Barriers to Medication Adherence America's Other Drug Problem

The problem is so large that Allen J. Taylor, MD, FACC, chief of the cardiology service at Walter Reed Army Medical Center, Washington, DC, calls poor medication adherence “America’s other drug problem.” During a presentation at the American Heart Association 2006 Scientific Sessions, he noted that the elderly typically have two or more chronic medical conditions and about half of the elderly take four or more chronic medications.

Barriers to medication adherence include complex regimens, treatment of asymptomatic conditions (e.g., hypertension), and convenience factors. These barriers are particularly prevalent in the elderly making them especially at risk for medication nonadherence.  Dr. Taylor noted medication adherence is “vastly under studied” compared to the extensive literature on the effectiveness of pharmacotherapies, but available data suggest that for adherent patients, there is a 50% lower risk of hospitalization and up to 50% lower health care costs compared to nonadherent elderly patients.

The Federal Study of Adherence to Medications in the Elderly (FAME) sought to test the impact of a comprehensive pharmacy care program on medication adherence and control of blood pressure and low-density lipoprotein cholesterol (LDL-C). FAME was a single-center study conducted at the Walter Reed Army Medical Center. It included a 2-month run-in phase followed by a prospective observational trial of the pharmacy care program intervention (adherence) lasting 6 months duration and a randomized controlled trial phase of continued pharmacy care (persistence) versus usual care, also lasting 6 months.

A total of 200 patients were studied; all were military health care beneficiaries aged 65 years or older and taking four or more chronic daily medications. All participants were living independently.

After the run-in period, all pill bottles were confiscated and discarded. All regularly scheduled medications were custom packaged in blister packs, sorted by time of day (morning, noon, evening, and bedtime), and used throughout the adherence phase by all study patients. The packaging combined up to nine pills per blister and each pack cost 14 cents per month per card. All participants received the pharmacy program, including blister packs, during the adherence phase of the study. The persistence phase of the trial included randomization to either continued pharmacy program care or a return to usual care, defined as the original method of medication administration at baseline.

In this first prospective randomized trial to specifically address medication adherence in the elderly, there were marked improvements in the rate of medication adherence. Mean baseline medication adherence was 61.2% (+/- 13.5%) which increased to 96.9% (+/- 5.2%; p < 0.001) during the 6 months of pharmacy program intervention. There was a 16-fold increase in the number of participants who were 80% or more adherent to all their medications.

At the conclusion of the trial (14 months), adherence associated with usual care had fallen to near baseline levels, while continued pharmacy care was associated with a continued high adherence rate (p < 0.001). Improved compliance was associated with “clinically significant” improvements in systolic blood pressure (p = 0.02 versus baseline) and LDL-C (p = 0.001).

In the FAME study, pharmacy health care personnel were essential, he said, offering invaluable expertise. Also, the study suggests a new paradigm for a team approach to pharmacy care involving physicians, pharmacists, and patients.

Source: Diabetes In Control: Heidenreich PA. Patient adherence: the next frontier in quality improvement. Am J Med 2004;117:130-2. Blackburn DF, Dobson RT, Blackburn JL, Wilson TW. Cardiovascular morbidity associated with nonadherence to statin therapy. Pharmacotherapy 2005;25:1035-43