Pinpointing the cause of nonadherence
It’s been cited as one of the biggest health crises facing the United States and, if solved, the equivalent dollar value of a blockbuster drug. According to the latest statistics from pharmacy benefit manager Express Scripts, poor medication adherence costs the country $317 billion per year, an upgrade from the $290 billion calculated in a study released in 2009 by the New England Healthcare Institute.
Of course, solving medication nonadherence is no simple task. It’s one of those issues like alcoholism and crime, the result of a complex mix of economic, personal and societal factors that combine to create one big social problem. Everything from concerns about cost and fears of side effects and efficacy to simple forgetfulness conspire to keep people from taking their medications as prescribed.
In May, for example, CVS Caremark released results of a study showing that Food and Drug Administration warnings about drug efficacy — even those that aren’t safety-related — can adversely affect medication adherence. The study cited one high-profile FDA communication that questioned the efficacy of the cholesterol drug ezetimibe, sold by Merck under the Zetia and Vytorin (ezetimibe and simvastatin) brands, after which the monthly level of patients who stopped filling their prescriptions increased by nearly 6%, while only 16.5% of those who stopped taking the drug switched to another, clinically appropriate therapy.
But like alcoholism and crime, even if it can’t be solved overnight with some magic panacea, it and its effects can be mitigated, and recent studies released since ESI’s annual drug trend report have offered some clues as to how.
Another CVS Caremark study in May, titled “Targeting Cardiovascular Medication Adherence Interventions” and published in the May/June issue of the Journal of the American Pharmacists Association, found that more than one-third of adherence interventions targeted to nonadherent patients resulted in improved medication adherence, compared with 18% of broad interventions.
The researchers reviewed nearly 60 peer-reviewed articles about randomized controlled trials for three types of interventions to improve medication adherence for cardiovascular disease or diabetes. These interventions included broad interventions targeting all patients, focused interventions targeting nonadherent patients and dynamic interventions initially administered to all patients but then targeted to nonadherent patients based on real-time adherence information. Results found that dynamic interventions and focused interventions were more likely to show impact on adherence as compared with broad interventions.
“While medication nonadherence is widely recognized as a major public health issue that impacts patient health and contributes to rising healthcare costs, there has not been a clear consensus about how best to influence patient behavior and support appropriate medication use,” said Sarah Cutrona, a former research associate at Brigham and Women’s Hospital. “These results suggest that broad interventions, which aim to prevent nonadherence by educating and motivating all patients, were the least effective. Without the benefit of identifying patients and their specific barriers to adherence, these types of interventions may be too general to motivate individual patients to change their medication taking behavior.”
A study released by Walgreens found that patients starting cholesterol medication for the first time who participated in enhanced face-to-face counseling sessions with a community pharmacist demonstrated better medication adherence than those who did not participate in the sessions.
Nonadherence is an especially important issue for patients with high cholesterol, as the condition places them at a greater risk of complications from heart disease. The study, titled “The impact of pharmacist face-to-face counseling to improve medication adherence among patients initiating statin therapy,” was published in April in the online journal Patient Preference and Adherence.
“This study demonstrates the power of face-to-face pharmacist interactions,” said Jeff Kang, Walgreens SVP health and wellness services and solutions. “Just two sessions focused on barriers to adherence for patients taking a new medicine for high cholesterol helped them establish a routine for adhering to their treatment. As a result, these patients potentially improved their long-term health outcomes. At Walgreens, our goal is to help our patients stay well while reducing overall healthcare costs, and programs that address the significant issue of prescription medication nonadherence are a crucial element of this.”
The study followed a group of more than 2,000 patients new to statin therapy for 12 months. After inclusion and exclusion criteria were applied, the intervention group consisted of 586 patients, and the comparison group comprised 516 patients. Pharmacists trained in brief motivational interviewing conducted counseling sessions that addressed barriers to adherence for statin patients, such as perceptions of the value of the therapy, fear of side effects and simple forgetfulness or establishing a routine to take medication.
