Barriers and benefits to Medicine adherence in a pandemic

 Benefits & Barriers to Medical Adherence

Hi, my name is Garvan Lynch and I am a community pharmacist, working in Douglas, Cork city for nearly 20 years. I am going to start with an observation on the healthcare industry today.

The advances in medical science and research in the last 20 years has been nothing short of miraculous. Today, we have the best trained Medical professionals, researcher scientists and medical technologists ever in history, with instant access to their colleagues and global research, further more we have access to the very latest advances in medical diagnostic tolls, medical technology and big data, that is truly stunning. (And the creation of The COVID vaccine is a case in point, 12 months from start to finish, must be considered one of medical sciences, if not sciences greatest achievements). 

But surprisingly, this explosion in progress in research has not spilled over into medicine adherence. The world health organisation reported in 2003 that medicine adherence was just under 50% (WHO 2003). Unbelievably, This figure has actually decreased marginally in the last 18 years to just over 45%. That is 45 out of every 100 patients are actually taking their medicines as prescribed by their prescriber. It is a truly unbelievable statistic, considering in parallel, how advanced medicine has progressed in the same period. 

Medicine Adherence is obviously a very big problem today, and by all accounts, the problem stretches back to the actual dawn of the medical profession itself, to Hippocrates, and Hippocrates believed that patients actually faked ingestion of their medicines. So, Doctors have been struggling to get medicines into their patients for nearly two and a half thousand years and while medicine has advanced phenomenally in this time period, adherence has barely budged!

So, Why is this?

One could reasonably assume that medicine adherence would be close to 100%. It doesn’t seem logical that only 45 out of every 100 patients would then go and actually take the medicine as directed. Medicine adherence is counter intuitive, complex and multi factorial. 

Medication Adherence as defined by John Hopkins Medical centre is “The amount of time someone is taking medications as instructed”. It, is in fact a combination of compliance and persistence. Here is a quote, that is very relevant, and which some of you have heard numerous times, from the former Surgeon General in the United States, C.Everett Kopp: “The drugs don’t work in people who don’t take them”. It is obvious but true. Having the best trained and educated medical professionals counts for very little, if patients don’t keep to their end of the bargain, and take their medicines as directed.

Adherence is a multidimensional phenomenon. The WHO developed five dimensions in order to categorise the main barriers to medicine adherence. These barriers can combine with each other to produce very poor medicine adherence. These barriers are

1. Social/economic factors - for example low health literacy
2. Provider-patient/health care system factors - for example poor doctor-patient relationship
3. Condition-related factors - for example lack of symptoms
4. Therapy-related factors - for example complexity of regime
5. Patient-related factors - for example cognitive impairment

Patient-related factors are just one determinant of adherence behaviour. The common belief that a person is solely responsible for taking their medications often reflects a misunderstanding of how other factors affect people's medication-taking behaviour and their capacity to adhere to treatment regimens.

It is clear that adherence is a complex behavioural process strongly influenced by the environments in which people live, health care providers practice, and health care systems deliver care. Adherence is related to people's knowledge and beliefs about their illness, motivation to manage it, confidence in their ability to engage in illness-management behaviours, and expectations regarding the outcome of treatment and the consequences of poor adherence.

Because there is usually no single reason for medication non adherence, there can be no "one size fits all" approach to improving adherence.

Many of the interventions used to improve adherence focus on providing education to increase knowledge; simplifying the medication regimen (fewer drugs or fewer doses); or making it easier to remember (adherence aids, refill reminders). However, simplifying a dosage regimen is unlikely to affect a person who does not believe that taking medications is important or that the therapy will improve his or her health, and the available evidence shows that knowledge alone is not enough for creating or maintaining good adherence habits (World Health Organization, 2003).

The costs of poor adherence are truly staggering. So, from the EU Health Policy debate in 2012, the cost of non adherence in the EU was €125 billion and 200,000 premature deaths annually. In Ireland in 2013, the HSE estimated the cost of poor health literacy (which is a leading cause of non adherence) to be 20% of the Irish Health Budget or €15 billion and from the states, the centre of disease control estimated up to 50% of chronic disease failures are due to medicine non-adherence. 

