4 Factors Affecting Patient Medication Adherence, and How Pharmacists Can Help
Key takeaways:
Costs are a significant barrier to a patient’s medication adherence, especially for the uninsured. But costs can be a barrier even for those with insurance.
Psychological barriers, like fear of side effects, denial of conditions, and fear of dependency, as well as physical barriers like hand-eye coordination, can also affect a patient’s ability to take certain medications.
Complicated drug regimens, involving numerous medications or taking them numerous times per day, are difficult for adherence, too. Pharmacists can help simplify regimens by reducing pill burdens and eliminating unnecessary treatments.
Medication adherence is often defined as a patient taking at least 80% of their medications for most diseases. For patients with a chronic disease, like diabetes, adherence rates hover around 50% to 60%. Unfortunately, for some diseases, even 80% adherence might not be enough. Older HIV antiretrovirals, for example, required adherence rates at or above 95%.
In the U.S., medication nonadherence has been estimated to lead to 125,000 avoidable deaths and $100 billion in avoidable healthcare costs annually. We’ll look at some of the most common barriers to adherence and offer tips to overcome them, pulling from outside sources and from my own experience as a practicing pharmacist.
Barrier #1: Medication costs
A RAND report comparing drug costs for more than 30 countries found prices in the U.S. to be 256% higher than the average of the other nations. Prices for branded, specialty medications can be especially high at the pharmacy counter. While these medications account for only 2.2% of all outpatient prescriptions filled, they account for 50% of outpatient drug spending.
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To further complicate matters, millions of Americans still do not have health insurance and, for those that do, millions more are underinsured. Add to that the complexity of Medicare Part D — the drug plan most older Americans rely on for their prescription drug needs — and it’s no wonder so many patients go without their prescriptions.
How you can help
Understanding prescription drug insurance can help pharmacists navigate rejections and get patients approved. Also, being aware of options for patients, both within and outside of the insurance system, can help providers steer their patients toward options they can afford. These are all areas where a pharmacist can help, so don’t hesitate to call the pharmacy.
Using GoodRx also helps patients ensure they are getting the best price on their medications and can help them explore their options for financial assistance.
From my own experience
I recently had a patient on a diabetes treatment (GLP1-RA), who was paying nearly $1,000 cash for a prescription every month. (In this case, the patient actually could afford the medication, but I was persistent in searching for options for him.) He was already on metformin (Glucophage), and his doctor wanted to add another therapy.
I eventually discovered I could get him an SGLT2 inhibitor and, by him using the copay card with it, I could dispense the medication at no cost to him.
Barrier #2: Psychological barriers
A range of emotions can come into play here. Fear of side effects, worries about becoming dependent on medication, denial about a health condition, and lack of education about the continued need for medication are just a few examples of psychological barriers facing many patients. Other patients might be unsure a medication will even help them, so they are hesitant to take it. Finally, there is a well-documented study about the relationship between patients who suffer from mental health conditions and poor medication adherence.
Medical mistrust, especially among Black Americans, remains a significant psychological barrier to receiving appropriate medical care, including pharmaceutical care. This is due to a long history of mistreatment, including medical students in the 1900s robbing the graves of Black people to use for research at medical schools; the focus on the management of white patients in medical education; false beliefs even among medical students about biological differences between Black and white people; the consistent undertreatment of pain; and, of course, the Tuskegee study.
How you can help
Effective communication with patients is key to overcoming many psychological barriers, according to the American Medical Association. This includes ensuring patients understand how they will know the medicine is working, when they will need to be seen in the office again, when to call the office if there is a concern of side effects, and what side effects the medicine might cause.
Medical mistrust is a difficult issue to take on, especially considering its deep roots and recent politicization of the COVID-19 vaccines and masking.
Here are some proven ways to build trust among your patients:
Cultural sensitivity: Perhaps one of the most common cultural differences encountered in the hospital setting is the refusal of blood products by nearly all Jehovah’s Witnesses, but cultural sensitivity goes far deeper than simple yes-or-no treatment decisions. Defined as an “awareness and appreciation of the values, norms, and beliefs characteristic of a cultural, ethnic, racial, or other group that is not one’s own, accompanied by a willingness to adapt one’s behavior accordingly,” cultural sensitivity goes hand in hand with shared decision making, as described below.
High standards for healthcare quality and safety: It should go without saying, but care that is safe and provides quality treatment is more likely to build trust than care that is not. The Institute for Healthcare Improvement offers numerous training courses and regular webinars to help healthcare professionals become more involved in the improvement of healthcare systems.
