Tools for Assessing Medication Adherence
Key takeaways:
There is no gold standard for assessing medication adherence despite the many validated tools available for use.
These tools measure whether a person is adhering to their prescribed medication plan and can also give reasons as to why someone may not be adherent.
Different methods can be used alone or in combination to inform improvement plans and ensure the best health outcomes, but more research is needed to establish a gold standard.
Correctly assessing adherence to prescribed medication is important for adequately managing chronic disease. More than half of people living with chronic disease struggle with adherence to their prescribed medications, which makes treatment less effective and can accelerate disease progression. Treating chronic disease often means taking medication for life, cementing the need for accurate assessment tools in clinical settings.
Here, we’ll review the most common methods for assessing medication adherence, possible barriers to implementation, and what would make an effective standard of care.
Methods for assessing adherence
There are several different methods that are designed to measure medication adherence for various conditions. Deciding which tools to use depends on the healthcare setting, budget, staffing, and patient population. Typically, a combination of tools will ensure the best results.
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Medication adherence questionnaires (MAQs)
Questionnaires that have been validated to assess adherence are a simple and effective way to gather helpful information from patients. These tools are easy to use, quick to administer, and provide results immediately.
These questionnaires can be administered to individuals in person by a healthcare provider, remotely by computer or phone, or as surveys in communities that may be lacking consistent access to healthcare. MAQs report adherence patterns and inform follow-up care to improve adherence.
Here are the most popular MAQs in use today:
Brief medication questionnaire (BMQ): The BMQ is a free, highly specific option to assess general medication adherence, with an overall accuracy of 95%. A set of nine questions look at medication-taking to determine adherence and self-efficacy as well as any barriers to adherence.
MMAS-8: The Morisky scale — or the MMAS-8 — is a diagnostic assessment instrument with eight validated questions used to assess adherence, with a sensitivity rating of 93%. It is most widely used for hypertension but can be applied to other diagnoses. It requires a licensing fee, which varies depending on how it is used.
The Hill-Bone compliance scale: This free method is used to assess behavior for hypertension. It looks at three categories: reduced sodium intake, appointment keeping, and medication use and identifies barriers while assessing for self-efficacy.
Medication adherence questionnaire (MAQ): The MAQ is a free tool that shows intentional and unintentional issues with adherence, based on patient response to four questions. The questionnaire is easy to administer and score and can be applied to hypertension, smoking, mental health, and HIV.
Drug attitude inventory questionnaire (DAI): The DAI is a free tool used in psychiatric disorders. It measures a person’s perception of drug treatment and their attitude toward prescriptions, resulting in a compliant or noncompliant score.
The medication adherence rating scale (MARS): Based on the MAQ and the DAI, the MARS is a free questionnaire tailored to assess adherence in psychiatric patients. There is also a version (MARS-A) for asthma medications.
Summary of diabetes self-care activities assessment (SDSCA): The SDSCA addresses adherence to diabetes medication therapy by measuring diabetes self-management behaviors in the past 7 days before the assessment. Then, it compares behavior to previously taught self-management education. It can be purchased through the Mapi Research Trust.
Adherence to refills and medications scale (ARMS): ARMS consists of 14 questions designed to be asked verbally to patients, reducing issues with low literacy. An optimized version — the ARMS-D — is specific to diabetes medication management. This tool can be used to predict glycemic control. It is licensed through Emory University.
Methods other than questionnaires
Alternatives to questionnaires vary from direct measurement methods to patient monitoring. There is a wide variety of alternatives depending on the needs of the patient and the provider doing the assessment. These alternatives are more successfully used in tandem with questionnaires to ensure all issues with adherence are identified and addressed.
Here are some of the most commonly used methods:
Drug adherence rate (DAR): Calculating the DAR is done through a patient interview. Patients will self-report how many pills they have consumed over a particular time period or can present the pills to be counted by a staff person. This creates a proportional value between 0 and 100. The goal is over 80% for chronic disease, 90% for tuberculosis, and 100% in antiretroviral therapy for HIV-AIDS.
Medication diaries: A written or electronic record is kept with the date and time of medication use. Additional information can be collected, such as whether or not medication was taken with food, method of administration, or any other relevant factor. This information is then presented to the managing healthcare provider to assess adherence either in paper form or integrated through an electronic health record.
Electronic adherence monitoring: Certain electronic packaging devices can record data and send it directly to a healthcare provider. In this method, whenever a specialized pill bottle or medication distribution system is opened, it registers that the medication was dispensed and taken. This type of monitoring is often used along with health provider guidance and reminders, to maximize effectiveness.
Pill counts: Pill counting involves counting doses between two scheduled visits. The patient provides the medication, and they are then counted by a healthcare provider.
Prescription/Pharmacy records: Assessing adherence by tracking refills can be done by obtaining pharmacy records. These records show the number of days between refills and when the medication was picked up.
Direct observation: This method utilizes an observer to monitor medication use. A trained individual physically watches or dispenses the medication to the patient at each dose. This is cumbersome to implement on a wide scale but can be helpful for specific conditions such as tuberculosis.
Collecting biomarkers: Samples of hair, urine, or blood are collected from an individual and then tested to measure the amount of drug present in the person’s body. These results provide data to assess appropriate usage.
Barriers to assessing adherence
Assessing adherence is difficult due to the subjective nature of patient experience and the varying qualities of each unique healthcare setting.
Here are some of the most common barriers that providers face when assessing patients for adherence to prescribed medications:
Accuracy of self-reporting: People most often overestimate adherence to seem more compliant. They may also overreport by accident if they cannot remember what they took when asked. Underreporting can occur when a person omits a record of when they did take the medication correctly.
Health literacy: Low literacy is a barrier to self-reporting, as well. Utilizing tools such as diaries and written questionnaires is not appropriate for someone with low literacy without additional assistance. Low health literacy negatively affects the understanding of drug indications, instructions, and dosing.
Implementation cost: Some MAQs require licensing fees that are cost-prohibitive for many providers. Tracking individuals through direct observation, using technology, testing biomarkers, or consuming pill counts requires additional costs and staffing to train and follow through.
Creating a gold standard for adherence assessment
Information learned from an adherence assessment is especially important, as it guides interventions toward improvement. When selecting a protocol for assessing adherence, there are a few important factors to keep in mind:
How accessible is the tool?
Is the tool affordable?
How long does the tool take to administer?
What is the literacy level of the patient population and the tool?
What conditions does the tool work for?
The most available and reliable method is self-reporting via questionnaire. Many of them are free or low-cost, set at simple reading levels, and are relatively easy to administer and score. The most effective questionnaires should be brief, reliable, and validated. These can be easily printed out or sent electronically and do not require additional or expensive equipment.
Overall, more research needs to be done to establish guidelines for what counts as adequate adherence in all conditions and medication classes. This has been difficult, due to the variability of each patient’s medical history.
Despite many existing studies on medication adherence, multiple validated questionnaires, and other available methods of measuring adherence, there are a few main problems in coming up with a gold standard:
Inability to compare studies due to poor methodology
A lack of clear language around adherence
Limited guidance on how best to measure adherence
Improvements to research surrounding medication adherence would provide greater clarity, allow standardization of what constitutes appropriate adherence, and create guidelines for how to best select adherence assessments.
The bottom line
Assessing for medication adherence requires an effective and validated tool that is targeted for a specific medical condition. Selecting the right tool depends on the patient population, budget, and ease of administration. Continued research is needed to unify a methodology and create a standard of care for healthcare providers tasked with monitoring adherence. This will improve health outcomes for all patients requiring ongoing medication management.
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