MEDICATION NON-ADHERENCE: THE HIDDEN EPIDEMIC

Author: Pankti Parikh

Participant in AMSACON White Paper Competition

According to WHO, Medication compliance (now better known as Medication Adherence) is the extent to which a person’s behavior taking medications, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare  provider. 

Introduction: 

Most preventable deaths are due to medication non-adherence of chronic diseases like asthma, cancer (palliative care), depression,  diabetes, epilepsy, HIV/AIDS, hypertension, tobacco smoking and tuberculosis.[1] So how big is the problem?  

So it’s fair to say that the problem is huge. It is a worldwide problem of striking magnitude. 

Key Findings: 

∙ Today in the US, medication non-adherence leads to 125,000 preventable deaths each year, and about $300 billion in avoidable healthcare costs. [2] 

∙ Non-adherence is not just a critical clinical problem but also an economic burden. Patient mortality is just the tip of the iceberg,  subsequent healthcare and pharma costs is a worldwide emergency. ∙ 10% of hospitalizations in older adults are attributed to medication non-adherence with the typical non-adherent patient requiring  three extra medical visits per year, leading to $2000 increased treatment costs per annum. In diabetes, the estimated costs savings  associated with improving medication non-adherence range from $661 million to $1.16 billion.[3] 

∙ The 2003 World Health Organization (WHO) report regarding medication adherence declared that “increasing the effectiveness  of adherence interventions may have a far greater impact on the health of the population than any improvement in specific  medical treatment.”[4]

Reasons of Medication Non-Adherence 

WHO has listed these reasons as ‘5 Dimensions of Non-Adherence’ [5] 

1. Health system based factors 

∙ Poor doctor-patient relationship 

∙ No patient education facilities 

∙ Long waiting time  

2. Socio-economic factors 

∙ Cost of medication 

∙ Illiteracy 

∙ No health insurance 

∙ Transportation 

∙ Stigma  

3. Therapy related factors 

∙ Complex drug regimes 

∙ Forgetfulness 

∙ Side effects 

∙ Long duration of treatment 

∙ Frequent changes in medication 

∙ Resistance to lifestyle changes 

4. Patient related factors 

∙ Limited language proficiency 

∙ Visual, hearing, cognitive impairment of the patients 

∙ Lack of insight into illness 

∙ No motivation to get better 

5. Condition related factors  

∙ Treatment of asymptomatic disease: Disappearance of symptoms may create an illusion of complete recovery leading to  discontinuation of medication.

How crucial is this problem and how fast we should start acting upon it? 

To understand this let’s take an example. Under Goal 3 of Sustainable Development Goals (SDG), WHO has laid down the following  targets to be achieved by the year 2030: 

∙ 90% Reduction in number of TB deaths compared with 2015 (%) 

∙ 80% Reduction in TB incidence rate compared with 2015 (%) 

∙ Zero TB affected families facing catastrophic costs due to TB(%)  

In order to achieve these goals, problem of Medication Adherence has to be acted upon urgently. More the number of  untreated/non-adherent patients, more will be the incidences of infections and deaths. 

SOLUTIONS TO INCREASE MEDICATION ADHERENCE 

1. Patient Education  

“Each patient carries his own doctor inside him.”  

Empowering the patients about their disease, its cause, progression and future complications arising as a consequence of  medication non-adherence is a crucial measure that should be undertaken. Benefits of patient education are:  

▪ Less prescription abandonment due to understanding why the medication is crucial to recovery. 

▪ More follow through with treatment plans due to understanding of the disease/illness. 

▪ Patient education leads to better patient satisfaction with providers and their overall care and come for frequent follow ups. ▪ An increase is compliance of treatment plans can lead to an overall reduced cost for patients. 

