National Diabetes Education Program Webinar
Empowering Patients
October 15, 2015
Joanne Gallivan, MS, RD—Director, National Diabetes Education Program, National Institutes of Health
Good afternoon everyone and thank you for joining the National Diabetes Education Program’s Webinar Empowering Patients to take their Medicine, What Can We Do?I am Joanne Gallivan; I am Director of the National Diabetes Education Program at the National Institutes of Health.
As a joint program the National Institutes of Health and the Centers for Disease Control and Prevention the NDEP’s mission is to reduce the burden of diabetes in the United States by facilitating adoption and proven approaches to prevent or delay the onset and the progression of diabetes and its complications.
I think many of you know that we host a variety of webinars throughout the year to support all of you working to improve diabetes management outcomes and to prevent or delay the onset of type 2 diabetes.I just want to review with you a few key items before we begin the main presentation.
All your lines are already muted so you do not need to mute yourself.We will have a Q&A session at the end of the presentation.If you would like to ask a question please submit it during the webinar using the “Questions Box” in the “Control Panel” and then we will read it out loud.Any questions not answered will be shared with Dr. John Ryan and Dr. Jennifer Bussell after the webinar so they can get back to you if they have not been able to answer your question.
This webinar is being recorded.We will post the video recording and presentation slides on the NDEP webinar page in the next three weeks and we will notify all of you when the files are available.You will also receive an e-mail from us this afternoon that asks you to evaluate this webinar, please give us your feedback because we use it to plan future events.And if you would like receive a certificate for completion of this particular webinar please send an e-mail to and you can see that URL on the slide.
So, we are very, very excited to have two guest speakers for today’s webinar, Dr. John Ryan and Dr. Jennifer Bussell.
Dr. Ryan is Professor of Family Medicine and Director of the Division of Primary Care Health Services Research and Development at the University of Miami Miller School of Medicine.His clinical and research interest is in type 2 diabetes with an emphasis on high-risk populations and mechanisms for achieving behavior change.
Dr. Ryan designed and supervises a coordinated care program for managing diabetes that targets low income, high-risk patients followed in a community health center affiliated with a tertiary care hospital.The program’s model includes clinical diabetes support as well as diabetes self-management education and behavioral support programs that are aligned with cultures and health literacy levels of the target population.
After Dr. Ryan we will have Dr. Jennifer Bussell who is an Instructor of Clinical Medicine at Northwestern University Feinberg School of Medicine.She previously served as Clinical System Professor in the Department of Medicine at the University of Chicago and Associate Program Director of Internal Medicine and Transitional Year Residency at MacNeal Hospital.
Dr. Bussell speaks nationally to the Institute for Healthcare Improvement on improving medication adherence and is involved in developing the medication adherence module for the AMA’s STEPS Forward Program.
Dr. Bussell is a member of the Patient Quality Committee at Northwestern Medicine and serves as Chair of the Patient Safety and Quality Committee and as an Executive Board Member for the Illinois Chapter of the American College of Physicians.
We thank both of you Dr. Ryan and Bussell for your commitment to promoting medication adherence and for today’s webinar.I will now turn the program over to Dr. Ryan.
John G. Ryan, Dr.P.H.—Professor of Family Medicine and Director of the Division of Primary Care Health Services Research & Development, University of Miami Miller School of Medicine
Thank you, Joanne, and thank you everyone for joining us this afternoon.We are going to first provide some definitions of some of the key concepts and terms that we are going to be talking about for the next hour to make sure that we are all on the same page and have a similar understanding of what these concepts really are.
When we say “adherence” what we are talking about is the active, voluntary and collaborative involvement of the patient in a usually acceptable course of behavior to produce a therapeutic result, which is a pretty conventional definition.
The phrase “adherence” is actually gone under an evolution over the course of the past 20 years.It had been called “compliance” but that concept has been softened a bit to adherence and I have to say that my own bias is against adherence.I prefer something that is even more neutral.I like to say medication taking behavior and so you might hear that term during the course of this presentation on and off and in the future so you know what you are hearing.
Medication adherence actually involves two main concepts, first of all there is adherence and second is persistence.So, adherence is the intensity of drug use during the therapy and persistence is the overall duration of drug therapy.It is important to know that we are talking about two different types of using medication and there are different ways of measuring that and also there are different things that you as a clinician or as a provider, or as an educator would want to be aware of as you think about medication adherence to talk to your colleagues or your patients about it.
