SPHS 11 22 15 Sally Huston 015 Edit

SPHS Professor Sally Huston Published in ‘Atlas of Science’

Many patients do not adhere well to their prescribed medication regimens. Evidence shows that improving medication adherence leads to lower overall health care use and costs. As a result, healthcare stakeholders are increasingly interested in improving patient medication adherence. The importance of this topic is illustrated by the fact that the United States (US) Medicare Part D 5-Star Rating System is linking triple weighted medication use and adherence quality measures to quality stars, and thus to compensation.

Pharmacists do feel that helping patients with medication use and adherence is an important part of their role, and have demonstrated in multiple projects and trials they can provide effective medication adherence services. Unfortunately, the limited evidence available to date suggests community pharmacists do not provide needed levels of adherence services. Increasing the delivery of adherence services in community pharmacies is important because most patients get their prescriptions there.

In the US, a 2004 study showed pharmacists counseled patients starting new HIV/AIDS drugs at best only 52% of the time. (Smith, 2004) This is strikingly disappointing because good adherence is particularly crucial for HIV/AIDS patients, and counseling is a basic adherence support measure. Two Australian studies found pharmacist’s tried to identify non-adherence for only 42% (Mansoor, 2014) and 45% (Mansoor 2015) of dispensed prescriptions.

Research has been minimal to date: much more work is needed. For example, while 42% and 45% nonadherence identification appears low, these levels may be appropriate after accounting for other factors. We need to determine how nonadherence and risk of nonadherence are best defined and identified. For example, is the proportion of days covered measure being used by the US Medicare Part D program the best choice, or is a group-based trajectory model that provides more detailed information better?

A recent Scottish study found academicians, health authorities, and others believed pharmacist attitudes and training were the most important factors influencing adherence services provision, while the pharmacists themselves felt remuneration was the most important. (Gastelurrutia, 2009) While there are undoubtedly multiple factors influencing its provision, payment for services is clearly important. Work is needed to identify appropriate reimbursement levels that will cover provision costs and incentivize pharmacists and pharmacy decision makers to provide adherence services.

Although pharmacists frequently state they do not have time to provide extra services, Mansoor et al. (2015) found time was not a significant barrier. They did find that having existing ‘enhanced’ pharmacy services and an adequate number of full time staff significantly enhanced adherence services delivery. Further work is needed to identify what pharmacists mean when they say they don’t have time. Does it mean that they have inadequate help, inadequate trained help, discomfort in delegating, or something else?

Policy has an important influence on adherence services provision. For example, the Australian government funds several different enhanced pharmacist-delivered services, thereby indirectly increasing the delivery of adherence services. In Switzerland however, inadequate direct adherence services payment, combined with program complexity and patient resistance, resulted in poor uptake. In the U.S., Medicare Part D quality ratings are influencing some Part D plans to pay adherence performance bonuses to pharmacies. Policy and context factors should be a high priority area for adherence research.

Overall, increasing the level of adherence service delivery in community pharmacies is a complex situation influenced by multiple factors. Research is needed on multiple levels, including governmental and organizational policies and practices, practice site level, pharmacist and patient challenges. As health systems and reimbursement mechanisms change, it is even more important that these research areas are addressed to ensure that pharmacist provision of the highest levels of adherence services and patient care quality is facilitated.

Sally Huston, PhD, Associate Professor, Keck Graduate Institute School of Pharmacy, CA, USA


Pharmacist provision of medication adherence services: More implementation and persistence research needed.
Huston SA
Res Social Adm Pharm. 2015 Nov-Dec

Read Pharmacist’s role to help patients get the most out of their medications on Atlas of Science here.