Medication adherence fundamentals and AI solution to combat non-adherence – Part 2
The non-adherence handbook for techies:
Types, reasons and consequences
Jim works in the health information technology (healthtech) industry. His latest assignment requires him to do some digging around in the field of medication adherence with an aim to zero in on a proven solution that can benefit his organization.
Here is the link to the first blog of this techies’ primer: part 1
In the first part of our blog series on medication adherence, we saw how healthtech professional Jim started on his journey to understand the basics of medication adherence. He also got a sneak peek into the not-too-bright global adherence scenario. In this blog, we show how Jim digs deeper to understand the reasons behind such widespread non-adherence and also how it impacts the stakeholders deeply. Let’s begin by getting to know the different categories of non-adherence.
Types of non-adherence
A patient is termed non-adherent if he/ she does not initiate, follow or continue prescribed care and medication that a provider recommends. According to a well-cited article, non-adherence can be categorized into three parts.
Primary: This is the most basic kind of non-adherence, also referred to as non-fulfillment non-adherence. In this case, patients do not fill or initiate prescriptions written by the provider.
Secondary: This type has more to do with non-persistence, where a patient stops medication on his own accord after starting it. It is mostly unintentional in nature and arises out of miscommunication on therapeutic plans between the provider and patient. Non-persistent non-adherence also occurs due to capacity and resource limitations like medicine cost, forgetfulness, poor medicine intake techniques, problem of accessing prescriptions, etc.
Tertiary: In this type, non-conforming patients do not take medication as prescribed by heathcare professionals and providers. Typical patient behaviors range from skipping doses, taking incorrect doses, taking doses at incorrect times or even taking more doses than prescribed.
Apart from this, non-adherence can also be classified into two generic variations – intentional and unintentional.
Intentional non-adherence: This is a planned and active process where the patient deliberately doesn’t follow the prescribed medical regimen to suit his needs. The key drivers to this kind of non-adherence include factors such as patient’s knowledge, motivation or beliefs about the treatment. He can choose to deviate from the treatment regimen either because of perceived bias or mistrust against the medicine, lack of immediate benefits of the treatment, lack of proper information, and so on.
Unintentional non-adherence: This is an unplanned and passive process where the patient involuntarily deviates from the prescribed treatment regimen with little or no realization. The key drivers to this kind of non-adherence include a patient’s age (he can forget taking his medication), treatment factors (medication side-effects can put off patients from taking the prescribed doses), patient-provider relationship (lack of communication, trust or understanding between patients and providers can lead to disinterest in taking medication), and so on. External factors to unintentional non-adherence include high cost, lack of proper access to provider/ pharma, interference with other activities like work, etc.
Reasons for non-adherence
The reasons for not adhering to medication are multifactorial in nature. According to an American Medical Association (AMA) report, the top eight reasons for medication non-adherence are fear, cost, misunderstanding, polypharmacy, lack of symptoms, worry, depression and mistrust.
Contrary to popular belief, the onus of non-adherence is not only upon patients. Other stakeholders in the medication adherence ecosystems like providers and healthcare systems, and related external agents like society and economy can impact a patient’s non-adherence. Let’s take a look at the five broad dimensions that impact reasons behind non-adherence in patients.
Social and economic factors
Under this category, patients practise active or passive non-adherence due to a number of reasons. In certain cases, lack of proficiency in English can act as a roadblock, thereby resulting in miscommunication between patients and physicians. Some patients might find it difficult to access pharmacies due to distance, lack of transportation, lack of confidence, etc. Lack of family or social support can also act as a trigger behind patients not adhering to prescribed lines of treatment. Poverty, illiteracy, unemployment and unstable living conditions are yet another social factor that impacts non-adherence. Some patients might choose not to, or find it difficult to, access healthcare due to lack of interest, knowledge, awareness or practical reasons. Age, sex and race also influence non-adherence tendencies.
Patients can also feel unmotivated to fill prescriptions or stock up on refills due to the high cost of certain medicines and even high transportation costs. Lack of health insurance is also seen as an economic factor that results in non-adherence.
Healthcare system factors
Healthcare institution visits are not always hunky-dory. Most patients have to go through long wait times and complex registration procedures, making some to drop out. Sometimes, patient education materials written in a complex, reader-unfriendly manner can act as a deterrent to awareness related to medication adherence. Stress also acts as a factor that impacts non-adherence in patients. There are patients who find it stressful to visit healthcare centres. Others might feel discomfort in asking medication-related questions to their providers.
The role of providers is also crucial in non-adherence scenarios. If there is no or less trust between patients and providers, medication adherence is bound to suffer. Some providers might not be able to explain medication or treatment to patients well due to lack of knowledge, training, empathy or efficient communication skills. Other reasons under this category include overworked staff, short consultation times, etc.
While some patients might ignore adherence due to lack of symptoms or their severity, depression and other psychotic disorders can also prevent them from following proper medication adherence. There are patients who might not feel comfortable in buying medicines prescribed for some disease associated with social stigma. Other factors include conditions like depression, drug and alcohol abuse, etc.
Sometimes, medications prescribed are so complex, patients tend to ignore adherence. Also, frequent changes of regimen, complex medication schedules, previous treatment failures and treatments requiring a certain degree of mastery (like insulin injections, inhalers, etc.) are valid therapy-related reasons for non-adherence. That’s not all. Unpleasant side-effects of medication, long duration of therapy and lack of immediate benefit – all add up to a patient’s reluctance in adhering to prescribed medication.
