Medication non-adherence and affordable, evidence-based solutions in chronic disease

What is medication non-adherence and why does it matter?
Medication non-adherence is the extent to which a patient’s behaviour matches agreed recommendations from the prescriber1. In chronic diseases such as cardiovascular disease (CVD), roughly 1 in every 2 prescribed medications are not taken as recommended with many people completely stopping their medications prematurely. ^2,3,4
The implications of medication non-adherence in chronic diseases include poor clinical outcomes, reduced health status and increased avoidable healthcare costs.^5,6 Eliminating non-adherence is thought to be one of the best investments for tackling chronic disease.⁷
Why don’t people take their medications?
Two very common reasons are cost and affordability. Being chronically sick is not cheap, reduces productivity, and can often send people below the poverty line. This is especially for those with multiple chronic diseases and those who are socioeconomically disadvantaged.⁵
Australia is no exception. Though many medications for chronic diseases are heavily subsidised via Medicare’s Pharmaceutical Benefits Scheme (PBS), 38.2% of the total healthcare expenditure paid out-of-pocket by individuals is spent on medicines.⁸
In the past, increasing medication costs in Australia resulted in significant and sustained decreases in dispensing volumes for essential medications for chronic diseases.⁹ This sensitivity to cost suggests that people have a price point at which they will actively decide to change their medication-taking behaviour, that is be intentionally non-adherent.¹
Addressing intentional non-adherence: a new way to combat non-adherence?
By recognising that much non-adherence is intentional, reflecting both patient preferences and the balancing of medication costs with other household needs, strategies are being developed that better align interventions
with patient adherence preferences, and thus providing new opportunities to combat the problem of non-adherence.
Case study 1:
The 4-in-1 polypill for cardiovascular disease (CVD): a cheap, simple intervention that potentially saves the health system money.
The Australian-based Kanyini Guidelines Adherence to Polypill trial demonstrated that a 4-in-1 fixed dose combination polypill for CVD could significantly improve self-reported adherence and clinical outcomes when compared to usual care¹⁰ and potentially save taxpayers around $623 per patient per year.11 Further studies^12,13,14 revealed that: 1. 55% of treatment decisions appear driven medication cost 2: Polypill treatment characteristics strongly align with patient adherence preferences; 3: This polypill was a broadly acceptable and relevant strategy meeting patient and provider needs.
While not a panacea to the problem of non-adherence, this appears to be a simple, cheap option that aligns with patient adherence preferences and has the potential to tackle the problem of non-adherence in CVD.
Case study 2:
A financial incentive to improve the use of guidelines recommended, cost-effective medications for asthma
Combination inhaled corticosteroids (ICS) / long-acting beta2-agonist (LABA) inhalers are recommended in patients whose asthma is not sufficiently controlled on low or moderate dose ICS alone.¹⁵ There is no evidence that patients who are well controlled on ICS alone will gain any benefit from the addition of a LABA. Yet in Australia, 81% of ICS-containing medications are dispensed as ICS/LABA combination devices.¹⁵ As the price of ICS/LABA inhalers are more expensive to the Australian government than ICS alone, this prescribing pattern is placing a significant, growing and potentially modifiable burden on the PBS.
For patients, cost is a reported barrier to the quality use of ICS agents in Australia¹⁶ and previous increases in medication co-payments had the largest impact on combination asthma medicines.⁹ Given this cost sensitivity, it has been hypothesised that a patient-directed financial incentive, in the form of a reduced co-payment, may be one way to promote the cost-effective use of ICS inhalers in the Australian community. This idea is currently being tested in an NHMRC-funded partnership grant, due for completion in 2016.

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In a Nutshell

1. Medication non-adherence continues to undermine the effectiveness and cost-effectiveness of therapies for chronic diseases


2. An under recognised component of non-adherent behaviour is intentional, whereby people actively makes decisions to stop or change the way they take medications.


3. Cost and affordability are common reasons people stop taking medications for chronic diseases, including in Australia.


4. Intentional non-adherence can thus be seen as reflecting both patient preferences and the balancing of medication costs with other household needs.


5. Simple, affordable and cost-effective strategies that better align interventions with patient adherence preferences are needed.

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Tracey Laba is a Research Fellow specialising in Health Economics at the George Institute for Global Health; Conjoint Senior Lecturer, the University of Sydney Medical School; and a registered pharmacist. Her research focuses on the translation and appropriate and equitable use of high-value, affordable health care interventions for chronic non-communicable diseases. Tracey is a member of both expert drug utilisation and economic subcommittees to the Pharmaceutical Benefits Advisory Committee.
 

