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Engaging Patients in Their Care: Medication Adherence & Health Literacy in Clinical PracticeSarah Aldrich, PharmDBree Meinzer, PharmDJoseph K. Daprano, MD, FAAP, MACPJoseph J. Sudano, PhD
Objectives
1. Describe the impact of medication nonadherence and low health literacy
2. Identify different tools that can be used in primary care to identify patients with low health literacy and nonadherence
3. Review strategies to improve medication adherence and health literacy
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Disclosures
The following planners, speakers, moderators, and/or panelists of the CME activity have no financial relationships with commercial interests to disclose:
Sarah Aldrich, PharmDBree Meinzer, PharmDJoseph K Daprano, MD, FAAP, MACPJoseph J Sudano, PhD
The Ohio Cardiovascular Health Collaborative is funded by the Ohio Department of Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in this presentation are solely those of the authors and do not represent the views of the state of Ohio or federal Medicaid programs.
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Medication Adherence
Sarah Aldrich, PharmD & Bree Meinzer, PharmD
University of Toledo College of Pharmacy and Pharmaceutical Sciences
University of Toledo Medical Center
What is adherence?
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AdherenceExtent to which medication intake behavior corresponds with the recommendations of the provider
Compliance Extent to which the patient follows the recommendations of the provider
PersistenceLength of time between the first and last dose (when patient discontinues treatment)
Hugtenburg JG, et al. Patient Preference and Adherence, 2013.7:675-82.
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Intentional vs. Unintentional Nonadherence
Unintentional
Unplanned behavior that is not commonly
linked to beliefs or cognition
IntentionalPatient ACTIVELY decides not to use treatment or follow recommendations
Hugtenburg JG, et al. Patient Preference and Adherence, 2013.7:675-82.
Measuring Adherence
• Proportion of Days Covered (PDC)• CMS defines adherence as a PDC >80%
• Medication Possession Ratio
Crowe M. Pharmacy times. 2015.9
Impact of Nonadherence
National Data
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Ohio Medicaid Data 2017-2018• Only 1/3 of Medicaid enrollees (132,685/424,851) age 18-
64 years old with a hypertension diagnosis filled a blood pressure (BP) prescription
• Of those who filled at least 1 BP medication (n=292,166), 7% filled their BP medication only once making it impossible to calculate their adherence
• Of those who filled the BP medications at least twice (n=271,963), 64% were considered adherent (MPR>80%)
What factors contribute to medication nonadherence?
Five Dimensions of Adherence
Social and Economic● Low health literacy● Medication cost● Lack of health
insurance
Health Care System● Lack of care
continuity● Restricted
formularies● Long wait times Condition-Related
● Lack of symptoms● Depression● Severity of symptoms
Patient-Related● Visual, hearing,
cognitive impairment● Perceived risk of
disease● Perceived benefit of
treatment
Therapy-Related● Complexity of
regimen● Frequent changes● Actual or perceived
side effects
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01
02 03
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Sabate E. World Health Organization. 2003. 14
Common Contributing Factors for Nonadherence
Regimen Complexity05● Too many medications; Multiple
dosing times; specific medication instructions
Forgetfulness04
Lack of Understanding03
● Health literacy; Risk of disease vs. benefit of treatment; Lack of symptoms; Mistrust
Adverse Effect01 ● Actual or perceived; Relation to benefit of treatment
Cost02
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Investigating Medication NonadherenceObjective Information
• Claims Data • How often has the medication been filled within a 90 day period?
• Clinical Data• Limited or no improvement in signs or symptoms
Subjective Information
• Motivational Interviewing • Creating a no-judgement / honest environment
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How do we improve medication adherence?
Regimen Complexity05● Change product or formulation;
Deprescribing; Medication Synchronization
Forgetfulness04 ● Set alarms; Keep pills visible; Incorporate into other routine
Lack of Understanding03 ● Education
Cost02● Coupons; $4 lists/$0 copay at specific
pharmacies; Investigate insurance formulary
Adverse Effect01 ● Prescribe alternative; Switch formulation; Address perceived AE
Overcoming Medication Nonadherence
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Patient Specific Approach to Medication Adherence
Case #1PA is a 57 yo WM with PMH of HTN, HLD, T2DM
• BP: 160/94, HbA1c: 7.0%, and lipid panel is wnl• Medications: atorvastatin 20mg daily, metformin 1000mg BID,
and lisinopril 5mg daily• You are discussing with him about increasing his lisinopril 5mg
daily. PA mentions that it doesn’t matter much, because he doesn’t take his lisinopril anyway. Upon further questioning, he states “I don’t feel any different if I take it, so why bother?”• How do you respond to the patient?
