Top Strategies for Improving Medication Adherence Rates

November 02, 2023 - Treating an acute or chronic illness doesn’t end with prescribing a drug or a treatment. Rather, achieving ideal clinical outcomes requires patients to actually take the prescription and strong medication adherence.

Medication adherence is generally defined as taking one’s medications as directed. This entails filling the prescription and taking the prescribed dose at the prescribed frequency. Poor medication adherence means patients are not taking their medications as directed, either by not filling the prescription, skipping doses, or cutting doses in half.

Strong medication adherence has long been elusive. In a 2023 JAMA Network Open article, researchers reported that around one in five adults with diabetes did not maintain use of glucose-lowering medications between 2005 and 2018. Meanwhile, an average of 17 percent and 43 percent of patients did not consistently take their blood pressure- or lipid-lowering medications during that same period, the researchers added.

That JAMA study may have been looking specifically at diabetes patients, but older data from the Centers for Disease Control and Prevention (CDC) corroborates it. A 2017 CDC Morbidity and Mortality Weekly Report showed that providers write 3.8 billion prescriptions every year, with one in five new ones never getting filled. Of those that do get filled, 50 percent are taken correctly.

Suboptimal medication adherence has its costs, the CDC report added, racking up a bill for the US healthcare industry of between $100 and $300 billion each year.

Improving medication adherence is not solely the patient’s responsibility. Healthcare providers need to be partners in patient care and help set up systems that will help patients achieve good medication adherence. Using various strategies, healthcare providers can help identify barriers to medication adherence and work to overcome them.

Data analytics identifies poor medication adherence

In an increasingly digitized healthcare landscape, many providers are using health IT to flag patients who are not taking their medications as prescribed. In a 2022 literature review published in JMIR MHealth UHealth, researchers listed common technologies to track medication adherence, including:

• Electronic pill bottles or boxes
• Ingestible sensors
• Electronic medication management systems
• Blister pack technology
• Patient self-report technology
• Video-based technology
• Motion sensor technology

These tools should alert providers when a patient has not taken their pills or filled a prescription.

Other healthcare providers are working with their payers to flag medication adherence. Health payers might check claims data to identify patients who have been issued a prescription and then assess pharmacy claims to flag when a patient has or has not filled the prescription.

Once providers can obtain information about which patients have not filled their prescriptions or who are not taking their pills as prescribed, they can work with patients to pick the tools needed to achieve medication adherence.

However, not every healthcare provider can rely on these technologies, either because they are cost-prohibitive, they provide variable data, or they do not have a partnership with a payer to analyze claims data. In these cases, providers will need to build trust with patients to obtain patient self-report about medication adherence.

Motivational interviewing

Motivational interviewing can be a good patient-provider communication strategy for clinicians without access to data about medication adherence. For any provider, it is a good tactic for uncovering the reasons why a patient does not take medications as prescribed.

Clinicians might start by asking patients whether they are taking their medications, the routine for taking their medications, or even how they pay for their medications (particularly salient if the out-of-pocket cost is high). Learning more about how patients take their medications may reveal whether that is truly happening.

It will be incumbent upon providers to approach these conversations with empathy and respect, as many patients may be reticent to admit that they are not taking their pills or that they face barriers in obtaining their prescriptions.

From there, clinicians can use motivational interviewing to assess why patients are not taking their medications as prescribed and how they can course-correct. Motivational interviewing requires providers and patients to work together to identify patients’ health and well-being goals and the most reasonable steps toward achieving them.

This factors into medication adherence discussions because it allows clinicians to outline the importance of medication in managing an illness, and it gives patients the opportunity to outline what medication regimen is reasonable for their needs.

After all, the best treatment a provider can prescribe is the treatment the patient can afford and can reasonably stick to.

Still, medication adherence is far more complex than whether the patient wants to take their medications. There are often financial, health literacy, and management barriers keeping patients from achieving medication adherence.

Cost-cutting

Out-of-pocket patient costs and variable health insurance coverage are by far the most common causes of poor medication adherence. Survey after survey shows that when patients can’t afford their prescriptions, they do not fill them.

In 2023, researchers wrote in JAMA Network Open that one in five patients experience at least one cost-related barrier to medication adherence every year.

For some patients, this means rationing pills to make them last longer. For others, it means not filling the prescription at all. Some patients took drastic measures to manage their finances and medication adherence; 8.5 percent of patients said they went without basic needs to pay their medication costs, while 4.8 percent said they’d gone into debt to afford their medications.

Healthcare providers need to counsel patients on prescription drug affordability, foremost by using empathic provider communication to uncover when there is a cost barrier. Providers who identify a cost barrier can look into lower-cost alternatives or adjust the dosage to make the price tag more tenable for patients.

The JAMA study showed that patients want to have these discussions, even if providers are reasonably nervous about broaching sensitive or personal information about money. A vast majority (89 percent) of patients said they are open to or at least neutral about being screened before a provider visit for wanting to have a conversation about medication costs. A similar number of patients (89.5 percent) said they wanted their clinicians to use a real-time benefit tool.