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References

1. Horne R, Weinman J, Barber N, Elliott R, Morgan M. Concordance, Adherence and Compliance in Medicine Taking. Report for the National Co-ordinating Centre for NHS Delivery and Organisation R & D (NCCSDO). 2005.


2. Sabate E. Adherence to long term therapies: Evidence for action (available at http://www.who.int/chronic_conditions/adherencereport/en/ ). World Health Organisation, Geneva, Switzerland: 2003


3. Yeaw J, Benner JS, Walt JG, Sian S, Smith DB. Comparing adherence and persistence across 6 chronic medication classes. Journal of managed care pharmacy : JMCP. 2009;15(9):728-40. Epub 2009/12/04.


4. Simons LA, Ortiz M, Calcino G. Persistence with antihypertensive medication: Australia-wide experience, 2004-2006. The Medical journal of Australia. 2008;188(4):224-7. Epub 2008/02/19.


5. See: Laba, Tracey-Lea, Usherwood, Tim, Leeder, Stephen, Yusuf, Farhat, Gillespie, James, Perkovic, Vlado, Wilson,Andrew, Jan, Stephen, and Essue, Beverley (2015). Co-payments for health care: what is their real cost?. Aust. Health Review 39, 33–36.


6. Bosworth HB, Granger BB, Mendys P, Brindis R, Burkholder R, Czajkowski SM, et al. Medication adherence: a call for action. American Heart Journal. 2011;162(3):412-24.


7. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence.[update of Cochrane Database Syst Rev. 2005;(4):CD000011; PMID: 16235271]. Cochrane Database Syst Rev. 2008(2):CD000011.


8. Health expenditure Australia 2013–14. Health and welfare expenditure series no. 54. Cat. no. HWE 63. Canberra: AIHW. Available online at: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129552833


9. Hynd A, Roughead EE, Preen DB, Glover J, Bulsara M, Semmens J. The impact of co-payment increases on dispensings of government-subsidised medicines in Australia. Pharmacoepidemiology and drug safety. 2008;17(11):1091-9. Epub 2008/10/2


10. Patel A, Cass A, Peiris D et al, for the Kanyini Guidelines Adherence with the Polypill (Kanyini GAP) Collaboration A pragmatic randomized trial of a polypill-based strategy to improve use of indicated preventive treatments in people at high cardiovascular disease risk. European Journal of Preventive Cardiology 2047487314530382, first published on March 27, 2014 doi:10.1177/2047487314530382


11. 11 Laba TL, Hayes A, Lo S, et al., An economic case for a cardiovascular polypill? A cost analysis of the Kanyini GAP trial. Med J Aust 2014; 201 (11): 671-673.


12. Liu, H., Massi, L., Laba, T., Peiris, D., Usherwood, T., Patel, A., Cass, A., Eades, A., Redfern, J., Hayman, N., Howard, K., Brien, J., Jan, S. (2015). Patients’ and Providers’ Perspectives of a Polypill Strategy to Improve Cardiovascular Prevention in Australian Primary Health Care: A Qualitative Study Set Within a Pragmatic Randomized, Controlled Trial. Circulation. Cardiovascular Quality and Outcomes, 8(3), 301-308.


13. Laba, T., Howard, K., Rose, J., Peiris, D., Redfern, J., Usherwood, T., Cass, A., Patel, A., Jan, S. (2015). Patient Preferences for a Polypill for the Prevention of Cardiovascular Diseases. The Annals of Pharmacotherapy, 49(5), 528-539.


14. Laba, T., Howard, K., Rose, J., Peiris, D., Redfern, J., Usherwood, T., Cass, A., Patel, A., Jan, S. (2015). Patient Preferences for a Polypill for the Prevention of Cardiovascular Diseases. The Annals of Pharmacotherapy, 49(5), 528-539.


15. AIHW: Correll PK, Poulos LM, Ampon R, Reddel HK & Marks GB 2015. Respiratory medication use in Australia 2003–2013: treatment of asthma and COPD. Cat. no. ACM 31. Canberra: AIHW.


16. Ampon RD, Reddel HK, Correll PK, Poulos LM, Marks GB. Cost is a major barrier to the use of inhaled corticosteroids for obstructive lung disease. The Medical journal of Australia. 2009;191(6):319-23. Epub 2009/09/23.