The New England Journal of Medicine summarises the causes of non-adherence as: 

• Inadequate transmittal of information about the condition or medicine from healthcare provider
• Lack of knowledge about the medicine
• Poor communication between patient and healthcare provider
• Lack of trust in healthcare provider
• Concern over side effects
• Lack of motivation
• Substance abuse/Cost/lack of caregivers
• Forgetfulness 

The main causes and largest potential barriers to non-adherence are all centred around health literacy and patient education.

A more recent barrier to adherence is emerging as technology and the access to information and the internet improves. The information age, or more appropriately as far as medicine adherence is concerned, the mis-information age has arrived. Anecdotal evidence from he United States is already demonstrating the power of mis-information on Vaccine uptake the US. The states with lower COVID vaccine uptake are associated with larger and more active anti-vaccines mis-information campaigns. These campaigns, even though not based on science, but on fear mongering and falsehoods, have never the less been very successful and influential in changing the publics view on the safety and effectiveness of vaccines, to the extent that some states have a vaccine take up rate of just 60%.

The COVID-19 pandemic has added a whole new dimension and barrier to medicine adherence: that barrier being fear. People have avoided healthcare locations-Dr’s/Pharmacies and hospitals (Santoli et al.2021) to stay out of contact with patients who may have the coronavirus.

For example, a May 2020 study from researchers in the United States, with the CDC found that vaccinations for children have dropped significantly (Santoli et al 2021) since the start of the COVID-19 pandemic, prompting concerns of forthcoming outbreaks of vaccine-preventable diseases. 

Measles vaccinations for children under age 2 dropped by half from March 13 through March 23, while vaccinations for children ages 2–18 dropped from 2,500 per week pre-pandemic to fewer than 500 per week. Researchers attribute the decline to parents’ concerns of exposing their children to COVID-19 during visits to healthcare providers.

On the other end of the spectrum, fear is in some cases driving up medication adherence. A study from researchers with the American Academy of Allergy, Asthma & Immunology, published in The Journal of Allergy and Clinical Immunology: In Practice, found a 14.5% increase in adherence (Presnell 2020) in controller inhaler use between January and March 2020, at the start of the COVID-19 pandemic in the United States.

A large body of medical research on the benefits of improving adherence, has consistently shown that patients who take their medicine enjoy better health outcomes.(DiMatteo MR, 2002, McDermott MM, 1997). After all, that is the point of controlled clinical trials: Taking Drug A yields a better clinical outcome than not taking Drug A. What’s more, patients who take their medicine spend less time in urgent care or in the hospital than those who don’t (Lau DT, 2004; Sokol MC, 2005). If there were no clinical benefit to medication adherence, all of us should be (and would be) and I would be out of business.

Brown et al. discuss this exact issue in their April 2016 article, “Medication Adherence: Truth and Consequences” (Brown M, et al 2006). They note an important study that examined the relationship between medication adherence in patients with chronic vascular conditions and the use and cost of healthcare services. As shown in the Figure, increased adherence resulted in reduced total annual healthcare spending, with savings far beyond the relatively modest increase in Rx costs.

Extending this line of logic a bit further, Mr. A.K. Jha  and colleagues in the United States, in 2012 estimated that improved adherence to diabetes medication alone could avert 699,000 emergency department (ED) visits and 341,000 hospitalisations annually, for a saving of $4.7 billion. 

So, from the vast database of studies published, we know what works in improving adherence; and achieving patient buy-in, is easier when there is a focus on education, training, and development provided, if there is no in-depth conversation about why or how a negative consequence occurs, a patient is more likely to give up or not stick with a regimented change. Plus, the education flow must be continuous as when the the eduction stops, adherence drops. This is why it has proven to be so difficult to have any meaningful impact on adherence.

Based on published studies, it is evident that single interventions are less successful than multiple, long-term interventions in affecting adherence. Studies have also shown that the most successful interventions have some follow-up component and address the underlying reason(s) for non adherence (Krueger et al., 2003). Comprehensive interventions should address a variety of issues, including knowledge, motivation, social support, and individualising therapy based on a person's concerns and needs (Krueger et al., 2003).