The scope of the problem, here is a set of bullets that rather succinctly illustrate some of the important things that we know about this issue and some of the things we do not know.So, first we know that the adherence rate for diabetes medications is represented by an incredibly broad range in the medical literature from 36 to 93%.So, to me this suggests that we really do not have a clear idea of what medication non-adherence rates are for diabetes medications and this is complicated because of the frequency with which all medications are changed during the course of treating the patient.It is also complicated by the way in which insulin is prescribed and administered.
All of the characteristics make meaning and use of these medications extraordinarily complicated and not always reliable.Furthermore, adherence rates differ depending on the demographics of the target population or comorbidities that exist in the target population.So, depending on the study and depending on the target population rates are going to vary and sometimes be wildly different.
As much as we like to be able to succinctly say, adherence rates for diabetes medications is “x” or “y” we really are unable to make a broad blanket statement at this point.What we do know, very well in fact, that less than 1% of patients who are medication non-adherent actually disclose that to their physicians suggesting that a provider may think that the patient is using their medication as prescribed but is very unlikely to know for sure.
We also know, from clinical trials, that a 10% increase in non-adherence, to for example metformin, is associated with an increase of 0.14% in HbA1c glycosylated hemoglobin level.We also know that a 10% increase in non-adherence to statins is associated with a 4.9% increase in LDL cholesterol.
Conversely, we know that each 10% increment in diabetes medication adherence increases the HbA1c levels by 0.16%.So, these are not unimportant changes.These are not insignificant clinical changes and lab values.So, it also suggests to us that small tweaks in the matter in which patients use or do not use their medications can have potentially serious implications for the extent to which their condition is controlled.
Finally, there are estimates suggesting that improving adherence to diabetes medication could prevent almost 100,000 emergency department visits in a year and 341,000 hospitalizations annually using 4.7 billion dollars.So, obviously, again, this is not an insignificant problem whether we are talking about an individual patient, the healthcare system or the healthcare system at large in the country.
We see the reasons for medication non-adherence is multifactorial which is to say that there are a great many factors that may contribute in medication non-adherence or that may mitigate against medication non-adherence.
So, this is kind of conceptual model is actually vitally important for us to look at, consider, think about not only for the course of this presentation but also as you go forward if you are interested in taking any actions to reduce medication non-adherence in any patient population.I am going to talk a little bit about some of these factors and then we will drill down on some of these factors later on in the presentation in a little bit more detail.
Framework, so, I do not know how many people are accustomed to working with a framework but this kind of a model is critical for understanding the problem like medication non-adherence. First, because it illustrates what kind of interventions may be useful for us to develop but it also shows value and dimensional intervention number one that addresses only one factor and that likely could be various---a multidimensional intervention with getting multiple factors at one time is more likely to be effective.
So, let’s take a little bit of a deep dive on this model because it is fairly important.First is the patients, but this shows that the language patients perceive their illness whether they are likely to think that medication is going to help or not can effect medication taking behaviors.
So, for example, we have a large Asian population here in Miami and many of our older patients with diabetes can have the perception that diabetes is something that comes from God and that they cannot do anything about it.So, that is definitely going to impact the way they think about taking their medications.
Another component of this factor is the extent to which patients perceive their medications.So, for example many of our patients have the belief that insulin is a habit-forming drug or that being prescribed insulin means that they have failed to conform their diabetes using other mechanisms so it is a negative perception.So moving patients to a different stage on the continuum of how they perceive their illness takes a lot of education and counseling.
Cognition, including memory and mental health, which also includes depression, plays an important role in medication non-adherence.Older patients with other mental health diagnosis could potentially use some triggers to help them to remember their medications.
Another consideration for cognition is the extent that the patient has internalized the motivation for taking the medication.So if the motivation for taking the medication comes from within they are more likely to be adherent than if the motivation is from an external source.
And finally, I want to say another quick argument about cognition, it is important for us to consider that most patients with diabetes have had numerous hypoglycemic episodes because of cognitive capabilities those patients may also be impaired and they will require some extra counseling and education, and again, potentially some reminders or physical mechanisms for helping them to take their medication as recommended.