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Case #2CM is a retired 78 yo African American female with PMH of CHF, HTN, HLD, CKD & T2DM• BP: 148/86, EF: 30%, LDL: 160, HDL: 38, TG: 172, HbA1c: 7.4%• Medications: Entresto 49mg/51mg BID, carvedilol 6.25mg BID,
rosuvastatin 10mg daily, metformin 1,000mg BID, Januvia 100mg daily• At the appointment, you notice that some of CM’s pill bottles are
empty. Upon further questioning, she states “I can’t afford to all of the medications and I know how important it is to take them. In order to save money, I pick up half of them one month and pick up the rest the next month.”• How can we improve the patient’s adherence?
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Case #3TA is a 62 year-old Caucasian female with a PMH of T2DM, HTN, and depression• BP: 124/84, HR: 70, A1c 6.9%, TG: 100, Total cholesterol 110, LDL:
70, HDL 51• Medications: metformin 1000 mg BID, Lantus 15 units QHS, lisinopril
40 mg daily, atorvastatin 40 mg daily and citalopram 20 mg daily• She presents to clinic complaining of left hip pain that extends
through her left thigh. Her sister told her it was probably the “statin drug” because she no longer takes hers due to muscle pain. She states, “I have enough aches and pains, I do not need a medication to make it worse.”• How do you respond to the patient?
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Case #4SR is a 52 year-old caucasian male with a PMH of HTN, CAD, and anxiety
• BP: 142/90 mmHg, HR: 75, FLP within normal limits
• Medications: lisinopril 40 mg daily, HCTZ 25 mg daily, metoprolol tartrate 25 mg BID, atorvastatin 80 mg daily, ASA 81 mg daily and fluoxetine 20 mg daily
• During the visit, the patient admits that he often forgets to take his second dose of metoprolol. He often falls asleep before remembering the dose.
• How can we improve this patient’s adherence?
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Adherence Chart Example 1
Drug For: Dose: Breakfast/Lunch Supper/Bedtime
Aspirin 81mg daily Heart 1 tab X
Metoprolol tartrate 25mg twice daily
Blood Pressure ½ tab ½ ½
Multivitamin daily Supplement 1 tab X
Tradjenta 5mg daily Diabetes 1 tab X
Lisinopril 5mg daily Blood Pressure 1 tab X
Caduet 5/20mg daily(contains Amlodipine 5mg and atorvastatin 20mg)
Blood PressureAndCholesterol
1 tab X24
Adherence Chart Example 2
Drug Dose: Breakfast Lunch Dinner Bed
Terazosin 2mg twice daily 1 cap X X
Sertraline 100mg twice daily X (1 tab) X (1.5 tabs)
Omeprazole 20mg twice daily 1 cap X X
Mirtazapine 15mg daily at bedtime
1.5 tabs X
Atorvastatin 20mg daily 1 tab X
Lyrica 25mg 3 times daily 1 tab X X X
Warfarin 2.5mg (0.5-1 tab) daily Dosed by Anticoag Clinic25
Adherence Chart Example 3
Drug Dose: Breakfast Lunch Dinner Bed
Losartan 25 mg twice daily 1 tab
Omeprazole 20mg twice daily 1 cap
Zolpidem 5 mg daily at bedtime 1 tab
Atorvastatin 20mg daily 1 tab
Gabapentin 100 mg 3 times daily 1 cap26
Questions?
ReferencesBaumgartner PC, Haynes RB, Hersberger KE, Arnet I. A systematic review of medication adherence thresholds dependent on clinical outcomes. Front Pharmacol. 2018; 9:1290.
Crowe M. Do you know the difference between these adherence measures. Pharmacy times. 2015. Accessed 19 March 2019. Available from: https://www.pharmacytimes.com.
Hinson J, Garofoli G, Elswick B. The impact of medication synchronization on quality care criteria in an independent community pharmacy. J Am Pharm Assoc. 2017; 57(2): 236-240.
