Poor Medicine Adherence in Americans with Multiple Chronic Conditions - Anticipating & Addressing a Looming Threat

Agenda-Setting Report Issued to Reduce Adverse Health and Economic Consequences

WASHINGTON, Oct. 15, 2013 /PRNewswire-USNewswire/ -- With mounting evidence that poor medicine adherence will increase dramatically with the projected rise in age-related chronic illnesses, the National Council on Patient Information and Education (NCPIE) –  a non-profit coalition of diverse organizations working to improve communication on the safe and appropriate use of medicines – today released a ten-step Adherence Action Agenda that places the spotlight on the pervasive and costly problem of poor medicine adherence, particularly among those age 65 and older with multiple chronic conditions, who are at the greatest risk of medication errors, drug interactions and costly disease complications.

Issued as a nationwide call to action, the report – Accelerating Progress in Prescription Medicine Adherence: The Adherence Action Agenda – finds that poor medicine adherence among patients with chronic and comorbid conditions is resulting in unnecessary disease progression and disease complications and the increased use of expensive components of health care, such as emergency room visits, hospitalizations, avoidable hospital re-admissions and post-acute care. According to estimates cited in the report, caring for approximately 27% of Americans with multiple chronic conditions accounts for 66% of the nation's health expenditures and is a major source of Medicare spending.  Of the $300 billion Medicare spent in 2010 on healthcare, beneficiaries with six or more chronic conditions – roughly 14% of the Medicare population – cost $32,658 or three times the national average. As a result, the price tag for treating patients with six or more concurrent diseases was over $140 billion, or almost half of Medicare's total spending.  

"Although the challenge of poor medication adherence has been discussed and debated extensively, what is lacking is the clear recognition that prescription medicine use and the rising prevalence of chronic and comorbid conditions are inextricably linked and together, represent a major opportunity to address this health threat," said Ray Bullman, NCPIE's Executive Vice President. "This report is intended as a wakeup call that action is needed now to confront this combined threat, before the predicted continuing upsurge of chronic conditions overwhelms the healthcare system."

Coming six years after NCPIE issued the landmark report – Enhancing Prescription Medicine Adherence: A National Action Plan – which defined poor medicine adherence as the nation's "other drug problem," the new action plan was developed in collaboration with nearly two dozen professional societies, voluntary health organizations, consumer and aging organizations, government agencies and industry leaders and based on evidence that multiple medicine use is commonplace among older Americans, especially those with multiple chronic conditions: 42% of adults aged 65 and older took five or more prescription drugs in 2012 with the average number of drugs prescribed increasing from five at age 65 to seven at age 85.  Further, there is a direct link between the number of medications taken by a patient and the risk of adverse drug reactions.  Studies document a rise in the incidence of drug reactions from 6% in patients taking two medications a day to as high as 50% in patients taking five drugs a day.

Designed to provide up-to-date information about the state of prescription medicine adherence in the U.S. and the impact of multiple chronic conditions on appropriate medicine use, the report also identifies numerous behavioral, social, economic, medical, and policy-related factors that contribute to poor adherence in this patient population.  This includes the complexity of the drug regimen, the need for patients to visit multiple pharmacies to fill different prescriptions, cost-control measures implemented by payers and health systems, poor communication between patients and clinicians, and the breakdown in provider communications during the transition to care from the hospital to the outpatient setting. All of these problems contribute to medication errors, poor health outcomes and higher health care costs and all must be addressed.

Ten New Priorities for Action
Intended to accelerate progress in appropriate medicine taking, the new Adherence Action Plan advocates for an increased focus on the overlooked challenge of multiple chronic conditions, where the need for patient adherence is most acute, and lays out these ten policy and programmatic solutions to improve medication adherence:

