple medications account for a disproportionate share of all health spending in America. Recognizing the important opportunity to improve the care for such patients, CareMore Health, a division of Anthem, Inc. that serves Medicare and Medicaid beneficiaries, launched a program. It was designed to leverage the clinical expertise of pharmacists to identify the root causes of non-adherence and hyper-personalize solutions to better support the patients we serve.
Our discovery: The reasons patients don’t take medicines vary significantly; consequently, to improve adherence, you have to customize the solution for each individual. This is a significant departure from past efforts to improve adherence, which have tried to apply a single solution across a whole population.

We started our pilot program by identifying about 250 non-adherent patients and then dividing them into two groups: an “intervention” group and a “control” group. These were patients who typically had multiple chronic diseases and many prescriptions — who were not taking them because they either didn’t fill their prescriptions or irregularly refilled them. We challenged pharmacists embedded within our clinics to use “any reasonable means” to support patients in the intervention group in improving their adherence.
The pharmacists conducted educational meetings with patients — both in person and over the phone — to understand why they weren’t taking their medications as prescribed and designed personalized care plans to improve adherence. We started to see some repeated patterns: patients’ stories that are emblematic of the challenges patients face and the solutions that can help them.
About a third of patients told us they were overwhelmed by the complexity of their medication regimens. One patient we’ll call “Stanley” told us he was supposed to inject insulin up to five times per day. Meanwhile, Stanley’s mealtime insulin was based off a “sliding scale,” meaning he had to check his sugar level before each meal to determine how many units he had to inject. Stanley is retired and babysits his grandchildren after school every afternoon. He told us that he found it difficult to carry his glucometer and mealtime insulin with him when he was out of the house each day. Not surprisingly, Stanley used words like “stressed” and “frustrated” to describe how he felt about his medication regimen.
Additionally, almost half of the patients said they didn’t understand why they were prescribed certain medications or what those medications were supposed to do. “Anna,” another patient, told us she only injected insulin if she “felt” her sugar levels were high. Not surprisingly, Anna’s blood sugar remained dangerously hyperglycemic.
While some patients reported that cost was a barrier to adherence, many more spoke frankly about their own cognitive functioning. Many older patients told us they had trouble remembering when or if they’d taken their medications. “Laura” stated that she had spilled her pills on the counter one morning, couldn’t remember which pill went in which bottle, and gave up on them all.
In total, we discovered that each patient identified, on average, about two dominant obstacles to adherence per patient. Our teams went to work with the express goal of removing those obstacles. Stanley’s care team, for instance, adjusted his medication regimen to make it less burdensome, putting him on a different formulation of insulin that he injects just twice a day. Within two months of the change, his A1c number, which indicates blood sugar levels, was lowered from 9.8% to 7.7%.
In many cases, clinical care teams spend a lot of time simply educating patients about their medications. A pharmacist explained to Anna the difference between maintenance and mealtime insulins and how they work together to regulate blood sugar levels. He also simplified her regimen by putting her on premixed insulin and an oral medication that meant she only had to inject herself twice a day. To avoid any further confusion, the CareMore pharmacist called Anna’s retail pharmacy to stop all old insulin prescriptions. He performed a home visit and disposed of all of Anna’s expired medications, created a new easy-to-read medication list for her to follow, and consolidated her pills into a pillbox labeled to show her which pills to take in the morning, afternoon, and evening. Anna’s blood sugar control has also improved significantly.
Many of the solutions that emerged were quite creative. In Tucson, Arizona, for example, a pharmacist encountered a patient who didn’t open her door very often because it was too hot outside. Consequently, when delivery services left her insulin on the front porch, it would spoil in the 115-degree heat. So the pharmacist found a local, independent pharmacy to deliver this patient’s insulin. That pharmacy schedules deliveries with the patient and makes sure she puts her insulin inside the refrigerator before the deliverer leaves.
As the pharmacists learned more about the specific obstacles older patients face, they adjusted their practices accordingly. For example, switching from bottles to pill boxes and pill packs, in which medications are pre-sorted and packaged by dose, so there’s never any guesswork about whether a patient has missed a dose. Also, the packages are easy to open, which makes things easier for patients like Frank, who’s 68, has arthritis in both hands that it made it difficult to open his pill bottles — something he was embarrassed to disclose even to his wife.
The success that this flurry of innovation produced was frankly surprising. To validate our findings, we partnered with a biostatistics team at the University of Southern California to observe our experiment and corroborate the results. According to their report, we improved medication adherence among the patients in our intervention group by 46% compared to people in our control group, who received usual care from their doctors and nurses but no special interventions from pharmacists.
The problem of non-adherence is as old as our oldest medicines — and is grounded in the simplistic belief that patients will always behave as we expect them to. Our early work in this area suggest otherwise. Although there’s certainly more to learn, we’re not waiting to implement what we call a “culture of adherence.” It starts with humility in recognizing that patients may not always follow what their doctors and nurses recommend and we need to continuously try to understand why.
While some common themes emerged from our program, we found that the reasons any one patient does or doesn’t take his or her medications is often exquisitely personal. Pharmacists on clinical teams can be deployed to identify causes of non-adherence and carefully tailor solutions. It is now standard practice for our care teams, which include clinical pharmacists, to regularly examine medication adherence data for each patient. We lead with the mantra that “medication adherence is our problem, not the patient’s problem.”
As pharmacists and pharmacies begin to play a bigger and bigger role in the delivery of health care, we believe a mandate to drive an enhanced hyper-personalized focus on medication adherence will unlock significant savings and, more importantly, improve the quality of care.
The best medicines are only effective if we ensure our patients take them.

*Humaira Ameer is manager of clinical pharmacy operations at CareMore Health System, a division of Anthem, Inc.
* Sachin H. Jain, MD, is president and CEO of the CareMore Health System, a division of Anthem, Inc. He is also a consulting professor of medicine at the Stanford University School of Medicine. He previously was the chief medical information and innovation officer at Merck. Follow him on Twitter at @sacjai.