Hugtenburg JG, Timmers L, Elders P, Vervloet M, Dijk LV. Definitions, variants and causes of nonadherence with medications: a challenge for tailored interventions. Patient Preference and Adherence. July 2013. 7:675-682.
Kefale B, Tadesse Y, Alebachew M, Engidawork E. Management practice, and adherence and its contributing factors among patients with chronic kidney disease at Tikur Anbessa Specialized Hospital: A hospital-based cross-sectional study. PLoS One. 2018;13(7):e0200415.
Lycett H, Wildman E, Raebel E, et al. Treatment perceptions in patient with asthma: synthesis of factors influencing adherence. Resp Med. 2018; 141:180-189.
Measuring adherence. American Pharmacist Association. https://www.pharmacist.com/measuring-adherence?is_sso_called=1. Accessed March 13, 2019.
Naqvi AA, Hassali MA, Aftab MT, Nadir MN. A qualitative study investigating perceived barrier to medication adherence in chronic illness patients of Karachi, Pakistan. J Pak Med Assoc. 2019; 69 (2):216-223.
Patton DE, Cadogan CA, Ryan C, et al. Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators. Health Expect. 2017;21(1):138-148.
Sabate, Eduardo. Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organization; 2003.
2018 Medicare-Medicaid Plan Performance Data Technical Notes. Centers for Medicare and Medicaid Services. Updated April 2018.https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MMPPerformanceDataTechNotesCY2018_04252018.pdf. Updated April 2018. Accessed March 13, 2019.
Health LiteracyThe Medical Imperative
Joseph K. Daprano, MD, FAAP, MACPAssistant Professor, Internal Medicine & Pediatrics, Case Western
Reserve UniversityPhysician, The MetroHealth System
Joseph J. Sudano, PhDAssistant Professor of Medicine, Population and Quantitative Health
Sciences, Case Western Reserve UniversitySenior Researcher, The MetroHealth System
The Bottom Line
• Only 12 percent of adults have Proficient health literacy. In other words, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease.
• Fourteen percent of adults (30 million people) have Below Basic health literacy. These adults are more likely to report their health as poor (42 percent) and are more likely to lack health insurance (28 percent) than adults with Proficient health literacy.
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Measuring Health LiteracyMeasures of health literacy at the individual level were largely developed in the 1990s:
• Rapid Estimate of Adult Literacy in Medicine (REALM)
• Test of Functional Health Literacy in Adults (TOFHLA and S-TOFHLA)
Recently developed for Spanish speakers:• Short Assessment of Health Literacy–Spanish and English (SAHL-
S&E) (2010)
• Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) (2006)
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Measuring Health Literacy• Health literacy measures based on functional literacy do not capture the
full range of skills needed for health literacy.
• Current assessment tools (for populations and individuals) cannot differentiate among:• Reading ability• Lack of health-related background knowledge• Lack of familiarity with language and materials• Cultural differences in approaches to health
• However, these measures are the best we have at this time for research purposes involving populations. In the clinical setting, single item measures are often used for quick screening for health literacy issues.
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Literacy
•From the 1991 National Literacy Act, asdefined by the U.S. Congress:
“…an individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and to develop one’s knowledge and potential.”
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Literacy Statistics• Average American reads at the 8th grade level• One out of five read below grade level five• 9% of Ohio’s population lack basic literacy skills • Varies from county to county: • Adams county 13%• Logan 10% • Hamilton 7% • Delaware 4%
https://nces.ed.gov/naal/estimates/StateEstimates.aspx 200337
Low Literacy
Adults who cannot read or cannot read well:• Rely on oral sources for information: TV, radio, friends, family• May be reluctant to ask questions of those they do not know• May feel embarrassed• Do not self-identify• Cannot be identified by appearance• Exemplify perseverance in life
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Examples of Literacy Levels and TasksTasks People with Level 1 Literacy
(Grade level K-2)Usually Can Perform:
• Locate 1 piece of information from a short article• Read current net pay from a pay
stub• Add 2 numbers on a bank deposit
form
Tasks People with Level 2 Literacy(Grade level 2-6)
Usually Can Perform:
• Read the gross pay year-to date from a pay stub• Calculate total costs from
items on an order form
InitialFindings,PreparedbytheCenteronUrbanPovertyandSocialChangeCWRU39
Health Literacy
Health Literacy is defined in the Institute of Medicine report Health Literacy: A Prescription to End Confusion as:
“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."