Demographics we know from research that patients belonging to minority groups are more likely to be less adherent with their DM medications.We also need to enter the characteristics of the medications themselves, for example, potential adverse reactions that may cause a patient to stop using them.Another consideration here is that if they are using multiple medications instead of a single combined medication or medication prescribed three times a day instead of a once daily formula.
All of these factors interact with external stimuli as the patient does.So, an example of an external influence that may alter a patient’s medication taking behavior is a commercial from a legal firm looking for patients to sign onto a class action suit like 1-800-BAD-DRUG.I am sure we have all seen those on TV or have had patients asking us about the danger of taking something based on watching a commercial.
Then we also have to think about the healthcare system or physician factors that may contribute to or protect against many patient nonadherence, so for the healthcare system we have to figure in about co-payments, frequency of needing prescription refills, the validity of the medications that we know, etcetera.
For the physician we have to think about the quality of what we call the therapeutic alliance.This describes the nature of the relationship between the provider and patient.We have to think about whether the patient feels satisfied with the doctor or that the doctor is taking enough time to talk to the patient, or if the patient is fully informed about potential side-effects.We used to call this doctor/patient relationship but that relationship actually began with the doctor it includes every member in the healthcare team and any incident to which the patient feels satisfied with the overall healthcare experience.
So, just a word about considering multifactor nature of medication nonadherence, planning and introducing intervention, in my population, here in Miami, I have received a considerable amount of funding to help patients without any health insurance so that we could cover their pharmacy co-payment.So, we are introducing a tremendous intervention to address what we call “cost-related medication non-adherence.”
To take advantage of this program patients have to present to a central pharmacy in the hospital that is not necessarily something that is easy for our patients to do.And we also found, later on, that patients with any kind of mental health diagnosis ended up having higher medication non-adherence rates than those patients who did not have those mental health diagnoses.So, we would have actually probably had better outcomes if we had some kind of counseling or behavioral health component to this.
So, with that discussion I am going to turn the presentation over to Jennifer who is going to take a deeper dive on some of these factors from her perspective as a physician, but I recommend to you that you keep this central model of mine during the course of her comments, think about these factors after the webinar is over and think about where you might have some influence in making changes that would reduce this particular issue of medication non-adherence for your patients.Jennifer?
Jennifer K. Bussell, MD, FACP—Instructor of Clinical Medicine, Northwestern University Feinberg School of Medicine
Thank you Dr. Ryan.So, among patients with chronic illness such as diabetes approximately 50% of patients do not take their medications as prescribed and 25% of initial prescriptions are never filled.A 2003 report on medication adherence, by World Health Organization, stated that increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any improvement of specific medical treatment.
Medication taking behavior is complex and individual, and requires multifactorial strategies to improve adherence.And although long-term use of medications are effective to decrease mortality and morbidity their full effect is really not realized and for medication treatment to show outcome benefits patients must have medication adherence, the key factor, associated with the effectiveness of all pharmacological therapies and is particularly critical for medications prescribed for chronic conditions such as diabetes.
For instance, nearly 85% of adult patients surveyed in six US States reported that they would never tell their provider if they did not plan on buying a prescribed medication.Physicians or healthcare providers, on the other hand, tend to assume that their patients are adherent.The two studies listed on this slide nearly 85% of surveyed physicians believe that the majority of their patients were adherent.
There really is a great need to screen for non-adherence because patients do not voluntarily tell their healthcare provider about their adherence intentions nor their behavior.Not addressing medication therapy is really an opportunity lost and significant time wasted.
We are all about efficiency, efficiency, efficiency in healthcare and we are in a crunch for our time limitations and when our patients that we see do not reach their A1c goal what do we do?We add another medication or we increase their current medication.We assess the drug interaction, we order those medications, we review the side-effects, the dosing and the costs and if, God forbid, it is not on their patient’s formulary we have to go through the pre-authorization, additional phone calls, additional visits, additional tasks all that combined is an incredible amount of time and effort that we have gone through to ensure the patient is hopefully reaching their A1c goal or their better diabetes control.
Whereas, if we were to address their medication adherence or it is identified, their medication adherence or non-adherence is identified, then the patient is able to improve their medication adherence and reach their goal therefore time and frustration is saved for all of us.