Less Cost and More Patient Education Equal Better Adherence

Jennifer Garcia

September 10, 2012

September 10, 2012 — Researchers have found that patient education with behavioral support, lower out-of-pocket expenses, and case management all improved adherence to treatment for various chronic health conditions. The results of this systematic literature review were published online September 10 in the Annals of Internal Medicine.

The primary aim of the review was to assess the effectiveness of patient, policy, provider, and systems interventions aimed at improving adherence to self-administered medications for chronic diseases (eg, hyperlipidemia, diabetes, asthma, and multiple sclerosis). Meera Viswanathan, PhD, from Social, Statistical, and Environmental Sciences, RTI International, Durham, North Carolina, and colleagues included 73 articles on adherence intervention trials conducted between 1994 and June 2012.

Of the 73 articles, 68 (representing 62 trials) evaluated the effect of patient, provider, or systems interventions on medication adherence..Overall, "33 [of the 62 trials] (53%) reported improvement in medication adherence. Of these 33 trials, 18 (29%) reported improvements in at least 1 health outcome, 8 (13%) reported no improvements in health outcomes, and 7 (11%) did not evaluate changes in health outcomes," the authors write. "The remaining 29 trials (47%) showed no improvement in medication adherence."

The researchers note that despite finding evidence of effective strategies to improve medication adherence for conditions such as hypertension, heart failure, depression, and asthma, not all interventions led to improved outcomes for all conditions. Collaborative care interventions, for example, did not provide evidence of benefit for patients with hypertension; however, this intervention did appear effective for patients with diabetes and/or depression.

"Certain intervention types may provide the most benefit for patients with a specific clinical condition," the authors write.

The researchers also found that the most consistent evidence for improved outcomes was improved medication adherence among patients with hypertension, heart failure, depression, and asthma. Decreases in systemic blood pressure were noted among patients with hypertension who received both case management and face-to-face education by pharmacists, and "a pharmacist­led multicomponent adherence intervention reduced emergency department visits and improved patient satisfaction" among patients with heart failure.

Among the studies that evaluated policy interventions, the researchers found that such interventions that reduce patients' out-of pocket expenses also appeared to have a beneficial effect on medication adherence among patients being treated for cardiovascular disease and diabetes.

Interventions Tested Across Clinical Conditions

Seven intervention approaches were tested across different clinical conditions: education; case management; reminders; pharmacist-led, multicomponent approaches; collaborative care; a combination of telephone-based counseling, care management, and reminders; and decision aids. The researchers found that among these interventions, education/behavioral support and case management were the most effective at improving medication adherence and significantly affecting health outcomes across a variety of conditions. Conversely, when tested under conditions including diabetes, multiple sclerosis, depression, and musculoskeletal disease, interventions that included telephone counseling, care management, and monitoring failed to show significant improvements to medication adherence.

The authors acknowledge study limitations such as the fact that studies were limited to adults with chronic conditions in the United States and that heterogeneity among the studies precluded quantitative data pooling.

"Poor medication adherence produces large downstream health care costs," Dr. Viswanathan and colleagues write. "Thus, policymakers contemplating changes in health policy should take note of our assessment, from 5 consistent studies (moderate-strength evidence), that reducing patients' out-of-pocket costs improves medication adherence. Compared with other effective interventions, such as case management and collaborative care, which are relatively complex and labor-intensive, reducing copayments can potentially improve adherence for large numbers of geographically diverse patients."

Funding for this study was provided by the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online September 10, 2012.

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