There seems to be a pill for just about everything these days. Pills can help you lose weight, lower your cholesterol, treat depression, and even prevent HIV transmission. But just because there’s a pill for everything that ails us, that doesn’t mean everyone who gets a prescription will be healthy (or healthier) as a result. Medication nonadherence is a serious problem that leads to decreased workforce productivity, hospitalizations, and increased health care costs.
Medication adherence is a complicated issue. It is affected by multilevel determinants at the patient, provider, and health care system levels. For example, patients often forget to take their prescribed medication, and some providers may inspire more motivation to adhere to treatment than others. Therefore, interventions need to operate on multiple levels to optimize adherence. Furthermore, those interventions need to be evidenced based and show improvements in adherence or health outcomes. So what exactly makes an effective adherence intervention when working on multiple levels?
To help address this question, the NIH Adherence Network organized a session at The Society of Behavioral Medicine’s 2016 annual meeting called “Promoting Practical Adherence Interventions at the Patient, Provider, and System Level” with the speakers Frank Treiber, Ph.D., Deborah Jones, Ph.D., and Niteesh Choudhry, M.D., Ph.D. The session was led by NIH Adherence Network Co-Chairs Michael Stirratt, Ph.D., and Janet de Moor, Ph.D.
Practical Adherence Interventions: mHealth Solutions for Uncontrolled Hypertension
Frank Treiber, Ph.D., and his colleagues are testing a promising mHealth self-management system that was shown to improve medication adherence and blood pressure control among patients with uncontrolled hypertension in feasibility studies.
mHealth technology and its ubiquity holds much promise to tackle nonadherence. There are many mHealth interventions, but few have led to actual improvements in medication adherence or health outcomes to date.
What makes Treiber’s approach effective where others have failed to yield positive results? For starters, Treiber and colleagues designed the system to be patient and provider-centered, theory guided, and iteratively developed. They incorporated input from patients and health care providers in the prototype’s development and then tested usability and acceptance of the system in both the lab and the field. After this initial feasibility testing, the group further refined the system with additional patient recommendations. The system involves medication reminder devices, blood pressure monitors, a patient’s smart phone, motivational messages, and communication between the patient and provider. The motivational messages, while automated, are personalized and take a patient’s background, life goals, and motivations into account.
In feasibility trials with groups of patients with uncontrolled hypertension, Treiber saw high acceptability and adherence to the protocols, 95 to 100 percent medication adherence, large reductions in blood pressure, and reduced emergency room visits. Treiber’s system is now in a randomized controlled study to test efficacy.
Practical Adherence Interventions: A Multilevel Approach to Improving HIV Medication Adherence
Medication adherence also plays a critical role in the treatment of HIV. Deborah Jones, Ph.D., conducted a pilot study of an intervention aimed at improving adherence among patients with HIV who were not engaged in care. She focused on patients in Argentina where free HIV treatment has been available to residents since 1992. Despite this availability, about one-quarter of patients with HIV remain unengaged in care.
Jones’ intervention had both patient and provider components and she compared them separately and collectively. The patient intervention consisted of four informational sessions on topics such as HIV knowledge, medication, and social relationships. The provider intervention trained providers in motivational interviewing, a patient-centered technique that promotes long-term health behaviors.
The study results showed a difference between the effectiveness of the provider and patient interventions. Patients in the provider intervention group reported sustained improvements compared to provider control groups. Improvements included treatment adherence, viral suppression, and better patient-provider relationships. Results from the patient intervention were not as promising, as there were no sustained benefits.
Overall, the study suggests that training providers in motivational interviewing can be a powerful tool in improving medication adherence. Jones is hopeful that future clinical trials will determine whether provider-based interventions are more generalizable.
Practical Adherence Interventions: Targeting the Health Care System
Aside from providers and patients, the health care system is also an important and valid target for adherence intervention. Niteesh Choudhry, MD, Ph.D., points out the advantages of targeting health care organizations and insurance company systems:
- Health system interventions address factors, such as medication cost, delivery, and appearance, that can’t otherwise be addressed.
- Insurance providers have a wider reach than single centers, so interventions can be more widely adopted.
- System-based interventions rely on routinely collected administrative and health data to target subjects and assess outcomes, thereby providing additional efficiencies.
- Systems approaches can facilitate the adoption of successful interventions.
In his talk, Choudhry provided examples of health system adherence interventions and studies. One example involves variations in pill appearance. In a recent study, published in JAMA Internal Medicine, Choudhry examined how pill color and shape affect adherence. He assessed more than 11,000 patients who failed to fill a prescription within five days of the previous prescription elapsing. He also studied data from more than 50,000 control patients who had no delay in refilling medications. He found that changes in pill color significantly increased the chances of nonadherence. To address this, he suggests reconsidering current policy that permits variation in the appearance of bioequivalent drugs.
In another study, published in Health Affairs, Choudhry tested the impact of providing full coverage for medications to treat cardiovascular disease. The randomized clinical trial was conducted among 5855 patients who had a prior heart attack. In this trial, the elimination of medication copayments resulted in improved medication refill adherence rates. This reduced racial disparities in clinical outcomes by 35 percent, and a cost analysis showed that health care spending was reduced by 70 percent overall. The findings from this trial have been influential and have helped prompt insurers to reduce copays for this population.
Related Reads
Read Frank Treiber’s recent publications related to his mHealth intervention:
Sustainability of Improvements in Medication Adherence Through a Mobile Health Intervention
Mobile Health Medication Adherence and Blood Pressure Control in Recent Stroke Patients
Read Deborah Jones recent publications related to her patient/provider intervention:
Improving Adherence to Care Among “Hard to Reach” HIV-Infected Patients in Argentina
Examining Adherence Among Challenging Patients in Public and Private HIV Care in Argentina
Read Niteesh Choudhry’s recent publications related to health care system interventions and studies:
Variations in Pill Appearance of Antiepileptic Drugs and the Risk of Nonadherence
Eliminating Medication Copayments Reduces Disparities in Cardiovascular Care
Full Coverage for Preventive Medications After Myocardial Infarction
The Implications of Therapeutic Complexity on Adherence to Cardiovascular Medications
Trouble Getting Started: Predictors of Primary Medication Nonadherence
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