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Breaking Down Barriers for Medication Administration
Lourdes Cross, PharmD, BCACP, CDCES
Sullivan University College of Pharmacy
University of Louisville Hospital, Louisville, KY

Approximately half of patients with type 2 diabetes are unable to achieve glycemic goals.¹ It is estimated that only 50% of patients take their medications as prescribed, which can contribute to increased morbidity, mortality, healthcare costs, emergency room visits, and hospitalizations.² Therefore, it is important to recognize and minimize factors that may introduce barriers to medication administration. This blog addresses some barriers for taking medications appropriately and strategies to help improve patient outcomes.

Identify or Predict Medication-taking Behaviors
In one study, up to 61% of patients stated they rarely or never discussed medication-taking behaviors with their physicians, and 67% of physicians reported being unaware of how often their patients missed a dose of medication.³ Asking the right question can reveal if a patient is adherent. Consider asking the patient these open-ended questions:

• How often do you have difficulty remembering to take all your medications?
• Taking medications can be inconvenient. How often do you feel bothered about taking medications?

Another method to assess medication administration is to retrieve electronic pharmacy data to identify refill frequency. However, this does not always ensure that the patient is taking the medication correctly. Some tools have been developed to predict medication-taking behavior. The Medication Adherence Questionnaire and Morisky Medication Adherence Scale use patient-reported measures to assess this area.⁴ Ultimately, increasing trust and communication between the health care provider and patient will improve the identification of problems with medication administration.

Barriers and Solutions

Patient Knowledge
It can be challenging for patients to take a medication when they do not understand why it is prescribed or how to use it. Other patients want to reduce the potential for side effects and/or test the lowest possible dose that will be effective for them. Up to 35% of English-speaking, Medicare-enrolled patients demonstrated "inadequate" health literacy, defined as the ability to read and understand health information (e.g., medication instructions).⁵ A meta-analysis study found that patients are 2.16 times more likely to take their medication as prescribed if their physician communicates with them effectively.⁶

Regimen Complexity
As the number of medications prescribed and dosing frequency increases, low adherence becomes a growing concern. Strategies to overcome this barrier include eliminating unnecessary medications, prescribing combination products, and utilizing once-daily regimens. In one study, the adherence rates for 2-times, 3-times, and 4-times daily regimens were -6.7%, -13.5%, and -19.2%, respectively, compared to once-daily regimens.⁷ Moreover, using combination medications allows patients to decrease pill burden while benefitting from a single copayment.

Financial Burden
A major reason why patients do not take medications as prescribed is cost. Consider insurance formularies, generic formulations, and 90-day supplies to help reduce costs. However, one study showed that patients who pay nothing for medications improve their adherence by only 4-6%.⁸ Therefore, there are likely multiple factors that affect adherence beyond financial barriers.

Unintentional Behavior
Unintentional nonadherence may be due to forgetting to take a medication, never picking up a medication, and physical inability (e.g., poor vision or dexterity impairing the ability to inject medications or open pill bottles). Forgetfulness tends to be the most commonly reported reason for not taking medications.⁹ Text message reminders have been shown to improve the odds of medication administration by 2.11 times, increasing baseline rates from 50% to 67.8%.¹⁰ There are also free phone apps, such as Care4Today and Medisafe, to help patients track and remember to take their medications. Written reminders for prescriptions sent electronically may also help, considering that 22% of e-prescriptions are never filled.¹¹
 

 
Conclusion
U.S. Surgeon General C. Everett Koop once stated, "Drugs don't work in patients who don't take them." Given the benefits of improved health outcomes with medication administration, it is important to utilize multiple strategies to remove barriers to appropriate medication administration. Four key areas to review include patient knowledge, regimen complexity, financial burden, and unintentional behavior.

What methods have you successfully utilized to help your patients with medication administration? Reply to this blog post to share your tips with the ADCES community.


References

1. Ali MK, McKeever Bullard K, Imperatore G, Barker L, Gregg EW, Centers for Disease Control and Prevention (CDC). Characteristics associated with poor glycemic control among adults with self-reported diagnosed diabetes--National Health and Nutrition Examination Survey, United States, 2007-2010. MMWR Suppl. 2012;61(2):32-37.
2. Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: Meta-analysis on 376,162 patients. Am J Med. 2012;125(9):882-887.
3. Hines R, Stone NJ. Patients and physicians beliefs and practices regarding adherence to cardiovascular medication. JAMA Cardiol. 2016;1(4):470-473.
4. Lam WY, Fresco P. Medication Adherence Measures: An Overview. Biomed Res Int. 2015;2015.
5. MacLaughlin EJ, Raehl CL, Treadway AK, Sterling TL, Zoller DP, Bond CA. Assessing medication adherence in the elderly. Drugs Aging. 2005;22(3):231-255.
6. Haskard Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: A meta-analysis. Med Care. 2009;47(8):826-834.
7. Coleman CI, Limone B, Sobieraj DM, et al. Dosing frequency and medication adherence in chronic disease. J Manag Care Pharm. 2012;18(7):527-539.
8. Choudhry NK, Avorn J, Glynn RJ, et al. Full coverage for preventive medications after myocardial infarction. N Engl J Med. 2011;365(22):2088-2097.
9. Gadkari AS, McHorney CA. Unintentional non-adherence to chronic prescription medications: How unintentional is it really? BMC Health Serv Res. 2012;12(1).
10. Thakkar J, Kurup R, Laba T-L, et al. Mobile telephone text messaging for medication adherence in chronic disease. JAMA Intern Med. 2016;176(3):340.
11. Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: Analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010;25(4):284-290.