Managed Care - February 2008 - (Page 52) TABLE 3 Nonadherence with prescription medications, by chronic conditions % of Patients not adherent with medications (MPR<70%) 42% 37% 19% 25% 15% 26% 22% 25% 20% 16% 21% 11% Chronic Condition Pediatric persistent asthma: ICS Adult persistent asthma: ICS Chronic heart failure: ACE inhibitor Beta blockers Coronary artery disease: ACE inhibitor Depression: SSRIs or SNRIs Diabetes: Sulfonylurea Biguanides Thiazolidinedione Any oral therapies Hyperlipidemia: Statins or other alternatives Hypertension: Any acceptable therapies Drug and drug classes reviewed by condition Asthma: inhaled corticosteroids (ICS) Chronic heart failure: angiotensin-converting enzyme (ACE) inhibitors, betablockers Coronary artery disease: ACE-inhibitors Depression: selective serotonin reuptake inhibitors (SSRIs), serotonin & norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOI), bupropion, nefazodone, mirtazapine Diabetes: Biguanides, thiazolidinediones, alpha-glucosidase inhibitor, sulfonylurea, meglitinide, D-phenylalanine Hyperlipidemia: statins, niacin, fibric acid derivatives Hypertension: ACE-inhibitors, angiotensin receptor blockers (ARBs), diuretics, calcium-channel blockers, alpha-adrenergic blockers, central alpha-adrenergic agonists, vasodilators, peripheral adrenergic antagonists, selective aldosterone receptor antagonists Concerns remain about how well physicians and others assess patients’ medication adherence, and further, what they are doing to improve poor rates (Shrank 2006). Yet as we noted earlier, it is not the sole responsibility of the provider and/or the patient to take on the challenge of improving medication adherence, as others’ policies and practices also influence adherence rates. Studies find that in patients with diabetes and high cholesterol, high levels of medication adherence correlate with subsequent lower disease-related medical costs, and these savings more than compensate for the increase in medication costs, often borne by companies offering employer-based insurance (Epstein 2004). Several studies find that medical care utilization rates for various conditions, including diabetes, high cholesterol, hypertension and chronic heart failure, were significantly lower for patients with high levels of medication adherence (Rosenthal 2004, Stuart 2005). Improving medication adherence Patients carry the primary responsibility of being adherent to their medication regime. Still, the fact that patients aren’t receiving prescriptions for appropriate medication, or are receiving multiple, possibly contraindicated, prescriptions from one or more providers, necessitates strategies that go beyond the individual patient. Another approach to improving medication adherence encourages the delivery of evidence-based care. Literature continues to emphasize the poor level of evidence-based care delivered to patients with chronic conditions. McGlynn et al found that for the conditions we reviewed (hypertension, CAD, CHF, diabetes, depression, hyperlipidemia, and asthma), the percent- to a 35 percent decrease in pediatric hospitalizations and a 27 percent decrease in emergency department visits, while another also demonstrated an association between nonadherence to asthma medications and increased risk of hospitalization (Cloutier 2005, Piecoro 2001). Chronic heart failure patients have been shown to cost nearly $8,000 per hospitalization, leading to aggregate costs in the millions of dollars that can be reduced by greater adherence to beta-blockers and ACE inhibitors (Xuan 2000). Fi- nally, patients with depression have lower costs for both primary depression care and care associated with comorbid conditions (Eaddy 2005, Katon 2005). Costs for primary care of depression run more than $6,000 and potentially could be reduced by one sixth, while charges for three common comorbidities have been determined to range from $400 to more than $1,100, with a possible 6 percent to 20 percent reduction in these charges with adequate medication adherence. 52 MANAGED CARE / FEBRUARY 2008
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