In India, due to an abysmal doctor-patient ratio, doctors do not have the time to educate every patient about their illnesses. We  have to come up with solutions to reduce the workload on the physicians. So how can we achieve our goal of patient education?  Here’s how:  

o Involvement of Interns and Residents:  

These young budding health professionals are zealous and enthusiastic to spread their medical knowledge and would  educate the patients whole-heartedly. After consultation with the doctor, the patient arrives at the intern’s desk for an  elaborate explanation of their diagnosis. Use of animations, audio visual presentations would accentuate the effect. Thus, a help from these students would be a great asset to our health system and they will be more confident and  ready to become fully fledged physicians.  

o Pharmacists 

Pharmacists have been long ignored from an integrated patient experience. Patients often stop their medications or  not begin their medications because they read a few side effects on the internet and make a decision of not aggravate  their suffering. Here is when the Pharmacist comes into play. Every time a patient buys new medication, the  pharmacists would brief them about how and when to take their medicines and what could be the possible side effects 

in their individual case. If a patient is alarmed of any other side effect, he should come for a medication change to the  Pharmacist. For example, Rifampicin in TB regime causes urine to turn orangish red. If the patient is made aware of  this side effect from the start he/she would not stop the drug regime. 

Explaining the importance of each drug is also encouraged. For example, an antacid in the prescription for an acne  problem will definitely make the patients doubt the drugs and thus may end up not buying the antacid. Imparting  knowledge that one of the acne drugs causes acidity and hence the antacid is very important to gain the trust of the  doctor’s prescription. 

Pharmacies can also turn into basic health check up centers where blood pressure and sugar levels can be measurement. 

Patients can subscribe to periodic medication supplies with the pharmacy which will eliminate the hassle of going to  the pharmacy. 

Otherwise, Pharmacists should send timely reminders to the patients to come and buy medications for the remaining  course. This will prevent missed medication days before their next purchase.  

The complexity of medications can also be addressed with inputs from the Pharmacist. Prophylaxis of chronic  diseases involves a lot of medicines to be taken at different times. Patients often get confused discouraging them to  adhere to long term medications. Pharmacists can make a simple chart as follows: 

o Training of ASHA workers 

Majority of Indian population resides in rural areas where physicians are not abundantly present and also the health  facilities. Therefore ASHA workers, the strength of the medical system of rural India should be invited to the 3- tier  hospitals and trained for 2-3 months. The training should focus on ‘predictive’ aspect of the diseases. Early  detection of high risk patients, education of the patients about their illnesses and simple life changes to efficiently  tackled it. Dr. Devi Shetty, a worldwide renowned Indian Cardiologist has trained lakhs of ASHA workers till date  and according to the reports it has brought a huge difference in quality of health delivery in rural regions. A 24×7 distress helpline number should be established, to attend to the concerns of the people to ensure immediate care. 

o Importance of Prevention 

Maintaining a healthy lifestyle like regular exercise, consumption of balanced diet, maintaining good personal  hygiene and sanitation, avoiding smoking & alcohol consumption; would keep a person less prone to diseases. This  should be widely practiced all over the country as it is the best solution for better health and saves future costs on  illnesses.  

General Practitioners who share a personal relationship with their patients should promote healthy living like  balanced diets, daily exercise, home based care. Patients because of their complete trust on the GPs would take their  advice more seriously and start acting upon them.  

Health days organized by ASHA workers, Anganwadi workers in rural areas would empower patients and put the  responsibility of their health in their own hands. 

Major public gatherings like in theatres, festivals would help to reach a large audience.

2. Cost reduction 

“Healthcare is a basic right. One should not be in a position to choose between food and medicines.” 33 million fall under the poverty line due to expenditure on medicines alone (PHFI, 2018). 70% of expense in healthcare goes  into purchase of medicines. India has one of the highest out-of-pocket expenditure (OOPE) in healthcare. The SDG-3 emphasizes  on ‘financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable  essential medicines and vaccines for all’ to achieve Universal Health Coverage by 2030. 

o Promotion, funding and expansion of generic medicines and stores: 

