Optimizing medication adherence communication with prescribers

Introduction

In the last decade, poor medication adherence has grown as a major health concern. An estimated $300 billion is spent annually as a result of non-adherence, including the extra costs occurring from medical complications and hospital admissions.¹

Numerous barriers exist that contribute to poor medication adherence. On the physician side, physicians do not have sufficient information about patients' adherence to appropriately take care of patients. This may be due to the time pressure that physicians face when trying to address numerous issues during a short office visit. Physicians also tend to expect that patients will take their medication as directed, and rarely ask detailed questions about adherence or missed medication doses.⁶ As a result, adherence rates are often overestimated by physicians.²

On the pharmacist side, pharmacists' ability to address non-adherence is limited by functional barriers such as space limitations, time constraints and lack of management support. Complex medication regimens may further complicate a pharmacist ability to identify and address adherence problems.⁵

Adherence interventions, carried out by a pharmacist, can be effective for increasing adherence rates,³ in part because pharmacists can identify the various reasons for non-adherence including a busy lifestyle, a belief the medication isn't needed, the medication was not available, or the medication made them feel bad.⁴ Identifying the specific causes for non-adherence can help the pharmacist and prescriber tailor interventions to meet the patient's needs.

However, even though pharmacists may be able to identify reasons for non-adherence, there remains a huge question about how pharmacists should be conveying said information to prescribers in a manner that is meaningful and actionable.

Currently, communication occurring between pharmacist and physicians is often sporadic and reactive to problems once they occur. This does not support opportunities for collaboration, and hinders the achievement of treatment goals.⁷

This study explores how information about patients' medication adherence, gathered by a community pharmacist, can be optimally communicated with prescribers to improve medication non-adherence.

Methods

This study was a qualitative investigation using semi-structured interviews for data collection. Prescribers were identified for recruitment if they were currently practicing as a primary care provider and participated in chronic disease management.

Prescribers were contacted by phone. A verbal explanation of the study purpose, what participation involved, and the estimated time commitment was provided. If they agreed to participate, an interview was set-up and the prescriber was provided with the research consent form and interview outline.

Simulated patient cases were developed that included information that would be obtained through the use of the Comprehensive Medication Adherence Assessment Program (CMAAP), an electronic consultation platform, developed by Aprexis Health Solutions, which allows the pharmacist to identify multiple medication adherence barriers, and then generates techniques to help the patient overcome them.

This information was presented on four different example fax forms, which were created to stimulate prescriber reaction on the type of information and formatting they preferred.

Forms were designed on a gradient from simple to complex (Appendix A). Form one included the least amount of information sections and required the pharmacist to document in their own words the interaction with the patient. Forms two, three and four included varying amounts of pre-formed, generalized responses that allowed the pharmacist the check off the one most closely representing the patient's response. Form three included a table that connected the barrier category to problem description to solution provided by the pharmacist flowing horizontally, while form four included a similar table that flowed vertically.

A semi-structured interview guide (Table 1) was designed to investigate prescribers' thoughts and practices related to medication adherence and collaborating with pharmacists. The first question, related to current practices, was intended as a “warm up” question, and was used to get a sense of the prescribers' attitude and current methods of addressing medication adherence. After the first question, the four sample fax forms were presented to the prescriber for their review. The remaining questions specifically asked questions about their reaction to the four different fax forms. The primary question was followed with probes to verify that the researcher had a complete understanding of the prescribers' perspectives of each form and how they would use it.

Table 1. Interview Guide.

Topic	Primary Question	Probing Questions
Current Practices	How do you address medication adherence with your patients?	Pieces of information you find useful Number of patients believed to be non-adherent?
Response to simulated patient cases	What information would you want from this case?	Discuss different categories Is there specific information needed for certain medications or disease states?
Format	How would you like this information presented?	Which fax forms do you prefer? Pre-formed responses with check boxes or free-formed
Method of transmittance	What is your preferred method to receive this information?	When would you like direct contact versus fax?
Regularity of communication	How often do you want to receive this information?	Type of patients for which you would want it more often, not at all?
Form Use and Processing	What would you do with this information?	Information storage in records Willingness to sign and fax back
Barriers	What are barriers to sharing information?	How would you use this information?
Referrals	Have you ever referred a patient to a pharmacy for help with adherence?	Would you refer patients to take part? Best way to refer patients

The University of Wisconsin Institutional Review Board approved this study.

All interviews were conducted one-on-one in a private setting, took up to 30 minutes, and audio taped. The recordings were transcribed into a Microsoft Word file. The text was analyzed in a descriptive and interpretive manner, guided by the topics identified in the interview guide.

Results

Of the six prescribers that were contacted, four prescribers contacted agreed to participate: one Medical Doctor, one Doctor of Osteopathy and two Nurse Practitioners. Each worked as a family practitioner and provided services within small communities. Three worked within larger health systems, while one was in independent practice.

Current practices

All prescribers reported that evaluating their patients' medication adherence is part of their current practice. They reported using clinical measures (lipid levels, blood pressure readings, etc.) as markers for non-adherence. Prescribers noted that the reason why the patient was non-adherent was part of their thought process. One prescriber stated, “I'd like to know why. You know was it a medication side effect, was it a misunderstanding about the medication? Is it about cost? Is it because insurance wouldn't cover it…”

Response to simulated patient cases

Figure 1 displays the information-components prescribers reported as desirable. All prescribers stated that reason for the consult, and description of the barrier should be included. Half of the prescribers did not want the entire medication list included. When asked about the medication list, one prescriber stated, “Just the ones [medications] that you have concerns with.”