The ideal time to initiate adherence interventions is when therapy first begins. Interventions that are initiated early in the course of therapy can support older persons through a period when they are most likely to have questions or to experience side effects from therapy.

Small steps can make a difference: consider this,  “Patients knowing that you can monitor medicine adherence may be more important than actually monitoring medicine adherence” So, just actually telling patients that you are monitoring them, has an actual effect on adherence. This psychological oversight, is apparently very powerful and is very effective. Making a difference doesn’t actually require a lot of money and commitments from numerous stakeholders, but a simple statement saying the patients medicine adherence will be monitored closely from here on in, by prescribing doctor. Imagine, that alone could make a difference.

Never before have we been more connected, with smart technologies being used to navigate our roads, drive our cars, monitor our home safety, clean our rooms, and aid in surgeries. Not surprisingly, recent years have also witnessed the use of smart technology in increasing medication adherence (Perez-Jover,V.2019).

Mobile apps are user-friendly, remind patients to take their medications on time, warn about interactions with other medications, send notifications to other family members when a pill is missed, and help communicate with the doctor. A recent review that studied whether they really help has shown that these apps are indeed effective in increasing adherence, and the authors of the review recommend the personalisation of an app for better results (Perez-Jover,V. 2019).

Medicine adherence is something I have been passionate about for a number of years and I am currently in the process of developing software to manage medicine adherence. We have received funding in Europe under the Horizon 2020 healthcare innovation initiative and also our company was shortlisted to receive support from the health innovation hub in Cork in 2020. 

Our path is a 2 pronged approach. We hope to use educational technology with a medicine adherence platform which has oversight from a healthcare professional.

I will finish with another observation. There is 1 stakeholder who up to this point, who could possibly play a pivotal role in the future. Having paid for research and development, running trials, getting licence approval and marketing authorisations etc. Drug manufacturers, probably would think they could not possibly have any input once the medicine is prescribed and dispensed. But, maybe they could be the very key to the whole adherence conundrum. A hidden benefit to adherence increasing to over 85% is actually increasing profits to drug manufacturers. More medicine is used and will be needed to be manufactured. Improving adherence to 85% would add billions of dollars to the profits of drug companies.

References:

World Health Organization 2003. Adherence to long-term therapies: Evidence for action. http:// www.who.int/chp/knowledge/publications/adherence_report

DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. “Patient Adherence and Medical Treatment Outcomes: A Meta-analysis.” Med Care. 2002; 40(9):794–811.

McDermott MM, Schmitt B, Wallner E. “Impact of Medication Non adherence on Coronary Heart Disease Outcomes: A Critical Review.” Arch Intern Med. 1997;157(17):1921–9.

Lau DT, Nau DP. “Oral Anti hyperglycemic Medication Non adherence and Subsequent Hospitalisation Among Individuals with Type 2 Diabetes.” Diabetes Care. 2004;27(9):2149–53.

Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. “Impact of Medication Adherence on Hospitalisation Risk and Healthcare Cost.” Med Care. 2005;43(6):521–30.

Brown M, et al. “Medication Adherence: Truth and Consequences.” Am J Med Sci. 2016;351(4):387–399.

Jha AK, Aubert RE, Yao J, et al. “Greater Adherence to Diabetes Drugs is Linked to Less Hospital Use and Could Save Nearly $5 Billion Annually.” Health Aff (Millwood) 2012;31(8):1836–46.p

Santoli et al. Effects of the COVID-19 Pandemic on Routine Paediatric Vaccine Ordering and Administration — United States, 2020

April Presnell, “Asthma and COPD medication adherence has increased during the COVID-19 pandemic” Journal of allergy & clinical immunology, May 4, 2020.

Kruegar, K.P. et al, Improving adherence and persistence: a review and assessment of interventions and description of steps toward a national adherence initiative. J Am Pharm Assoc (2003)

Perez-Jover,V. Mobile Apps for Increasing Treatment Adherence: Systematic Review. J Med Internet Res 2019;21(6):e12505