1. Establish medicine adherence as a priority goal of all federal and state efforts designed to reduce the burden of multiple chronic conditions.
   Because patient adherence is not viewed as an essential element of government initiatives to reduce the burden of multiple chronic conditions, the report calls for adherence to be integrated throughout the range of efforts now underway through a new HHS Multiple Conditions Strategic Framework to improve health systems change and facilitate new research efforts.
2. Establish the role of the patient navigator within the care team to help patients with multiple chronic conditions navigate the health care system and take their prescription medicines as prescribed.
   Building on the patient navigator model now used in hospitals and cancer clinics nationwide, the action plan advocates for pairing patients with multiple chronic conditions with specially trained adherence navigators who will, in collaboration with patients and caregivers, obtain the patient's medical records, create an accurate medication list, set up medication counseling as needed, schedule timely follow-up physician visits, and facilitate communication between the patient and his or her different physicians.
3. Promote clinical management approaches that are tailored to the specific needs and circumstances of individuals with multiple chronic conditions.
   Since patients with multiple chronic conditions differ in the severity of their illnesses, prognosis, and functional status, the report encourages health professionals to adopt the American Geriatric Society's guiding principles for treating older adults with three or more diseases, which calls for eliciting and incorporating patient preferences and choosing therapies that optimize benefits and minimize the harm for older patients.
4. Incentivize the entire healthcare system to incorporate adherence education and medication support as part of routine care for MCC patients.
   With research showing that the interactions between patients and their health care providers affects how well patients manage their chronic conditions, the report advocates for an expanded investment in patient/provider education and engagement tools so clinicians can implement best practices for medication adherence and counsel their patients on the importance of following treatment plans.
5. Eliminate the barriers that impede the ability of patients with multiple chronic conditions to refill their prescription medicines.
   One of the reasons patients fail to refill their prescriptions is the need to pick up prescriptions at different times and sometimes at different pharmacies, requiring numerous trips to the pharmacy. To reduce these obstacles, stakeholders support implementing the "pharmacy home" model, which gives patients a single pharmacy point of contact for filling prescriptions, and adopting refill synchronization, which allows patients to fill different prescriptions at one time and therefore, reduce the number of visits they must make to the pharmacy.
6. Reduce the cost-sharing barriers for patients by lowering or eliminating patient copayments for prescription medicines used to treat the most common chronic diseases.
   The report makes clear that the cost of medications for some patients is a barrier to filling their prescriptions and taking their medicines as prescribed and advocates adopting policies that will reduce the out-of-pocket costs for medications, especially for patients on multiple prescriptions for chronic condition.
7. Accelerate the adoption of new health information technologies that promote medication adherence.
   Because significant innovations in health technology have the potential to improve the flow of timely and complete information on medicine use between patients and providers, the report calls for the swift adoption of new standards for using electronic health records, incentivizing providers to use health information technology to identify patients at risk for medication misuse, and the expanded use of electronic reminders and personal health records to improve medication adherence.
8. Establish medication adherence as a measure for the accreditation of healthcare professional educational programs.
   Currently, the nation's medical residency programs are moving towards an outcomes-based accreditation system, where all medical residents will be evaluated on the basis of required core competencies, including interpersonal skills and communication.  From the standpoint of medication adherence, this represents an important opportunity to integrate medication management and e-prescribing into the curriculum of medical residency programs and paves the way for establishing medicine adherence skills as core competencies within the curricula of schools of pharmacy, nursing, and other allied health professions and as a measure for accreditation.  
9. Address multiple chronic conditions and optimal medication management approaches in treatment guidelines.
   Clinical practice guidelines typically focus on managing a specific chronic condition and do not take into account the presence of multiple chronic conditions.  The report advocates the accelerated development of updated treatment guidelines where information on the most common comorbidities clustering with the incident chronic condition is included, starting with the most common combinations of multiple chronic conditions, called dyads and triads, which have already been identified by the Centers for Medicare and Medicaid Services (CMS).
10. Stimulate rigorous research on treating people with multiple chronic conditions, including focused research on medication adherence to promote the safe and appropriate use of different medicines in this patient population.
    There is a paucity of evidence-based data on how to treat patients with two or more concurrent diseases who are taking drugs developed and tested in people who have a single condition. According, the report supports incorporating medicine adherence throughout the research agenda for multiple chronic conditions and advocates for increasing the budget for HHS research efforts on the best ways to treat the most prevalent clusters of concurrent diseases.

About the Report
To prepare this new report, in the fall of 2012, NCPIE commenced a new initiative called the Adherence Action Agenda or the "A³ Project," bringing together 22 professional societies and voluntary health organizations, government agencies and industry leaders to identify the major gaps in current adherence efforts and provide input into creation by NCPIE of a new Adherence Action Agenda for the nation. Members of the A³ Project are:

• AARP
• Academy of Managed Care Pharmacy
• Agency for Health Care Research and Quality, Center for Outcomes and Evidence
• American Academy of Nurse Practitioners
• American Academy of Physician Assistants
• American Diabetes Association
• American Heart Association
• American Medical Association
• Cardinal Health
• Council for Affordable Health Coverage
• Kaiser Permanente
• McKesson Patient Relationship Solutions
• Merck
• National Association of Chain Drug Stores
• National Community Pharmacists Association
• National Consumers League
• National Council on Aging
• National Council on Patient Information and Education
• National eHealth Collaborative
• National Pharmaceutical Council
• NEHI
• NIH Adherence Network, National Heart, Lung and Blood Institute
• Pharmacy Quality Alliance

Support for development of the Adherence Action Agenda was provided by Merck, known as MSD outside the United States and Canada. NCPIE is solely responsible for the content, and maintains editorial control of all the materials and publications produced for the A3 Project.

About NCPIE

Established in 1982, the National Council on Patient Information and Education is a diverse non-profit coalition that works to stimulate and improve the communication of information about the appropriate use of prescription and OTC medicines. NCPIE's members include consumer organizations: patient advocacy groups; voluntary health agencies; health professional associations, schools of pharmacy, health-related trade associations; prescription and over-the-counter pharmaceutical manufacturers; and local, state and federal government agencies. More information about NCPIE is available through its Web site: www.talkaboutrx.org.

SOURCE National Council on Patient Information and Education