Whatever it takes to combat the problem of medication nonadherence, one thing is certain: Pharmacists are one of the most important components. The National Association for Chain Drug Stores emphasized last month in a statement sent to the U.S. Senate Health, Education, Labor and Pensions Committee the value of community pharmacies in improving patient health and lowering health costs through medication therapy management.
“Community retail pharmacies are at the front line in the healthcare system, interacting with patients on a daily basis,” NACDS wrote. “Community pharmacists are uniquely qualified through their comprehensive education and training to significantly reduce the problem of poor medication adherence. We are convinced that [medication therapy management] is a key way to vastly improve health outcomes and reduce costs by ensuring that individuals receive the maximum health benefit from their prescription medicine.”
Telepharmacy enables pharmacists to supervise techs remotely
Pharmacists are widely considered the most accessible healthcare professionals, and their expanded responsibilities have made this more true than ever before. In many parts of the country, however, especially remote and rural regions, even pharmacists can be about as easy to find as a cornfield in New York City. But technology is helping pharmacists provide services to rural areas by allowing them to remotely monitor pharmacy technicians, according to the country’s largest organization that certifies pharmacy techs.
The Pharmacy Technician Certification Board said telepharmacy allows a pharmacy tech to be supervised remotely in real time by a pharmacist and prepare prescriptions. Boards of pharmacy in several states have begun adopting regulations that allow for telepharmacy, including those in Kansas, North Dakota, South Dakota, Texas, Idaho, Utah and Hawaii.
“Telepharmacy expands patient access to pharmacy consultations and vital healthcare services in rural and medically underserved areas,” PTCB executive director and CEO Everett McAllister said. “PTCB-certified pharmacy technicians play a significant role in this safe and cost-effective alternative, providing patients with maximum coverage.”
Recently, the Kansas State Board of Pharmacy adopted regulations that allow state-licensed pharmacists to electronically supervise one pharmacy technician or pharmacy student in a licensed pharmacy at a medical facility in the state, with the techs performing typical duties, such as reviewing cart fills and filling automated dispensing cabinets with the pharmacist observing the procedures through a real-time audio, video or computer connection.
New Drugs — Chain Pharmacy, 6/25/12
The Food and Drug Administration has approved a branded acne drug made by Ranbaxy Labs, the drug maker said. Ranbaxy announced the FDA approval of Absorica (isotretinoin), a drug for treating severe recalcitrant nodular acne. The company expects to launch it in the United States in fourth quarter 2012 under an agreement with Canada-based Cipher Pharmaceuticals.
“Absorica is a critical milestone in our commitment to serve the dermatology community and will be the flagship brand for Ranbaxy’s specialized dermatology sales force,” Ranbaxy SVP and regional director for the Americas Venkat Krishnan said.
A generic antiretroviral drug for treating HIV infection has won approval from the Food and Drug Administration. Mylan announced the approval of nevirapine tablets in the 200-mg strength. The drug is a generic version of Boehringer Ingelheim’s Viramune. Mylan began shipping the drug immediately after approval. Various versions of the drug had sales of $116.6 million during the 12-month period ended in March, according to IMS Health.
The Food and Drug Administration has approved a new treatment for acne made by a GlaxoSmithKline subsidiary. Stiefel announced the approval of Fabior (tazarotene) foam in the 0.1% strength, calling it the only retinoid in a topical foam for treating acne in patients ages 12 years and older. “Stiefel is dedicated to meeting the needs of patients and dermatologists, and we believe Fabior foam will be an important treatment option for people with moderate to severe acne,” Stiefel VP North America dermatology Jean-Christophe May said.
The Food and Drug Administration has approved a treatment for Type 1 diabetes in children ages 2 to 5 years. Drug maker Novo Nordisk announced the additional approval of Levemir (insulin detemir [rDNA origin]). The insulin already was approved for Type 1 diabetes in older children and adults and Type 2 diabetes in adults, and the drug maker said the new FDA approval made Levemir the only basal insulin analog for use in the 2- to 5-year age group.
Actavis has launched a generic drug for high blood pressure and chest pain, the company said. Actavis announced the launch of nifedipine extended-release tablets in the 90-mg strength, a generic version of Bayer’s Adalat CC. Various versions of the drug had sales of about $23 million in 2011, according to IMS Health.