Improving Medication Compliance Among
College Students
Presented to the
American College Health Association
May 31, 2012
by
Benjamin F. Banahan III, Ph.D., Director
Conflict of interest disclosure
I have NO actual or potential conflict of interest
in relation to this educational activity or
presentation.
Improving Medication Compliance Among College Students
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Educational objectives
• Describe the medication compliance problem.
• Identify major factors contributing to poor compliance.
• Identify special situations for college health pharmacies.
• Discuss strategies and tools for improving compliance.
Powers et al 2008. Complex chronic care: patient, provider and organizational issues. J of Management and Marketing in
Healthcare, 1(2): 179-190
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Medication adherence = How well patients
manage their medications
In order for prescription medications to be effective at treating illnesses,
patients must:
• Fill the prescription given to them by the physician
• Routinely take the medication as directed by the physician:
• Quantity of medication to be taken
• Number of times per day medication is to be taken
• Time(s) of day medication is to be taken
• Refill the medication as needed in order to take the medication
as long as recommended by the physician.
If a patient fails to do any of these –
medication adherence is less than perfect.
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Medication adherence includes
two related components
Adherence:
Medication compliance refers to the act of conforming to the recommendations made by
the provider with respect to timing, dosage, and frequency of medication taking.
Medication Possession Ratio (MPR) = 120 days supply / 140 days covered = 86%
30 days to refill
30 days supply
35 days to refill
30 days supply
30 days to refill
30 days supply
45 days to refill
30 days supply
Medication persistency = 140 days
Medication persistence is defined as the duration of time from initiation to discontinuation
of therapy.
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Adherence:
What is acceptable?
Medication compliance is often considered appropriate if MPR is >= 80%.
•
Some medications such as HIV meds, antisiezure meds, antipsychotics may need higher
MPR to be clinically successful.
30 days to refill
30 days supply
35 days to refill
30 days supply
30 days to refill
30 days supply
45 days to refill
30 days supply
Medication persistence is considered to be acceptable if medication is taken as “long as
needed”
•
•
Antibiotic taken for 5 days with 10 day course of therapy can be a problem.
Stopping medication against or without advice of physician can be problem.
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Background: Why
is adherence getting so
much attention?
• Increased availability of chronic medications that can manage
symptoms or prevent progression of serious illnesses.
• Poor adherence can increase total health care costs.
• Poor adherence can make a potentially effective medication a
useless health care expenditure.
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Background: Chronic
diseases are managed
with “maintenance medications”
• Maintenance medications are prescription medications taken
regularly to help prevent or manage chronic diseases.
• Most patients with chronic diseases will need to take maintenance
medications the rest of their life.
• Most patients with complex chronic conditions require multiple daily
medications for adequate control.
• Many patients struggle with self-management of their maintenance
medications.
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Background: Health
care increasingly is
focused on managing chronic diseases
• 82% of adults 65 years old and older have at least 1 chronic
condition.
• 24% of older adults have four or more chronic conditions.
• Even among the non-elderly, managing chronic diseases is
increasingly the largest use of pharmaceutical products.
Powers et al 2008. Complex chronic care: patient, provider and organizational issues. J of Management and Marketing in
Healthcare, 1(2): 179-190
Improving Medication Compliance Among College Students
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Adherence: Adherence
is the # 1 problem in
treating chronic conditions today
Rates of Noncompliance with Medications
As many as half of all
patients fail to take their
medications as directed .
..
Condition
Epilepsy
Arthritis
Hypertension
Diabetes
Asthma
Clotting, embolism
Estrogen deficiency
Rate of Noncompliance
30-50%
55-70%
40%
40-50%
20%
30%
57%
National Association of Chain Drug Stores, 2004.
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Adherence: Adherence
is the # 1 problem in
treating chronic conditions today
. . . and that failure has
very costly implications.
Medical Complications That Result From Medication
Noncompliance Are Responsible For . . .
10% of all hospital admissions
25% of all hospital admissions among the elderly
23% of all nursing home admissions
Loss of 20 million work days annually
National Association of Chain Drug Stores, 2004.
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Many factors contribute to
medication non-adherence
Adherence:
• Patient attitudes, knowledge and behaviors
•
•
•
•
Forgetfulness
Not understanding the instructions for when/how to take the medication
Lack of knowledge about disease being treated
“Feeling better” and deciding to quit the medication
• Poor disease management
• Failure to appropriately manage transient side effects when starting new
medications
• Failure to maintain effective therapeutic levels
• Cost factors
• Co-pay and co-insurance levels
• Transportation problems
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Adherence:
Cost issues limit access to care
% saying they or a family member have done
the following in the past year because of cost.
Among those who did each: % saying
their condition got worse as a result
Kaiser Family Foundation. Economic Problems Facing Families. April, 2008.
Improving Medication Compliance Among College Students
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Adherence:
Adherence can vary by physician
Physician Distribution Based on Average Patient Compliance
Lipid Market (n = 23,812)
LOW
Some practices
do very poorly
HIGH
While others do
very well
Source: Verispan patient data for the cholesterol market + ZS analysis.