Prescription drug affordability is also getting some health policy treatment that could help move the needle for at least some demographics. In particular, researchers have found that the $35 insulin cap for Medicare Part D beneficiaries helped improve medication adherence rates.

Patient education

Medication adherence relies on patients knowing what they are taking and why, but often, that level of patient understanding is lacking.

This is particularly salient for patients who regularly take a medication to prevent a certain health conditions and who do not necessarily see the effects of the medication. It can be hard to prove that adherence to a medication can stop a heart attack that hasn’t happened, for example.

In a 2021 report in the Journal of the American Geriatrics Society, patients told researchers that limited awareness and confusion about pill efficacy got in the way of taking their atrial fibrillation medication. Some patients began tapering because they did not know the pills were working, while others skipped doses because they stopped experiencing symptoms.

Better patient education about how to take pills, what they will do, and how the pills might make the patient feel will be crucial to increasing medication adherence, experts have said.

And although patient education can be time-consuming for providers already facing a litany of tasks, it does have payoff, data has shown. In 2023, researchers from the Johns Hopkins School of Nursing found that patient education sessions, supplemented by educational materials, improved patient adherence to post-operative blood thinners to prevent venous thromboembolism (VTE).

Medication synchronization, dose packaging

Many patients with low medication adherence cannot stick to their medications because their regimen is too complex. This is common among older patients or patients who manage multiple chronic illnesses.

Healthcare providers and pharmacists may consider different strategies to help patients—and, in some cases, their family caregivers—be more organized in their medication management. This can be as simple as a medication reminder or alarm alerting patients to take their pills all the way to more complex medication synchronization programs, which align the refill date of all of a patient’s prescriptions.

Data shows that these management strategies can work. A 2019 Government Accountability Office (GAO) report included a literature review of medication synchronization plans, finding that some indicated the practice can boost adherence by as much as 3 percent.

Other studies have gone as far as to say that medication synchronization can improve adherence and subsequently improve health outcomes. After implementing the program, researchers observed a drop in hospitalization and emergency department utilization.

A January 2018 Health Affairs study also found medication synchronization increased medication adherence rates by 9 percent.

Dose packaging can have a similar effect.

Dose packaging, or blister packs, can help patients taking more than one prescription keep track of which pills get taken together and when. By placing the pills in the same blister or pouch, patients can keep these regimens aligned.

Manage side effects

Side effects, or drug-related symptoms, are the adverse aftereffects patients sometimes feel when they take a certain medication. The specific side effects a patient might feel depends almost entirely on the drug, but the most commonly cited drug side effects may include:

• Nausea
• Dizziness
• Fatigue
• Headache
• Constipation or diarrhea
• Dry mouth
• Skin reactions
• Weight loss or gain

If a medication makes a patient feel sick, they may not be likely to take it, although there’s limited data exploring this issue.

In 2016, researchers wrote in the American Journal of Hypertension that side effects can adversely impact medication adherence rates. Looking particularly at patients taking medication for hypertension, the researchers reported that 85 percent of patients experience medication side effects.

Of those experiencing side effects, 34 percent said they stopped their medications because of them.

As noted above, the most effective treatment patients can take is one they can afford and which they can tolerate. Healthcare providers who identify patients who discontinue their medications because of side effects should work with patients to adjust the dosage, identify solutions to the side effects, or explore other treatment options that come with fewer side effects.

Mail-order pharmacy

Mail-order pharmacy is exactly as it sounds: the delivery of prescription medications via the mail or other home-delivery service. These services can help circumvent transportation issues that get in the way of medication adherence. Patients who don’t have a car or who cannot drive may benefit from mail-order pharmacy, for example.

This mode of prescription access has become more common in the past few decades, but still, it’s not entirely common. One 2021 analysis showed that mail-order pharmacy use increased from 10.2 percent of adult prescription users in 1996 to 17 percent in 2005. By 2018, that figure had decreased to 15.7 percent.

Although mail-order pharmacy users haven’t reached a critical mass, some data has shown that it’s useful in improving medication adherence. A 2010 report showed that people who received mail-order prescriptions had medication adherence that was 10 percentage points higher than those who did not. In 2016, a literature review showed that folks who used mail-order pharmacy had higher medication adherence and were also more likely to have received an incentive to use mail-order pharmacy.

Mail-order pharmacy is not a panacea, research has found. In focus groups of patients with diabetes in Hawaii and California, researchers found that patients are worried about the unpredictability of a medication delivery date, the security of their medications in the mail, and challenges around coordinating refill of multiple prescriptions.

That said, patients also know that mail-order pharmacy can be more convenient and help overcome transportation barriers to treatment. Mail-order pharmacy companies and providers may motivate more patients to join by adding a pharmacy benefit to their plan or offering a free one-month supply of medications for signing up for mail-order pharmacy.

Medication adherence is a lingering problem in chronic disease management. As healthcare continues its work to cut costs and improve outcomes, providers will need to uncover patients with low medication adherence, the barriers keeping them from taking their pills, and the strategies that will help improve adherence rates.