Recent research in patients with cystic fibrosis (CF) suggests that there are associations between medication non-adherence and an increased risk for hospitalizations, pulmonary exacerbations, lower baseline lung function, and longer hospital lengths of stay (Table). Patients and providers alike understand that non-adherence is associated with higher morbidity and mortality rates in CF. However, most studies find that the rate of adherence among patients with CF is only about 50%.
“When managing CF, there is strong potential for improved health outcomes just by increasing adherence to prescribed drug regimens,” explains Kristin A. Riekert, PhD, co-author of a review on medication adherence in patients with CF that was published in Current Opinion in Pulmonary Medicine. “Our healthcare system is increasingly offering incentives for preventing hospitalizations and making clinicians and hospitals more accountable in the care they provide. This includes ensuring that patients are taking their prescribed medications.”
Addressing a Key Issue
Patients tend to overestimate how often they perform positive health behaviors, including taking their medications as prescribed, explains Dr. Riekert. “As a whole, healthcare providers have difficulty in identifying which patients are likely to be adherent or non-adherent to their treatment regimen,” she says.
Despite the challenges facing clinicians, it is important for providers to assess adherence and establish a baseline in order to have an appropriate conversation with patients about their behaviors. “Personal behavior is one aspect of care that patients can control,” says Dr. Riekert. “Providers should support positive behaviors and find approaches to help their patients overcome barriers to adherence.”
Pharmacy records are often used to measure adherence because they provide an existing, objective measure. However, studies indicate that a year’s worth of pharmacy records are required to provide a reliable estimate of adherence, and short-term changes—positive or negative—are oftentimes not taken into account.
Dr. Riekert says that electronic monitors, however, can put a date and time stamp on medication use so that specific patterns can be established. Some electronic monitors feature memory chips within the pill bottle that register use. Others measure the duration of use, such as with inhalers, or whether the user is inhaling medications properly. Data can be downloaded through a port on the device by a provider during patient office visits. Emerging Blue-tooth capabilities also allow for this type of infor-mation to be downloaded automatically, requiring less work for patients who already face a burdensome daily regimen. “By examining these use patterns,” Dr. Riekert says, “we can establish where a person’s specific challenges exist—such as on weekends or in the mornings—and target efforts to increase adherence accordingly.”
Identifying Barriers
Among the numerous barriers to medication adherence among patients with CF are system-level barriers that make it difficult for patients to get medications in their homes. “Many CF medications require prior authorization that consists of extensive paperwork,” explains Dr. Riekert. “This can delay the distribution of needed treatments for patients. In addition, many CF medications are expensive, even for patients with medical insurance. Furthermore, because CF is a relatively rare condition, patients may need to travel far distances to receive care, making it difficult to have opportunities to get support from providers.”
Adherence is frequently affected by how well patients feel their medication is working. Some CF medications can make patients feel worse, such as inducing coughing, making use of these drugs less desirable for patients. Also, many CF medication regimens take up 2 to 3 hours per day to administer. “That’s a lot of time to dedicate to one’s health,” says Dr. Riekert. “Our challenge as healthcare providers is to find what will keep each patient motivated to follow a life-long regimen.” She adds that organizational challenges and misunderstandings between providers and patients can also be barriers to adherence.
Overcoming Obstacles
Pulmonologists can help overcome medication adherence barriers in several ways, but a tailored approach will likely be necessary. Some strategies that can be used to overcome adherence barriers include:
• Establishing a good relationship with patients
so that they are comfortable discussing non-
adherence challenges.
• Using jargon-free language when explaining medical and treatment information.
• Providing written treatment plans to increase patient understanding of treatment plans.
• Asking patients about financial challenges and referring them, as needed, to any assistance programs for which they qualify.
• Assessing and screening for interpersonal barriers to adherence, such as asking patients how they perceive their medication is working for them and ensuring that expectations are realistic.
• Screening for depression and anxiety when appropriate. Both of these mental health conditions are associated with non-adherence in any patient population.
“Taking these steps in an already busy practice can seem daunting for many healthcare providers,” Dr. Riekert says. “However, these efforts are worthwhile and becoming more integrated with the use of technology and other advances. We hope that efforts to improve medication adherence in CF become second nature. Ideally, providers and patients alike will begin to see the benefits, including fewer sick visits and a greater ability to focus more on preventive care.”
