Another go at medication adherence

Autumn brought a flurry of reports and news announcements about medication adherence. CVS Caremark sponsored a survey among pharmacists, and the Healthcare Compliance Packaging Council issued a compilation of clinical research on the topic, among others. The subject has been getting increased attention over the past couple years as the components of the national HIT (Healthcare Information Technology) program (which includes incentives for IT implementations that demonstrate “meaningful use,” such as improved adherence) come to the fore. Medication adherence is also a factor in the Affordable Care Act’s performance incentives for healthcare providers.
 
For the moment, though, the spotlight should be directed at a new study, published in the Sept. 11 issue of Annals of Internal Medicine, which represents one of the most rigorous, and exhaustive, reviews of clinical information on the topic seen in recent years. The study, “Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review,” available with free access at www.annals.org, surveyed 4,124 citations involving medication adherence, and then evaluated the quality of conclusions drawn from 18 types of interventions that have been used.
 
Of those 4,124 citations, only 758 met a first cut for appropriateness, and 73 a final cut. Those 73 were then evaluated on the basis of low strength of evidence of no benefit (L-), low strength of evidence of benefit (L+), and moderate strength of benefit (M+). The results: At least a few studies showed an L+ grade for compliance packaging (specifically, blister packaging); and for collaborative care (telephone or in-person); and a category that has us scratching our heads, “self-management” (which would seem to be the basic problem of medication adherence). But the most common grade was “I”— “insufficient evidence.”
 
One of the frustrating aspects of such a study, from an industry perspective, is that economic issues were not a factor—neither comparing the cost of various interventions, nor the value of outcomes. (However, the study does find that “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.”) The oft-cited statistics that poor adherence cuts 125,000 lives short annually, and that it causes a waste of $100–298 billion to overall healthcare costs, are the 800-lb gorilla in the room. At the same time, the rigor of the analysis (which used the randomized, controlled trials as the measure of research quality) points to a puzzling gap in research in this area: With so many important consequences riding on medication adherence, why isn’t the science of it better understood?
 
We’ll put a plug in here for one of our favorite interventions—compliance packaging. For relatively little additional cost (at least compared to something like in-person counseling), compliance packaging has been shown by this study to have positive results. The HCPC compilation reinforces that message. But we’ve been told more than once that medicine buyers (P&T committees, PBM managers and others) rarely factor the added value of compliance packaging into their decisionmaking, thus removing the incentive for pharma manufacturers to provide those features. More evidence of this (cited in the Annals article) is that compliance tends to be better outside the US (where compliance packaging is more common) than here.
 
Like so many other scientific studies, the bottom-line conclusion of this one is that more study is needed. With the dramatic consequences of poor adherence facing all of us, that should happen faster. Meanwhile, members of the healthcare system (suppliers, providers and payers alike) should feel more confident that a commitment to improve adherence is worth the effort.