Understanding Primary and Secondary Nonadherence to Chronic Oral Medication

Proactive strategies—such as clear communication, shared decision-making, multidisciplinary collaboration, and standardized documentation—are essential to improving medication adherence in chronic illness. Two studies presented by the American Medical Group Association at this year’s AMGA Annual Conference highlighted the impact of these factors by examining primary and secondary nonadherence to oral anticoagulants (OACs) and anti–prostate cancer medications (OPCM) from the patient and clinician perspectives.

Personalized interventions are paramount to achieving positive health outcomes, with not only the patient’s health at stake but the financial bottom line as well. Potential consequences of medication nonadherence include worsening disease, prolonged hospitalization, increasing medical bills, undermined medication effectiveness, and lower quality of life.^1-4

Overall, patients who delay in filling their prescription even 1 day are less likely to be adherent and to ever fill their prescription, while those who filled prescriptions were most likely to do so within a few days of receiving them.^5,6

From the Clinician Perspective

Patient, provider/clinic, and health system factors were all implicated in this database study that utilized electronic health record data, administrative adjudicated claims, and audio-recorded interviews to gather insight on primary and secondary nonadherence issues running through prescribing practices, patient communication, outcomes disparities, and follow-up.⁵ Primary nonadherence is never filling a new prescription, and secondary nonadherence is filling an initial prescription but nothing beyond that.

For the interview portion of this investigation, clinicians were asked about their organization’s current practices, data sources, and initiatives; their own prescribing practices and follow-up communication; and what they perceived to be patients’ barriers to adherence and how they strove to address those barriers. The health care providers interviewed had been practicing for an average of 19.3 years.

Data from this investigation show that of the 90% of patients thought to complete an initial fill for an OAC or an OPCM, there are 24% and 31% chances of becoming nonadherent, respectively.

Proactive strategies—such as clear communication, shared decision-making, multidisciplinary collaboration, and standardized documentation—are essential to improving medication adherence in chronic illness. | Image Credit: © Maggie L. Shaw

Patient factors involved in these outcomes are their disease state and medication education, cost barriers not always communicated to the provider or limited availability of financial assistance, and medication-related factors, such as adverse effects, e-prescribing, and requirements (eg, take with food). Principal provider/clinic factors are provider-patient communication via lack of shared decision-making and insufficient visit time, focusing on procedural interventions vs medication interventions, needing office staff support for the common issues of prior authorization and financial assistance that affect medication initiation, and pharmacy engagement by way of pharmacy reports and medication reminders. Health system factors encompass needs for training on adherence reporting, improving transitions of care, having sufficient administrative and financial resources to help support medication procurement efforts, consistent sharing of fill data with specialty pharmacies, faster follow-up, and workflows that facilitate medication initiation through partnerships with specialty pharmacies.

Opportunities for improvement start with the first instance of prescribing. The authors of this study emphasize that the first few days in the prescription process are crucial, and that shared decision-making is essential to ensuring therapies align with what patients can afford, their lifestyle, and follow-up schedules. To optimize outcomes with initial fills, they recommend payment assistance programs; increased engagement from nurses, social workers, and pharmacies to help with prior authorization approvals and disease state education; and starter packs/samples, co-pay cards, and immediate on-site initial fills. To keep patients persistent in their adherence, feedback loops to prescribers on objective medical fill data, standardizing outreach and documentation, and multidisciplinary engagement are paramount.

From the Patient Perspective

The authors of this poster say that it is more challenging to track and characterize primary nonadherence compared with secondary adherence, and that a better understanding of the barriers that impede care delivery and patient receipt of medications is paramount.⁶ For OACs and OPCM, this is even more important because of the high out-of-pocket costs associated with these medications.

This analysis included 31,928 adult patients who had a prescription for an OAC and 1692 who had a prescription for an OPCM; their index date was date of first prescription between January 1, 2021, and December 31, 2022. All patients had to have at least 180 days of continuous prescription coverage immediately prior to the index prescription and for 45 or more days after. These patients were older (aged 75 to 84 years or 65 to 74 years), few were Black or Asian, and most were White.

For OACs, most encounters were on an outpatient or unknown patient basis (P < .001), and the most common indications for the prescription were to treat atrial fibrillation, multiple conditions, or venous thromboembolism. For the OPCMs, prescriptions from oncologists, urologists, primary care providers, advanced practice providers, other, and unknown providers were analyzed.

The investigators used logistic regression for associations between patient characteristics and nonadherence. For OACs, adjusted odds of adherence were 16% lower among male patients, 55% lower for patients with Medicare Part D vs commercial insurance coverage, and 24% lower for patients who had atrial fibrillation; for OPCMs, adjusted odds of adherence were improved with Medicare Part D low-income subsidies, but with a low sample size, the authors found it challenging to identify characteristics influencing outcomes beyond that. Patient race did not play a significant role in nonadherence to either of these long-term treatments.

Among the patients who filled an OAC or OPCM prescription, most did so at their first visit or immediately after, and among those who did not immediately fill an OAC or OPCM prescription, just 28% went on to fill within 10 days, and patients were more likely to not fill if the 10-day mark was reached without a fill.

Overall, primary nonadherence was seen in 23.4% of patients prescribed an OAC and 31% prescribed an OPCM.

The authors note that their estimates of adherence rates may be low because other measures of adherence often begin at the time of first fill, and because the highest rates of adherence were seen among patients who had commercial insurance, financial barriers could be influencing nonadherence.

“Ensuring that patients leave with medication in hand is likely to improve adherence,” they concluded.

References

1. Schultz L. Why personalized interventions for medication non-adherence are critical. AllazoHealth. November 20, 2024. Accessed March 27, 2025. https://allazohealth.com/resources/4-consequences-of-medication-non-adherence/

2. Noncompliance with medications: the alarming reality. ChenMed. November 17, 2023. Accessed March 27, 2025. https://www.chenmed.com/blog/noncompliance-medications-alarming-reality

3. Kenny K. Medication nonadherence poses risks to patient safety. Pharmacy Times^®. September 18, 2024. Accessed March 27, 2025. https://www.pharmacytimes.com/view/medication-nonadherence-poses-risks-to-patient-safety

4. Julius ME. The consequences of non-adherence to medicines. African Centre for HIV/AIDS Management. September 30, 2022. Accessed March 27, 2025. https://osf.io/preprints/africarxiv/arpqj_v1

5. Obenrader J, Ruvalcaba, Mohl J, Ciemins E. Clinician perspectives of primary and secondary medication non-adherence. Presented at: AMGA Annual Conference; March 26-29, 2025; Grapevine, TX. Poster 33.

6. Mohl JT, Shields S, Ciemins EL. Primary medication non-adherence among patients requiring long-term treatment. Presented at: AMGA Annual Conference; March 26-29, 2025; Grapevine, TX. Poster 35.