Shared decision making: A critical role of a physician is to communicate the risks and benefits of each treatment, allowing the patient to choose their own path. Involving the patient in decisions about their medical care can help build trust, because for many medical decisions there is more than one option available to patients.
From my own experience
Pharmacists can make sure medications that provide comfort or relieve symptoms are a good choice and are actually helping patients. I recall a patient who was prescribed dronabinol (Marinol) because of weight loss and what was thought to be a low appetite. However, when she came to pick up the medicine, she told me she did not have a problem with her appetite, but her mouth hurt from ulcers that developed after chemotherapy.
I was able to call the provider’s office and switch it to viscous lidocaine (Xylocaine), a better choice given the situation.
Barrier #3: Physical barriers
Some disabilities can make both traveling to the pharmacy and taking medication more difficult. This includes patients who are unable to drive due to a disability, their medical condition, or a combination of these.
Some medications might also require coordination patients might not have. This includes eyedrops, injections, and inhalers. Finally, patients with dysphagia often have a hard time swallowing tablets or capsules, especially large ones like metformin or ibuprofen.
How you can help
Pharmacists can help identify these issues and address them. For example, pharmacists who have spent time in dispensing roles often know without looking which tablets or capsules are larger and more problematic in patients with swallowing challenges. In those instances, pharmacists can research which of these can be split, crushed, or opened, or determine if a liquid formulation is available and what the difference in cost will be.
Home delivery and mail order services can remove transportation barriers and, for patients with dysphagia, speech therapy might be able to help, so it’s important to consider a referral for these patients.
From my own experience
Pharmacists can also help navigate the insurance approvals necessary for these alternatives. For example, I had a patient with Parkinson’s disease who once received approval for additional eyedrops every month to treat glaucoma, because she had more waste due to a shaky hand.
Barrier #4: Complicated regimens
Taking numerous prescriptions or over-the-counter medicines (OTCs), vitamins, and dietary supplements along with medications multiple times per day can make adherence a challenge for anyone. In addition, there are medications that must be taken at certain times, and still other medications that can’t be taken with anything else the patient is taking.
Colesevelam (Welchol), for example, can be difficult because of its requirement to be spaced out at least 4 hours from many other medications. Levothyroxine and proton pump inhibitor coadministration is perhaps an even more common scenario, requiring timing that can be difficult to adhere to, especially considering that both are often taken in the morning.
How you can help
Adherence packaging, medication alarms, and vial dose counters are just a few examples of tools available to help your patients remember to take their medications. Medication synchronization is a pharmacy service that times a patient’s refills to reduce the number of trips to the pharmacy. It has been shown to significantly increase adherence.
Pharmacists can also help review a patient’s medications and look for opportunities to simplify the regimen and reduce unnecessary medications.
Consider these examples:
A patient taking an immediate or twice-daily release formulation, like bupropion SR (Wellbutrin), might have an opportunity to switch to a once-daily formulation, like bupropion XL.
If a patient has been taking medications as part of a prescribing cascade, there could be opportunities to eliminate some prescription medications.
If the patient is taking vitamins or OTCs not recommended by their provider, pharmacists can discuss those with the patient as a way to reduce their pill burden and reinforce the provider’s recommendations.
Finally, if a patient has one or more medications that need to be taken separately, then written instructions might help. While this is a common practice in warfarin (Coumadin) clinics, many patients might benefit from having a personal medication record to list all their medications and the time they are supposed to take them. This is, in fact, a required element of medication therapy management.
From my own experience
During my last year of pharmacy school, while on a rotation in geriatrics, the geriatrician asked me to go to a patient’s home and perform a medication reconciliation before she got there for a home visit. For this patient, she wanted to be sure she had a full medication list while evaluating the patient. I was shocked when she also asked me to get there an hour before her to perform this task.
I went through everything the patient took and documented a total of 28 medications. To my surprise, I finished her medication list right before the doctor showed up! Many of the medications ended up being unnecessary, and many were herbals and supplements the patient had heard about on TV and decided to try. In the end, nearly half of this patient’s medications or supplements could be eliminated if she had wanted to do so.
While in this case the biggest barrier was convincing the patient she didn’t need everything she was taking, in other cases, patients are eager to decrease the number of medications they take but just don’t know how.
The bottom line
Medication adherence remains a significant barrier to positive health outcomes and, while there are many reasons for this, medication costs, psychological barriers, physical barriers, and complicated drug regimens are the most common. By following these suggestions, you can help your patients receive the most benefit from their treatments.
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