Managed Care - February 2008 - (Page 51) TABLE 2 Evidence-based guideline adherence, by chronic conditions % of patients receiving recommended care Quality Indicators Coronary artery disease (CAD) patients with ACE inhibitor Hyperlipidemia patients with statin or acceptable alternative Congestive heart failure (CHF) patients with beta blocker Congestive heart failure (CHF) patients with ACE inhibitor Depression patients with SSRIs or SNRIs Depression patients with any antidepressants Migraine patients with narcotics Adult persistent asthma patients with ICS Diabetes patients with oral diabetes therapy Pediatric persistent asthma patients with ICS *Medicaid pediatric population data # of eligible patients 26,220 622,110 5,883 5,883 26,068 26,068 33,984 53,470 162,394 8,378 All 35% 36% 50% 55% 56% 85% 57% 78% 80% 97% Commercially insured 36% 38% 53% 58% 56% 85% 57% 79% 81% 97% Medicare 29% 27% 39% 44% 45% 72% 66% 58% 74% 96%* cent for ACE inhibitors, and 38 percent for statins (Shrank 2006). These studies generally find nonadherence to be even more prevalent than we did, and this may reflect the lack of standardization of study design and/or the effect of insurance coverage on our population. Other studies demonstrate that those covered under Medicaid and Medicare may have more medication adherence problems, particularly related to cost barriers (Mojtabai 2003). Nevertheless, it is clear that even patients who have commercial insurance are frequently non-adherent with their medications. This study’s results show that adherence to guidelines as well as patient adherence to medication is a cross-cutting issue, irrespective of socioeconomic status and level of insurance coverage. The differences in the rates of the commercial and Medicare populations raise interesting questions about the effects of insurance coverage on quality of care. Past research has focused mainly on individual conditions, types of providers or patients, local regions, and methods for improving adherence. The data presented here, representing a national commercially insured population, illustrate the need for a widespread approach to address problems with medication adherence. It is necessary but not sufficient to say that providers and patients must comply. The issue of medication adherence is far from new, and not restricted to the United States (WHO 2003). This may be the ideal time to tackle these problems again as health care costs continue to rise and poor outcomes, some perhaps resulting from nonadherence, assist in strangling an already flailing system. Along with costs, the advent of consumer-directed health care and the growth of consumerdirected health information has primed this key target audience. Now may be the ideal time to reach out to consumers on the importance of medication adherence, by implementing a variety of strategies. Clinical and economic problems Studies have demonstrated that nonadherence to medication is a costly problem because of poor out- comes. Sokol et al found that annual medical costs for patients with high cholesterol fell from $6,810 to $3,124 as medication adherence improved from the lowest range studied (less than 20 percent) to the highest range (80 percent and greater) (Sokol 2005). Similarly, they found that costs for diabetic patients dropped from $8,812 to $3,808. Hepke et al, also studying a diabetic population, showed a consistent decrease in costs from a peak of approximately $6,200 as compliance rose above 40 percent (Hepke 2004). Another study observed a decrease of $685–$950 in 1997 dollars per diabetic patient as glycemic control improved, while two recent studies discovered that adherence reduced diabetic costs by somewhere between 4 percent and 29 percent, respectively, due mainly to substantial decreases in hospitalizations (Wagner 2001, Shenolikar 2006, Lee 2006). Hospital admissions and emergency department utilization are also expensive and preventable for patients with asthma. One study showed that increased use of inhaled corticosteroids contributed FEBRUARY 2008 / MANAGED CARE 51
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