Cost is one of the most important factors when it comes to medication non-adherence of chronic diseases.  Government of India launched ‘Jan Aushadhi’ stores which sell medicines at one-fifth to one-tenth the price of  branded medicines. Many more stores should be opened across the country and manufacturing should increase  several folds to meet the demand. Doctors should be encouraged to also prescribe alternative generic drugs. 

o A formulary of interchangeable medicines must be developed. Pharmacists should have a system where they can  access relevant information about generic medicines before dispensing them as well as have the authority to change  to a generic unless the patient demands the originator and/or the physician indicates do not substitute. 

o The length of the supply chain should be reduced to avoid unnecessary distribution costs to ensure affordable prices.  o Financial incentives given to physicians for prescribing generic medicines.[6] 

o Recycling and donation of unused unexpired medicines 

Every year unused medicines worth lakhs of rupees go to waste.  

When patients pass away, especially older patients who tend to take daily medications, they often leave a surplus of  drugs behind them which tend to be binned by the family. Excess medicines may remain after the patient has  recovered. Drugs which can be used are checked to ensure that they are at least 15 months from expiry and are  housed in their original packaging with no visible signs of tampering. These medicines can be collected and donated  to the underprivileged who have to make a choice between food or medications. 

o Health Insurance:  

Government of India has made a mark when it comes to providing health insurance. The Ayushman Bharat  Scheme[7], Rashtriya Swasthya Bima Yojana(RSBY)[8], Mahatma Jyotiba Phule Jan Arogya Yojana in  Maharashtra[9] are some of the schemes for the below poverty line citizens. 

Ayushmann Bharat Yojana provides coverage of Rs.5 lakhs per family per year without charging any premium. The  beneficiaries should fulfill certain criteria to be eligible for this insurance scheme. According to WHO, this scheme  will be a gamechanger in the health sector of India. 

3. Integration of all Health Services 

Implementation of structural and financial reforms to move away from the fragmented provided-centred models of care and to re orient them based on principles of integration to ensure everybody has access to a continuum of care that is responsive,  coordinated and in line with people’s needs. Integrated care contributes to improved access to services, better medication  adherence, increased patient satisfaction, greater job satisfaction for health workers and overall improved health outcomes. For  example: To ensure adherence in a patient coming from the rural area for treatment in CHCs requires many sectors to work in  coordination like Subsidized transport, patient education and counseling, easy and continuous supply of medicines, technology  support from the PHC of the patient’s village to ensure frequent follow ups.

o Electronic Health Records 

GOI in August 2020 launched the National Digital Health Mission (NDHM)[10] in which each individual in the country  will be assigned their own unique Health ID which will have all the records of their hospital visits, their pharmacy  purchases, blood tests, scanning tests. This was a much awaited advancement and the very first step towards integration of  health services. Now the physicians would be aware about the patient’s past history, his/her pharmacy refill rates to predict  their adherence rates and accordingly educating the patient. 

o Transportation 

“Hospitals are too far off from my house and I cannot afford the frequent travel costs”, this is also a very important factor in  medication non-adherence. Coalition with a Transport agency, to have a daily bus route to government hospitals at a highly  subsidized cost would be extremely beneficial.  

Setting up of at least one telemedicine booth in each PHC which can reduce time and cost of transportation. 

o Continuous supply of medicines in rural India 

Unavailability of essential drugs in PHCs has long been a problem of medication non-adherence in rural areas. Adherence rates  are only 21%. Database of frequent drugs consumed in a particular area, helps smooth coordination between E- pharmacies and  NGOs to keep transporting and supplying essential drugs in adequate quantities.  

4. Leveraging Technology and Innovation  

o Telemedicine: In today’s time 90% of the population uses smartphone. This can enable easy teleconsultation in the comfort  of their home and not worrying about a lost pay day. 90% of the patients require medical therapy and only the rest 10%  require surgeries. Telemedicine is one tool to solve multiple problems like reduction in transportation costs which ultimately  result in required follow ups. 

o Electronic Health Records 

o MEMS (Medication Event Monitoring System)  

It monitors number of bottle openings and the date and time of each opening. This is a helpful technique to supervise the  medication adherence of patients of chronic diseases.  

o Smart blister packs 

The smart packaging technology is designed to generate data in real time. When a patient pushes a tablet from the blister  pack, information regarding the medication type, the tablet extraction time is transmitted via a smartphone application to a  database.  