- Institute of Medicine. 2004. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press
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Why is Health Literacy Important?
Poor health literacy is a stronger predictor of a person's health than age, income, employment status, education level, and race
Health Literacy and Patient Safety: Help Patients Understand
2007 American Medical Association Foundation & American Medical Association
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WHY IS HEALTH LITERACY IMPORTANT?• Lower health literacy scores were associated with higher
mortality rates within a Medicare managed care setting. -Baker 2007
• People with low health literacy have a lower likelihood of getting flu shots, understanding medical labels and instructions, and a greater likelihood of taking medicines incorrectly compared with adults with higher health literacy. -Bennett IM, 2008
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Health Literacy and Hypertension
In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. -Pandit, AU 2009
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Health Literacy and Healthcare Cost
• $106-$238 billion is lost every year on health care costs due to a disconnect in the delivery of health information.Vernon, J.(2007). Low Health Literacy: Implications for National Health Policy
• In a study of 92,749 veterans with service utilization from 2007–2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581) than for patients with adequate health literacy ($23,508).Huan,J. BMC Health Serv Res. 2015; 15: 249
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What do we know about our communications with patients?• Up to 80 percent of medical information provided by
healthcare providers is forgotten immediately by patients. • Almost half of the information that is remembered is
incorrect.• Even though approximately 20 percent of American adults
read at or below the fifth grade level, most health information materials are written at the tenth grade level or above. - National Assessment of Adult Literacy 2003
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Health Literacy Levels
The National Assessment of Adult Literacy (NAAL) measures the health literacy of adults living in the United States. (2003)• Health literacy was reported using four performance levels: Below
Basic, Basic, Intermediate, and Proficient• 36% of adults in the United States have limited health literacy• 22% have Basic and 14% have Below Basic health literacy• The majority of adults (53 percent) had Intermediate health literacy• An additional 12 percent of adults had Proficient health literacy
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Health Literacy Live
Health Literacy includes the ability to understand: • How to negotiate complex health insurance and health care
systems• Appointment slips • Doctor's directions and consent forms• Instructions on prescription drug bottles • Medical education brochures• Pre-surgical and post-surgical instructions• Research assent / consent forms
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Skills Needed for Health Literacy
• Visually literate - able to understand graphs or other visual information
• Numerically or computationally literate - able to calculate or reason numerically
• Information literate - able to obtain and apply relevant information
• Computer literate - able to operate a computer
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The Single Item Literacy Screener
• "How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?"
• 1-Never, 2-Rarely, 3-Sometimes, 4-Often, 5-Always
• Scores greater than 2 were considered positive, indicating some difficulty with reading printed health related material
- Morris et al. BMC Family Practice 2006 7:21
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Five Steps to Improve Health Literacy
1. Conduct patient-centered visits• Engage in a dialogue with the patient• Listen more and speak less • Encourage patient questions -
(ASK Me 3)• What is my main problem?• What do I need to do?• Why is it important for me to do this?
- National Patient Safety Foundation
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2. Explain things clearly using plain language• Slow down the pace of your speech• Use analogies:
o “Arthritis is like a creaky hinge on a door.”• Use plain, non-medical language:
o “Pain killer” instead of “analgesic”
Five Steps to Improve Health Literacy
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3. Focus verbally on key messages and repeat• Limit information by focusing on 1-3 key messages per
visit• Review each point and repeat several times• Have other staff reinforce key messages
Five Steps to Improve Health Literacy
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4. Use “teach back” or “show me” techniques• Asking patients to repeat in their own words what they
need to know or do, in a non-shaming way• Not a test of the patient, but of how well you explained a
concept• A chance to check for understanding and, if necessary, re-
teach the information
Five Steps to Improve Health Literacy
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5. Use Patient –friendly educational materials to enhance interaction• Evaluate reading level of written health education
materials: http://www.readabilityformulas.com/free-readability-formula-tests.php
• Focus only on key points in educational material• Emphasize what the patient should do
Five Steps to Improve Health Literacy
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Discussion in Groups of Two
• How can I implement the Single Item Literacy Screener into my practice?
• What would a Plan/DO/Study/Act quality improvement effort on Health Literacy look like in my office?
Who will ask the question?
How will the result be communicated confidentially to all staff?
How will we mitigate patient embarrassment?
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Questions?