A patient’s personal beliefs and understanding about certain medications can be a cause of non-adherence. For example, they might have read or heard somewhere that a medicine has harmful side-effects, and without consulting their provider, can discontinue or not initiate that medication. Perceived risk is thought to be one of the most important reasons for non-adherence under this category. Other psychological patient-related factors include patient’s forgetfulness or carelessness, lack of proper knowledge and awareness about a disease, and lack of motivation and confidence in continuing therapy arising out of stressful life events. Other patient-related factors include anxiety, low motivation, low treatment expectations, etc.
Non-adherence can also be witnessed in patients with cognitive issues like visual or hearing impairment.
View the full infographic here
The impact of non-adherence on key stakeholders
Non-adherence is an epidemic. Consider these stats:
- Among 3.8 billion prescriptions written every year in the US, 20% aren’t filled. Among those filled, 50% of them are taken improperly.
- 1 in 3 medicine-related hospital admissions are due to non-adherence.
- 125,000 people die every year in the US as they either fail to take medication or take it improperly. The risk is more in patients with chronic ailments like hypertension or diabetes.
- The approx. annual avoidable healthcare cost due to non-adherence in the US, is a whopping $300 billion (which is 10% of total healthcare spendings in the US).
Whatever may be the reason – social, economic, provider-related or patient-related – it’s a sorry sight for the medication adherence scenario globally. Non-adherence doesn’t only affect the health of individuals but also has multi-dimensional impacts on the economy, businesses, public health, etc. It affects each and every key party in the medication adherence ecosystem. Let’s take a look.
Needless to say, medication non-adherence has the strongest impact on the well-being of patients. Around 2/3rd Americans with prescriptions are non-adherent. Not only does health deteriorate due to it, but chances of relapse, hospital admissions and readmissions increase considerably, not to mention deaths. Non-adherence also leads to polypharmacy and unnecessary high doses of medication, associated side-effects, increase in ER visits, doctor consultation, and so on. As a result, individual healthcare costs surge, which impacts associated stakeholders economically. That apart, patient-provider trust takes a beating due to lack of proper medication adherence, and the general population health gets affected too.
Non-adherence in patients could mean a jump in hospital admission and readmission rates. 66% hospital readmissions occur annually due to non-adherence. Poor patient outcomes, due to non-adherence, can impact the quality metrics that providers are required to make available yearly to public and private payers. These can lead to humongous financial penalties for providers per year. Apart from financial losses, non-adherence also means patient satisfaction and their “likelihood to recommend” in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey take a hit.
Non-adherence hits payers hard. A rise in hospital admissions and readmissions, and poor patient outcomes translate to payers having to reimburse providers and patients. This, in turn, negatively affects their chances to earn the highest star ratings possible for Medicare Advantage Plans. A greater financial burden on payers is ultimately passed on to patients through higher co-payments or higher premiums.
When patients do not fill their prescriptions as advised by their providers, medicine sales are impacted. $637 billion is the annual cost to the pharma industry globally due to non-adherence. Low sales orders could also mean supply chain gets affected, and manufacturers and brokers cancelling a particular pharmacy from their network. It also leads to loss in reputation for pharmacy, broker and manufacturer. Manufacturer revenue also suffers as a result, something that brings down the number of clinical trials and, thus, medicine efficacy.
Medication non-adherence is bad news also for other parties in the system like wholesalers. Due to widespread non-adherence, wholesalers have to sacrifice on the profit percentage of the total cost of the medicine. Similarly, for the government, a decline in general population health, due to non-adherent patients, leads to more spending in healthcare that impacts the state coffers.
As we can see, negligence in patients about medication adherence not only hampers health but also disturbs the adherence ecosystem balance, leading to a domino effect of multiple losses to the stakeholders. The correct approach to prevent this scourge is for every stakeholder to come together and resist non-adherence in patients through proven AI-based healthcare technologies and medication adherence solutions.
Current measures and their limitations
At ground-level, the basic traditional measures taken by various stakeholders seem to fall flat in containing non-adherence rates. Providers advise patients to keep a daily tab on their doses, either using dosing containers or labelled blister packs. They also encourage their patients to consult them, should any need or confusion arise regarding their medication. However, due to behavioral factors, most patients don’t take such advice seriously. Moreover, due to the short time spent per patient, providers find it difficult to constantly engage on adherence, and scale.
Similarly, pharmas ensure prescriptions are refilled when patients visit pharmacies. But it is almost impossible confirming ingestion outside the clinic. Follow-ups through tele-calling is not foolproof as some patients might provide wrong information or just not bother to pick up calls. Payers face identical issues while reaching out to patients with an aim to ensure adherence. Moreover, there are times when the intervention is ineffective as it is based on poor data like incomplete dosing history.
A lackadaisical approach to medication adherence by patients also worsen the scenario. While some might not bother to self-report or consult with practitioners, others might fudge enrollment data or do duplicate enrollments with malicious intent.
“Surely non-adherence can’t persist, given its huge social and economic implications affecting all stakeholders – notwithstanding the reasons behind it,” concludes Jim after a hard week’s research. The question Jim must find an answer for is: What are the available options that can eliminate the reasons behind medication non-adherence or at least control it optimally?
To know about it, stay tuned for our penultimate blog post of the series.
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