Managed Care - February 2008 - (Page 55) age of recommended care received ranged from a high of 68 percent (CAD) to a low of 45.4 percent (diabetes), with the mean percentage across these seven conditions being 57.4 percent (McGlynn 2003). Building on the literature regarding the challenges of promoting clinical practice guidelines, and the groundswell of work to promote patient-centered care and participatory decision making, it behooves quality improvement experts to take advantage of the tools and knowledge to access and reduce barriers to medication adherence. Some strategies include the use of opinion leaders to champion the use of practice guidelines and the use of quality improvement activities, such as pay for performance (Doumit 1997). Medicare’s pilot pay-forperformance program, which pays physicians on the basis of a set of evidence-based care measures (e.g., annual eye exams for diabetes, appropriate asthma medication) promises to improve quality by giving providers an incentive to follow evidence-based guidelines (Sokol 2005, Hepke 2004). While these payment models stand to influence provider behaviors, medication coverage policies more often create barriers to patient medication adherence. Coverage caps and gaps, copayments, and premiums all put financial strains on low-income patients. The “doughnut hole” in Medicare Part D design is a prime example of a coverage gap that has the potential to deter patients from being compliant with their medication to avoid an abrupt jump in out-of-pocket costs (Stuart 2005). All health care providers — physicians, nurses, pharmacists and others — have a key role in improving medication adherence, including promoting the importance of adherence to their patients. Involving their patients in medica- tion decisions and ensuring that these decisions fit within their lifestyle and budget will increase the probability of adherence. Providers can also encourage appropriate medication use by discussing adherence problems at follow-up visits and by working collaboratively with patients to overcome identified barriers (Hesiler 2004). Education, information, and access to medications are three important factors in medication adherence. Understanding the purpose of a medication, its possible side effects, and its health benefits will require education and information from providers, health plans, employers, and others. Tools such as automated pill cases and care management call can facilitate the timely and appropriate use of medications (Haynes 2005). Limitations It is widely acknowledged that the use of claims data for various analyses can be a limitation in the generalization and application of results (Motheral 1997). Problems with data entry, coding, and completeness all create challenges with analysis and the relative significance of findings. While these are examples of claims data limitation, it must also be recognized that until electronic medical records are more readily available, claims data constitute the most comprehensive form of information available for utilization research. Finally, the comprehensiveness of the database used for these analyses allows for assurance that findings are relatively generalizable. While MPR may not be an exact tool, it is widely used and accepted as a measure of adherence and persistence. As with clinical claims data, usage of pharmacy data has limitations, but again, pharmacy data are often used to assess fillrates; it is the most efficient way to obtain medication dispensing information. The authors acknowledge that the inclusion criteria of limiting medication adherence analyses to only those patients filling at least two prescriptions potentially underestimates the medication nonadherence rates; however, when using claims data, two medications are required to calculate a time-torefill ratio. Similarly, other inclusion criteria, such as those for persistent asthma, based on emergency room visits, hospitalization, and other health care service utilization measures, also serve to underestimate medication adherence. It is understood that a more restrictive inclusion rule requiring more claims for a condition would reduce possible biases and reduces the number of false positives — those that appear to meet the criteria but may have been misdiagnosed or miscoded. Considerations for research As this area of research matures, numerous questions must be addressed. Are patients simply not filling the prescriptions they receive, and therefore the rates of medication adherence are grossly underestimated? Are provider-prescribed changes in dose and/or medication types leading to alteration in fill rates that may be misinterpreted as poor adherence? Are patients getting medications from other sources, creating the impression of nonadherence? What role could and should health care providers play in enabling patients to adhere to their medication regimens? What role can health plans play in improving medication adherence? With nearly one-fifth of patients noncompliant with their medication regimen, it is imperative that these questions be considered as the field of health services research continues to evaluate medication ad- FEBRUARY 2008 / MANAGED CARE 55
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