Dr Niteesh Choudhry Highlights Outcomes From an Intervention to Promote Medication Adherence

Recent results from a team-based, scalable intervention to promote medication adherence highlighted that the relationship between adherence and clinical outcomes is not always clear cut, said Niteesh Choudhry, MD, PhD, associate professor at Harvard Medical School.

Transcript

You presented results from an intervention to promote medication adherence that is team based and potentially scalable. What are the goals of the intervention and how did it work?

We studied an intervention to try and help patients with common chronic metabolic conditions—diabetes, hypertension, and high cholesterol—adhere to their medications. So, there are lots of studies that have existed over the past number of decades, or that have been conducted over the past number of decades, to improve medication adherence. We know this is a major problem that everybody in the healthcare ecosystem now understands. It contributes to all kinds of preventable morbidity and mortality, and there’s all kinds of interventions that have been developed to try and improve adherence.

Most of the interventions that have been out there are only modestly effective, and even the ones that are effective have problems with sustainability or scalability—they’re often expensive and require specialized infrastructure. And, so, we wanted to figure out whether or not a technologically enabled intervention that leveraged pharmacists who are embedded already in a multipayer specialty practice would improve medication adherence.

So, we used a behaviorally tailored intervention that was mostly conducted by pharmacists, but that was wrapped around the technology. So, we sent patients progress reports on how they were doing on adherence and their disease control. We used text message reminders, we used relatively simple things, too, like pill boxes that were customized to people and the number of times a day people take their medications. Plus, this behaviorally tailored intervention. And we were trying to figure out what this did, predominantly for medication adherence, and for, then, clinical outcomes, like disease control—how well people’s blood pressure were controlled.

So, to remind you, we were studying a group of people who, to begin with, had poor disease control or suboptimal disease control—they were not meeting targets. And they were nonadherent to their medications, at least what claims data would tell us nonadherence is. So, what we found is that on average, adherence went up by about 5 percentage points for the entire population.

We studied this in an intention-to-treat framework, so everybody who was randomized to receive the intervention, we analyzed, including those people who didn’t receive the intervention at all. So, we were trying to test this in a way that could be scalable. We knew that some people when we invited them to participate would say, ‘No, thank you.’ About half the people accepted a pharmacist telephone consultation, which is what we expected upfront. When we, instead, didn’t look at the entire population, but looked at the as treated population or the people who got all of the components of the intervention, adherence went up by about 10 or 11 percentage points. So, overall, that’s a pretty big effect for adherence.

On the downside, when we looked at blood pressure control, and when we looked at [low-density lipoprotein] cholesterol, and we looked at hemoglobin A1C, we found very little if not any change at all in these outcomes. And, so, we see this disconnect that a moderately large improvement in adherence—certainly bigger than we expected going into this study—with no commensurate change in clinical outcomes.

Our take home is mixed. This is a strategy to improve adherence, yes, but this may not be all that’s necessary to improve actual clinical outcomes. We may need to do other things.

What does this mean for the population health movement?

I think it tells us a couple of different things. First of all, the relationship between adherence and outcomes is not as clear as we think it is. So, there have been other studies, including those I’ve conducted, in other disease populations in which improving adherence by 4, 5 percentage points is in fact the amount that you need to drive clinical outcomes. But in a slightly more stable population, outpatients with cardiometabolic conditions who have not just been discharged from the hospital, maybe we need a bigger improvement in adherence. That could be one take away.

The second take away could be that improving adherence in and of itself for patients with poorly controlled conditions may not be all that’s necessary. Sometimes we might need things like treatment intensification. And, so, focusing only on adherence may be missing the real problem or the real thing that patients need for success. There’s probably a mix of things that are really necessary.

The third is that we tested this intervention in a very specific way. We wanted to develop a scalable and sustainable intervention. And we studied it embedded in a health system using the infrastructure of a health system, used their electronic health records, and their access to claims data that they share with payers, and we used remote technology to help the patients. But, maybe that’s not the right solution for all patients. And, in fact, there are some patients that would be better served with that intervention, and other patients that have more complicated chronic conditions, maybe they do, in fact, need more expensive, in-person help.