Figure 1. Desired information.

Prescriber 1 noted the importance of including the solution provided to the patient so that it could be discussed at an office visit. One prescriber felt that a short summary of what was found could be included instead of the plan section.

In comparison, prescribers discussed how insurer-provided reports were not very useful because they identified medication(s) that were not being filled appropriately but did not provide any other information. One prescriber stated, “I guess they inform me… somebody is not filling their meds, …I mean that's okay but I hope this is a little beyond that.”

Formatting

After reviewing the four example fax forms, all prescribers indicated that “the simpler, the better.” For example, check boxes utilizing lists of potential patient responses increase the volume of text, which reduced simplicity. The main reasons given for favoring one form, over another, related to a desire to decrease information overload.

• “So the simple form [form 1], because we get so bogged down in forms and I know that is a big compliance issue, the forms with providers, I'm sick of the paper work.”

• “I see so much stuff going on and it drives me crazy … the third form [form 3] you know, when I'm looking at all this it's like, just tell me very specifically the adherence barriers and its description, very succinctly.”

Prescribers commented that the information presented in vertical columns helped with the flow, as they read from top to bottom of the page, while the horizontal columns did not follow the “usual direction we read”.

Mode of transmittance

It was uniformly agreed that fax communication would be the best way for a pharmacy to communicate non-urgent matters. If information found could lead to immediate patient harm, then a telephone call would be warranted.

Regularity of Communication

The rate at which pharmacists should provide follow-up to prescribers was not consistently clear. Three to six months was generally viewed as reasonable, however, given a patient's unique situation or persistent non-adherence, this might vary.

Form Handling

To better understand how this information may be used, prescribers described how the form would be processed in their clinics. Most commonly, fax forms start with the nurse. Two prescribers, utilizing electronic medical records, indicated a short note would be entered in the patient chart regarding the form. Two prescriber, who relied on dictation and paper records, felt the information may be included in the record if it was valuable; however, generally pharmacy communication was not included. Two prescribers were willing to fax the signed form back to the pharmacy as requested. The other two appeared less willing.

Barriers

Lack of time and lack of reimbursement was the most obvious barrier to using this form and reported by prescribers.

• “The average family doc spends 30% of his or her time doing paper work that he or she does not get paid for, can you imagine that? …That's insane.”

• “So if somebody wants to pay me … then I would get some money out of this [addressing adherence] and they would save billions of dollars.”

Referral

Three prescribers reported that they would refer patients to take part in an adherence intervention. One noted he would encourage the patient to ask the pharmacist for help while another stated he would call to make a referral. One prescriber suggested a referral form,

“If you had a referral form, maybe that you create that you know again is very short… and then we would keep it in a folder so I could keep it to use it if I needed it.”

Discussion

Adherence is an important issue for prescribers, but that prescribers have limited time, and information overload, to properly address non-adherence issues. It is incumbent upon pharmacists to convey necessary information to prescribers in a way that meets their information needs. In turn, prescribers can then act upon the information.

Results from the interviews were used to develop a fax template (Figure 2) to use in practice for adherence information communication.

Figure 2. Final fax form template.

The ideal fax template is designed to provide the prescriber with key, patient-specific details, while avoiding complexity and information overload. Prescribers' statements regarding the need for simplicity, and positive responses to the simplest form, suggest the importance of minimizing the time to review the form. To do this, the medication list was eliminated, as were most checkboxes with pre-formed patient responses, which increased form complexity.

The template must go beyond just letting a prescriber know a patient is non-adherent. An area was included that allowed to the pharmacist to state a brief description of why the patient was not taking the medication. The use of the different barrier category was also included to help the prescriber quickly understand the issue needing to be addressed.

Vertical columns were used to improve the flow in which the information was read. The patient name was enlarged to facilitate ease of identification.

Patient allergies were included, as this was independently stated by two prescribers as useful when working with pharmacies to provide quality care.

Throughout the collection of communication data, prescribers' beliefs about their role in medication non-adherence were brought to light. One stated that they did not believe medication non-adherence is a concern they were always responsible for addressing, suggesting the usefulness of communicating this information with select prescribers may be limited. However, prescribers' overall willingness to refer suggests they are in favor of this program and receiving pharmacist communication.

Given the lukewarm response received from some prescribers about documenting pharmacy information and faxing a response back to the pharmacy, more work needs to be done to explore and develop an effective and efficient communication style that supports the work of both physicians and pharmacists.

Prescribers have not yet conceptualized how frequent communication should occur. Investigation is required to determine when follow-up information would be beneficial for prescribers to receive.

This study created a method by which pharmacists may succinctly transmit to prescribers information that they gain on a daily basis. Non-adherence is a pervasive health care issue that does not have a simple answer, and a variety of approaches are needed to address it.

Limitations

Given the small number of prescribers from one region and one specialty, when variation in prescriber opinions occurred, it was difficult to develop conclusions due to lack of consensus beliefs.

Conclusions

Prescribers believe addressing non-adherence with their patients is an important issue. A pharmacist sharing patient medication adherence information, in an optimized format, was desired by a majority of the prescribers in this study. Prescribers are willing to participate in a team-work approach to address non-adherence. Further research is required to evaluate the impact of this form on adherence when used in practice.