MODERN TREATMENT OF DISEASE: THE IMPORTANCE OF MEDICATION

ADHERENCE

CURRENT EVENTS

• http://www.forbes.com/sites/wendydiller/2014/10/15/is-specialty-pharma-pricing-at-a-tipping-point/?ss=pharma-healthcare (David Yum)• Best motivation is “nagging”• Sovaldi ~ $96,000 per course of treatment (Pricey new pill: http://

news.yahoo.com/us-approves-pricey-pill-against-hepatitis-c-210744696.html )(Fola)

• I need my meds now… (Rachel)

• Medisafe (Amanda Wolfe – FYOS)

• Question: What should a pharmacist say if a patient says he/she does not know what the medication is for, especially if its for a sensitive drug like an antipsychotic? (Annie)

• Democrats more likely than republicans to believe in paranormal…(Kelsey)• Ultimate in adherence…stem cells? (Cindy)• Pharmacists and corporate greed... (Melody

SOME COMMON PROBLEMS

Colds, Sinus and Ear Infections

• Folk remedies• Antibiotics are now the

mainstay• Cost $4 to hundreds for

common infections

• Problem with resistance

Flu

• Those most at risk were infants, the elderly and those with chronic diseases, especially asthma and decreased immune systems

• Mortality rates were very high as there were not treatments

• Annual flu shot• Cost of flu shot is about

$25

LESS COMMON MEDICAL CONDITIONS

Arthritis

• Past: few effective tx’s• Patients suffered with

this deforming and debilitating disease

• Now have “TNF” inhibitors and anti-inflammatory drugs

• $4 for generic Ibuprofen to $1,000 a month for new injectable TNF therapy

Many Cancers

• Surgery if possible ( $$$ with uncertain outcome)

• Modern imaging technology have made early detection and prevention key – MRI is about $1-2,000

• Better chemo drugs but still very toxic

• Cost of chemo can be $$$ per treatment

OSTEOPOROSIS

• 40% white women, 15% white men over 50• Age, gender and race as risk factors for low bone

mineral density• There are good screening techniques (ultrasound, DEXA)• Forearm, hip, spine fractures• 20% -40% of those with a hip fracture expire within 6

months• High medical costs to treat, increases in nursing home

admissions• Boniva, Actonel, Fosamax – increase density but also

cause other problems such as GI irritation, possibly more brittle bones

SCHIZOPHRENIA

• 1-2% of all adults• What is it? Positive and Negative sx• 50% become permanently disabled• Drugs to treat can offer some relief• Zyprexa, Risperdal, Seroquel, Abilify, Mellaril,

Haldol, Thorazine, and others• Side effects are problematic: metabolic,

parkinson-like symptoms, drooling, somnolence, excitement, etc.• Modern drugs cost $300-$800 per month

compared to $4-50 for older therapies

STOMACH ULCERS

• Duodenal and Peptic ulcers• We used to treat by regulating the stomach acid

which was sometimes counterproductive• Surgery was an option that in the past was widely

accepted (thousands, including hospital stays)• H2s and PPIs as well as recognition there was a

bacterial cause of ulcers as well• Tagament, Zantac, Axid, Pepsid, Prevacid,

Prilosec, etc. at a cost of $4-100 a month

HEART DISEASE

• Causes can include family history, sedintary lifestyle, obesity, diabetes, high blood pressure, high cholesterol to name a few

• Drugs to treat all these conditions• Each of the previous examples showed how drugs can

be used to treat - in this case the root cause treatment may be to increase cardiovascular fitness through diet and exercise - - weight loss

• Literally hundreds of drugs you may have heard of like Lipitor, Crestor, various insulin, Ally, Zocor, Norvasc, Inderal, and lots and lots of others

• Costs are all over the board from $4 to many hundreds per month

SUMMARY

• Drugs are an important part of medical care, representing about 15% of each health care dollar• Over time, drugs reduce the total cost of care,

even when these drugs become very expensive• Modern medicine has made great advances –

more is needed (e.g. Schizophrenia)

• BUT: What happens when people don’t take their medications?

OUTCOMES

• Economic• increased cost of medications• lower total health care costs

• Clinical • better control of disease, symptoms

• Humanistic• patient satisfaction with therapy

WHEN PATIENTS DO NOT TAKE THEIR MEDICATIONS CORRECTLY:

• they may not get better• conditions can worsen• patients relapse

THE COSTS OF NONCOMPLIANCE:

• The stats:• ~290 billion dollars annually in unnecessary costs

(almost triple 10 years ago)• 125,000 unnecessary deaths (relatively constant)• 10% (more than 1,000,000) of all hospitalizations may be

due to noncompliance• 50% of all medication use is non-compliant

Fung, B. The $289 Billion Cost of Medication Noncompliance, and What to Do About It. The Atlantic. http://www.theatlantic.com/health/archive/2012/09/the-289-billion-cost-of-medication-noncompliance-and-what-to-do-about-it/262222/

HEALTH EFFECTS

• increased morbidity• treatment failures• exacerbation of disease• more frequent physician visits• increased hospitalizations• death

ECONOMIC EFFECTS:

• increased absenteeism• lost productivity at work• lost revenues to pharmacies• lost revenues to pharmaceutical manufacturers

BENCHMARK COMPLIANCE RATES:

• Disease• Epilepsy• Arthritis• Hypertension• Diabetes• Oral contraceptives• HRT• Asthma

