Interventions for Medication Adherence

Prescription drugs are a front-line therapy now for many chronic diseases.  Compliance with medication regimens is therefore a substantial issue.Cost-sharing in regard to medications inhibits many patients from even filling prescriptions and a variety of other issues, from poor health literacy to fear of side effects, also deter full compliance with a prescription.  A number of programs and products have tried to improve adherence.  The Journal of the American Medical Association carries a review of research regarding these efforts.   (JAMA Article)   The authors looked for randomized trials of interventions reported from 2000 to 2018.  49 trials were included, covering 6 general categories of interventions:  patient education, medication regimen management, pharmacist-led interventions, cognitive behavioral therapies, medication taking reminders and incentives for adherence.  Outcomes were generally measured through pharmacy claims data on missed medication or refills, electronic drug monitors and patient self-report, none of which may be perfect.  Broadly speaking, it isn’t clear how much of an impact any of the interventions had, partly because while non-adherence is widely discussed as an issue, it isn’t readily apparent how often it really occurs at a clinically significant level.  Some patient education interventions showed small but statistically significant effects, but the interventions that were effective tended to be the more complex, expensive ones.  Similar results occurred with interventions to simplify medication regimens, for example reducing the number of pills.  Clinical pharmacist consultation also had modest effects.  Cognitive behavioral interventions had similar outcomes, and again, the ones that appeared most effective were the most costly to deliver, using multiple coaching sessions and highly trained specialists.  Medication reminders, like a broken record, also showed minor improvements in adherence, as did electronic pill boxes and similar devices.  Finally, financial incentives, whether an actual payment or just using drugs with lower cost-sharing, had mixed results as well.  Overall, the review suggests that there may be interventions that can effectively improve medication adherence, but the ones most likely to be successful are more expensive to deliver.  Patient with very high number of conditions and medications probably benefit from and can justify the cost of very intensive interactions with pharmacists or other clinicians to ensure that the drugs are being taken and are working as intended, but for the vast majority of patients I would suspect the cost may not be justified by any improved outcomes.