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Adherence:
Adherence can vary by pharmacy
Performance scores for pharmacies meeting PQA criteria by measure type –
2004 – Proportion of Days Covered
2004 (%)
Measure
Mean
Min
10th
25th
percentile
percentile
Median
75th
90th
percentile
percentile
Max
Proportion of patients 18 years and older who met PDC threshold of 80 percent per pharmacy
BBs
CCBs
ACEI/ARBs
Statins
Biguanides
Sulfonylureas
TZDs
47.7
57.4
55.8
47.9
44.3
49.3
49.8
21.3
29.4
20.9
21.4
20.0
24.2
21.6
36.7
46.7
45.9
38.5
31.4
39.5
36.2
41.9
52.4
51.0
42.2
38.4
43.8
43.0
47.6
57.2
55.8
48.2
45.1
48.7
50.4
52.8
62.9
61.0
53.5
50.0
54.4
56.9
58.6
67.9
65.6
58.6
57.1
62.2
63.8
75.8
85.3
79.2
73.2
64.9
71.4
72.6
Note: Patients attributed to the pharmacy that dispensed majority of the medications related to the measure.
There were no major differences when modified attribution strategies were used.
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Co-pay Levels Also Affect Medication Use
Persistence With Statin Therapy by Co-Pay Level
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Medication adherence rates are
related to health care costs
Adherence:
• Better adherence results in: higher prescription costs.
and lowers overall health care costs.
Disease-Related Health Costs
at Varying Levels of Medication Adherence
Disease
Diabetes
Hypertension
Adherence
Level
1% - 19%
20% - 39%
40% - 59%
Medical
Cost ($)
$8,812
$6,959
$6,237
Drug
Costs ($)
$55
$165
$285
Total
Costs ($)
$8,867
$7,124
$6,522
Hospitalization
Risk (%)
30%
26%
25%
60% - 79%
$5,887
$404
$6,291
20%
80% - 100%
$3,808
$763
$4,570
13%
1% - 19%
20% - 39%
40% - 59%
60% - 79%
80% - 100%
$4,847
$5,973
$5,113
$4,977
$4,383
$31
$89
$184
$285
$489
$4,878
$6,062
$5,297
$5,262
$4,871
28%
24%
24%
20%
19%
Source: Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Medical Care 2005;43: 521-530.
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Adherence: So
what can we do about this
problem?
Informational interventions through educational processes
• Written and oral education material.
• Disease management education.
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Adherence: So
what can we do about this
problem?
Therapy modification interventions
• Simplification of dosage regimens
• Switching medications to avoid adverse events
• Switching medications to avoid higher out-of-pocket
costs
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Adherence: So
what can we do about this
problem?
Behavioral interventions
• Increased patient involvement in care
• Use of compliance aids (i.e., pill organizers, special
packaging)
• Reminder systems to combat forgetfulness
• Refill reminder systems
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Collaborative care models –
providers and patients working TOGETHER
Adherence:
• Collaborative care models encourage patients and providers to work
more closely together in order to strengthen and support self-care in
chronic illness.
• Collaborative care occurs when patients and care providers have:
•
•
•
•
Shared goals for managing the disease
A sustained working relationship
Mutual understanding of roles and responsibilities
The skills required for carrying out their roles
• Pharmacists have regular contact with patients and can develop
effective collaborative care services that can improve adherence
and outcomes.
Von Korff et al. 1997. Collaborative Management of Chronic Illness. Annals of Internal Medicine, 127(12): 1097-1102
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Pharmacy based programs have
been shown to reduce costs
Adherence:
• Patient care services provided by
community-based pharmacies to
diabetes patients in Asheville, NC
demonstrated:
• Improved control of the patients’
diabetes
• Improved compliance – resulting
in increased use and
expenditures for medications
• Lower overall health care
expenditures.
Rx claims other indications
$8,000
$7,082
Rx claims for diabets
$7,000
Medical claims
$5,882
$6,000
$5,210
$5,000
$4,651
$4,000
$3,000
$2,000
$1,000
$-
Cranor and Christensen. 2003. The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program.
J Am Pharm Assoc, 43(2): 149-159.
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Pharmacy care services also
reduced sick days
Adherence:
• Patient care services for the
group of Asheville city employees
resulted in a significant reduction
in sick days used every year.
• The employer estimated that the
value of increased productivity
was $18,000 per year.
Cranor and Christensen. 2003. The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program.
J Am Pharm Assoc, 43(2): 149-159.
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The RxSync™ program helps
community pharmacies with adherence
CPMM:
The RxSync ServiceSM is a community pharmacy practice
model that improves adherence and outcomes by:
• Simplifying the refill process to make it easier to avoid running
out of an important medication.
• Providing a timely reminder to the patient for refills needed each
month.
• Monitoring medication problems that might lead to medication
noncompliance or other health problems.
• Working with the patient and physician to appropriately address
medication problems that are identified.
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What should you focus on?
• What medications / diseases do you focus on most often
in college health pharmacy?
• Chronic / maintenance
• Acute
• What conditions have the greatest consequences if
students are not compliant / persistent?
• Chronic
• Acute
What can you do to improve adherence?
• Collaborative actions with other services or academic
programs.
• Health center providers
• Health educators
• Health professional students
• Use of technology
• Your pharmacy management software system
• Computer generated voice / text / e-mail messages
Contact Information:
Benjamin F. Banahan III, PhD
Center for Pharmaceutical Marketing and Management
(phone) 662-915-5352 (e-mail) benb3@olemiss.edu