So if the medication is not taken on a particular day by a certain period of time, a reminder is sent on the patient and his  relative’s phones.  

o An implantable device on a high risk patient which monitors drug level in the blood for 24hrs and after 24hrs it is fed into  the database. This cannot be hampered with by the patient and thus proving to be very efficacious. 

o Development of an online reliable platform with animations, videos of the major diseases in all regional languages aiding  the patient education and awareness. 

Recommendations 

o Countries like United Kingdom, United States, Australia have given prescription rights to pharmacists and nurses to reduce burden  on physicians and improve quality of care. This could really work in favor of India as we have the highest paramedical staff base  in the world.  

These countries have also established the role of pharmacists by providing them with knowledge and techniques to counsel  patients, provide information about medicines and disease conditions or advice about lifestyle modifications, drug administration,  dosage, side effects, storage of drugs, and drug-drug interactions.  

o Inclusion of ‘Lifestyle Diseases’ as a separate section in the syllabus of undergraduates which covers epidemiology, problems  statements, government policies, empathetic behavior towards the patients regarding such diseases.  

o The extremely essential medications that are needed by majority of the Indian population should be considered for inclusion in the  drug price control list. Another possible solution could be to negotiate drug pricing with the manufacturers to keep prices under  control and in return, the manufacturers could be provided with tax benefits [11].  

Conclusion 

Quoting WHO, “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population  than any improvement in specific medical treatment.” Medication non-adherence has been a worldwide burden since more than a decade.  In 21st century, when we have treatments and drugs for almost all the life-threatening diseases, mortality due to medication non adherence should be unacceptable. Increased manpower and funding in patient education programs, innovation, cost-saving interventions should be initiated without any further delay. Efforts should be made to build a trustworthy, sustainable, patient-centric healthcare  delivery model. 

References 

1) Haynes, R. (2015, December 21). ADHERENCE TO LONG-TERM THERAPIES: EVIDENCE FOR ACTION. Retrieved October 07, 2020,  from https://www.who.int/chp/knowledge/publications/adherence_report/en/ 

2) Cutler, R., Fernandez-Llimos, F., Frommer, M., Benrimoj, C., & Garcia-Cardenas, V. (2018, January 21). Economic impact of medication  non-adherence by disease groups: A systematic review. Retrieved October 07, 2020,  

from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5780689/ 

3) Cutler, R., Fernandez-Llimos, F., Frommer, M., Benrimoj, C., & Garcia-Cardenas, V. (2018, January 21). Economic impact of medication  non-adherence by disease groups: A systematic review. Retrieved October 07, 2020,  

from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5780689/ 

4) Kreys, E. (2016, October). Measures of Medication Adherence. Retrieved October 07, 2020,  

from https://www.journalofclinicalpathways.com/article/measurements-medication-adherence-search-gold-standard 

5) Albaz RS. Factors affecting patient compliance in Saudi Arabia.Journal of Social Sciences,1997, 25:5-8. 

6) Hassali MA TJ, Saleem F, Haq Nul et al. Generic Substitution in Malaysia: Recommendations from a Systematic Review.  Journal of Applied Pharmaceutical Science 2012;2(8):159-64. 

7) https://pmjay.gov.in/ 

8) http://www.rsby.gov.in/how_works.html 

9) https://www.jeevandayee.gov.in/ 

10) https://ndhm.gov.in/ 

11) Ahmad, A., Khan, M., & Patel, I. (2015). Drug pricing policies in one of the largest drug manufacturing nations in the world: Are  affordability and access a cause for concern? Journal of Research in Pharmacy Practice, 4(1), 1. doi:10.4103/2279-042x.150043

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