Challenges for Improving Medication Adherence

Abstract

OR CHRONIC MEDICAL CONDITIONS, SUCH AS HYPERcholesterolemia and hypertension, a wide and persistent separation exists between evidence-based recommendations and the actual care patients receive. 1 Reasons for this gap are not always clear, but some components are obvious, including failing to identify patients in need of treatment, not properly initiating treatment, failing to provide proper drugs at proper doses, and neglecting to involve the patient in the choices inherent in care. Lack of persistence with adherence to prescribed treatments is a critical part of the gap.2 A sustained high level of adherence identifies a pattern of healthy behaviors 3,4 and allows medications shown to be effective in clinical trials to improve outcomes, but this is difficult to achieve with many chronic conditions. For instance, adherence rates to cholesterol-lowering drugs or antihypertension medications are poor. [5][6][7][8] Despite its importance, adherence to therapy is an individual patient behavior that is difficult to objectively measure, monitor, and improve. Patient characteristics that may lead to poor adherence include advanced age, cognitive impairment, and depression as well as attitudes and beliefs about the importance of the medication, the disease being treated, and the potential for adverse effects. Barriers to target for optimal adherence include adverse effects, polypharmacy, frequent (more than once daily) dosing, and high costs. Health care systems and clinician barriers include insufficient access to physicians, lack of trust between clinician and patient, and in some cases, physicians' negative attitudes and inadequate knowledge about the disease and value of guideline-recommended care.9,10 Due to this complexity, improving adherence has been difficult to study and adherence rates have been refractory to simple interventions. Successful interventions are often labor intensive and multilayered. They often show limited efficacy 11 and generally target only one disease or risk factor.Interventions that successfully improve adherence generally involve patient education and structural support such as patient reminders, more frequent clinic visits, or telephone calls from staff or physicians. Attempts are often made to simplify the patient's drug regimen by reducing the number of pills consumed per day and by reducing medication costs. [7][8][9] Pharmacists are often involved in assessing adherence and offering advice to physicians about simplifying and improving drug regimens.12-16 Direct counseling of patients by pharmacists may be particularly promising because of pharmacists' specialized training and knowledge of medications and availability to patients.In this issue of JAMA, Lee and colleagues 17 report the results of a pharmacy care program designed to improve medication adherence for patients with multiple chronic medical conditions, including hypertension and elevated cholesterol levels. The study focused on elderly patients who were taking multiple medications and therefore were at risk for poor adhere...

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