Treatment Simplification and Personalized Interventions May Reduce Medication Nonadherence

Simplifying treatments, tailoring the care plan in alignment with patient priorities, and incorporating interventions in patient care are associated with improved patient adherence to medications, according to a review published in Medical Clinics of North America.

Treatment nonadherence is when a person’s behaviors do not align with an agreed-upon treatment plan from a health care provider.

There are two subdivisions for medication nonadherence:

• Primary nonadherence, when a patient receives a prescription but never fills the dispensation is estimated at 28%
• Secondary nonadherence, when a patient fills a prescription but does not take the medicine as prescribed, is estimated at 50%

Other types of nonadherences such as dietary and exercise are estimated to be at least 50%, though the authors note that this may be due to lack of appropriate counseling.

“Several studies show that nonadherence to chronic disease medications costs the US health care system more than $290 billion every year,” the authors explained. “Furthermore, treatment nonadherence is associated with increases in both morbidity and mortality across multiple conditions.”

The authors cite multifactorial reasons leading to nonadherence including the burden of normalizing and coping with the work required to manage multiple conditions, uncoordinated care from multiple subspecialists, and lack of insurance coverage.

In the review, the authors outlined tools for clinicians to effectively identify, evaluate, and manage nonadherence across the spectrum of chronic disease.

The first step of reducing nonadherence is understanding a patient’s risk for nonadherence by screening for a history of nonadherence risk factors, which also allows clinicians to optimize medication reconciliation. The authors also advise reviewing the electronic health record (EHR) to identify indicators of increased risk for nonadherence, such as insufficient refills, few visits, missed visits, or poor health outcomes.

Other recommended tools for measuring and discussing patient workload, treatment burden, and capacity include Adherence Estimator, ICAN Discussion Aid, and others.

The second step of reducing nonadherence is aligning a fitted care plan with interventions to support adherence.

A fitted care plan is derived from an examination of guideline-driven pharmacologic and nonpharmacologic treatments, while also taking into account the patient’s unique situation. The plan will maximize patient-important health outcomes, quality of life, and sustainability over time.

A variety of interventions have been studied to support medication adherence. While it may be difficult to draw firm conclusions from aggregated data of these interventions, many of the interventions have been shown to improve adherence.

The interventions highlighted are:

1. Patient-physician relationship and eliciting patient perspective. Validating the patient’s perspective promotes adherence and trust and improves patient satisfaction. Even when cost is high, patients with a trusting relationship with their health care provider have higher adherence.
2. Medication changes aiming at simplifying medications can reduce health care burden. Some changes may be discontinuing unnecessary medications or prescribing single-pill combinations.
3. Pharmacist-led interventions can improve not only medication adherence but also patient education. In addition, synchronizing medication refill to land on 1 date not only improves adherence, but couold improve Medicare Star Ratings.
4. Patient education has mixed results for reducing nonadherence on its own. This intervention may include in-person classes or sharing education materials to read.
5. Patient monitoring, reminders, and feedback also have mixed results; however, personalized and interactive feedback may work better. Overall, the authors suggested this may still be offered, but it needs to be tailored to the patient’s technological literacy.
6. Cognitive behavioral interventions, such as motivational interviewing has a small impact on nonadherence and can guide patients to create their own solutions that change behaviors.
7. Health care system and financial interventions, such as reducing out-of-pocket costs and expanding health care coverage—particularly for patients eligible for Medicare Part D—can improve medication adherence.

The authors advise that being nonjudgmental, supporting patient engagement, and using different tools to delineate patterns of nonadherence can help identify patients at risk and possible interventions.

“When nonadherence is identified, tailoring the care plan, simplifying the medication regimen, and incorporating multicomponent interventions that ameliorate patient, treatment, and health care system-related factors increase adherence and improve patient outcomes,” they concluded.

Reference

El Halabi J, Minteer W, Boehmer KR. Identifying and managing treatment nonadherence. Med Clin North Am. 2022;106(4):616-626. doi:10.1016/j.mcna.2022.02.003