• Rates of noncompliance• 30% to 50%• 50% to 71% • 40% (average)• 40% to 50%• 8%• 57%• 20%

DIMENSIONS OF COMPLIANCE

• Initial noncompliance or defaulting• 2% - 20%, possibly as high as 50%• average 8.7%

• Refill compliance or persistence• Improper medication use • rational noncompliance

PERSISTENCE

• Product persistency curves • after 1 year as

much as a 50 percent decline

• after 5 years, compliance as low as 29% to 33%

• greatest declines in first six months

0

20

40

60

80

100

1 3 5 7 9 11 13

Months

Percen

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CozarFosamaxZocor

IMPROPER MEDICATION USE:

• Over or under use, wrong time • Taking the wrong medicine• Not finishing medication• Administration errors • Using another persons medication• Using old, possibly expired medication

THE PRESENT SITUATION

• Measuring compliance• patient reports, clinical outcomes, pill counts,

refill records, biological and chemical markers, monitors

• MPR: medication possession ratio

• We need to be able to distinguish between patients not responding and patients not complying.

• Should recognize noncompliance cuts across drugs, diseases, prognosis, and symptoms.

THE PRESENT SITUATION

• Current research• most studies aimed at measuring,

understanding or improving compliance • most are single interventions; few

multifaceted interventions have been studied• more studies have begun to focus on

changes in economic, clinical and humanistic outcomes resulting from compliance interventions

• Some studies with asthma, CHD, HTN, diabetes and others

STRATEGIES TO IMPROVE COMPLIANCE

• multimedia educational campaigns• patient education, counseling, written

information, special labels• teaching methods for self monitoring• contracts with patients• devices, reminders (mail, telephone), special

packaging• follow-up

THE “RIM” TECHNIQUE

• Recognize• using objective and subjective evidence, the

pharmacist can determine if the patient may have an existing compliance problem

• Identify• determine the causes of noncompliance with

supportive probing questions, empathic responses, and other universal statements

• Manage• develop partnerships with patients

IDENTIFYING NON COMPLIANCE

• information from the patient• patient comments, concerns, questions

• certain clinical outcomes• non response to treatment

• information from refill records

PATIENT CONSIDERATIONS

• Factors believed to affect compliance• patient knowledge• prior compliance behavior • ability to integrate into daily life• health beliefs and perceptions of possible

benefits of treatment• social support (including practitioner

relationships)• complexity of regimen

PATIENT CONSIDERATIONS

• Factors which are not believed to be associated with compliance• age, race, gender, income or education• patient intelligence• actual seriousness of the disease or the efficacy of

the treatment

PATIENTS AT HIGHER RISK:

• Asymptomatic conditions• hypertension

• Chronic conditions• hypertension, arthritis

diabetes

• Cognitive impairment• dementia, Alzheimers

• Complex regimens• Irregular dosing

protocols

• Multiple daily dosing• qd < bid < tid, < qid

• Patient perceptions • effectiveness, side

effects, cost

• Poor communication• patient practitioner

rapport

• Psychiatric illness• less likely to comply

PATIENT CONSIDERATIONS

• Patient skills needed for behavior modification• problem solving• self monitoring • develop systems for reminders• enlisting social support• identify positive and negative compliance behaviors

ACTIONS NEEDED

• More fully implement the pharmacy care model• Challenges:• pharmacist commitment to pharmacy care • enhance the key skills necessary for patient care• develop partnerships with physicians, MCO’s and

patients• integrate, coordinate and manage drug use

THE COSTS

• Financial• training, experience, cost of interventions

• Time• pharmacy management

• Commitment• pharmacists, physicians, health administrators,

patients

THE PHARMACY CARE PROCESS

• Collect and utilize patient information (build rapport)• Identify patients’ drug related problems• Develop solutions • Select and recommend therapies• Follow up to assess outcomes

THE VISION

• The modern pharmacy practitioner will partner with patients, physicians (medical home) and managed care to facilitate achievement of desired health outcomes. (MI?)

• Managing medication compliance is a primary means to successful pharmacy care and better outcomes for patients. The issue of compliance is complex, but, has important implications for health practitioners.

VISION / CHALLENGE

• As pharmacists work to improve compliance, pharmacy care activities must also increase. Better compliance may result in improved outcomes, but, it may also mean more drug related problems. • over users who take less medication may

experience increased symptoms• under users who take more doses may experience

more side effects

GOALS FOR RESEARCHERS AND PRACTITIONERS:

• What is the net impact of pharmacy care on medication compliance?• Recommendations:• Better packaging (blister packs, compliance packaging,

“counter caps”, etc.)• Case management (medical home, gatekeeper, managed

care, etc.)• Educational behavioral support (e.g., MI, Pharmacists and

others)• Access to compliance data (its in there!)• Make drugs cheaper (when cost is a driver of non-

compliance)

SUMMARY: THE CHALLENGE OF COMPLIANCE AND OUTCOMES

• Pharmacists will partner with patients, physicians and MCO’s to ensure desired health outcomes are achieved. Working to improve compliance means pharmacy care activities must also increase to ensure safety with the use of “strong medicine”. Then, better compliance will result in improved outcomes.

BENEFITS OF IMPROVED COMPLIANCE:

• Patients - better outcomes and quality of life• Practitioners - healthier more loyal patients• MCO’s - lower total HC expenditures• Pharmaceutical Industry - increased sales