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Engaging Patients
in Their Care:
Adherence &
Health Literacy in
Clinical Practice
Sarah Aldrich, PharmD
Bree Meinzer, PharmD
Joseph K. Daprano, MD, FAAP, MACP
Joseph J. Sudano, PhD
Disclaimer for sharing or use of any of this presentation
1. Describe the impact of medication nonadherence and low
   health literacy
2. Identify different tools that can be used in primary care to
   identify patients with low health literacy and
3. Review strategies to improve medication adherence and
   health literacy


The following planners, speakers, moderators, and/or panelists of the CME
activity have no financial relationships with commercial interests to disclose:

Sarah Aldrich, PharmD
Bree Meinzer, PharmD
Joseph K Daprano, MD, FAAP, MACP
Joseph J Sudano, PhD

The Ohio Cardiovascular Health Collaborative is funded by the Ohio Department of Medicaid and administered by the Ohio Colleges of Medicine Government
Resource Center. The views expressed in this presentation are solely those of the authors and do not represent the views of the state of Ohio or federal
Medicaid programs.

Sarah Aldrich, PharmD & Bree Meinzer, PharmD

 University of Toledo College of Pharmacy and
           Pharmaceutical Sciences
     University of Toledo Medical Center
What is
Extent to which medication intake behavior
Adherence     corresponds with the recommendations of the

Compliance    Extent to which the patient follows the
              recommendations of the provider

              Length of time between the first and last
Persistence   dose (when patient discontinues

                                     Hugtenburg JG, et al. Patient Preference
                                     and Adherence, 2013.7:675-82.              7
Intentional vs. Unintentional

       Unintentional             Intentional
        Unplanned behavior       Patient ACTIVELY
       that is not commonly      decides not to use
         linked to beliefs or   treatment or follow
              cognition          recommendations

                                   Hugtenburg JG, et al. Patient Preference   8
                                   and Adherence, 2013.7:675-82.
Measuring Adherence

• Proportion of Days Covered (PDC)
  • CMS defines adherence as a PDC >80%

• Medication Possession Ratio

                                          Crowe M. Pharmacy times. 2015.
Impact of
National Data

Ohio Medicaid Data 2017-2018
• Only 1/3 of Medicaid enrollees (132,685/424,851) age 18-
  64 years old with a hypertension diagnosis filled a blood
  pressure (BP) prescription

• Of those who filled at least 1 BP medication (n=292,166),
  7% filled their BP medication only once making it
  impossible to calculate their adherence

• Of those who filled the BP medications at least twice
  (n=271,963), 64% were considered adherent (MPR>80%)
What factors
contribute to
Five Dimensions of Adherence
Social and Economic
    ●    Low health literacy                  05                             Patient-Related
    ●    Medication cost                                                 ●    Visual, hearing,
    ●    Lack of health                                                       cognitive impairment
         insurance                                                       ●    Perceived risk of
                               01                          04                 disease
                                                                         ●    Perceived benefit of

Health Care System                                                           Therapy-Related
●       Lack of care                    02            03                 ●    Complexity of
        continuity                                                            regimen
●       Restricted                                                       ●    Frequent changes
        formularies                                                      ●    Actual or perceived
●       Long wait times                 Condition-Related                     side effects
                                    ●    Lack of symptoms
                                    ●    Depression
                                    ●    Severity of symptoms   Sabate E. World Health Organization. 2003.
Common Contributing Factors for
                              Actual or perceived; Relation
     Adverse Effect
                              to benefit of treatment

02   Cost
                              Health literacy; Risk of disease vs.
     Lack of

03   Understanding
                              benefit of treatment; Lack of
                              symptoms; Mistrust

04   Forgetfulness
                          ●   Too many medications; Multiple
05   Regimen Complexity       dosing times; specific medication
                              instructions                           15
Investigating Medication
Objective Information
• Claims Data
   • How often has the medication been filled within a 90 day period?
• Clinical Data
   • Limited or no improvement in signs or symptoms

Subjective Information
• Motivational Interviewing
• Creating a no-judgement / honest environment
How do we
Overcoming Medication Nonadherence

                              Prescribe alternative; Switch formulation;
01   Adverse Effect

                              Address perceived AE

                          ●   Coupons; $4 lists/$0 copay at specific
02   Cost                     pharmacies; Investigate insurance

     Lack of
03   Understanding
                          ●   Education

                              Set alarms; Keep pills visible;
04   Forgetfulness

                              Incorporate into other routine

                          ●   Change product or formulation;
05   Regimen Complexity       Deprescribing; Medication
Patient Specific
Approach to
Case #1
PA is a 57 yo WM with PMH of HTN, HLD, T2DM
• BP: 160/94, HbA1c: 7.0%, and lipid panel is wnl
• Medications: atorvastatin 20mg daily, metformin 1000mg BID,
  and lisinopril 5mg daily
• You are discussing with him about increasing his lisinopril 5mg
  daily. PA mentions that it doesn’t matter much, because he
  doesn’t take his lisinopril anyway. Upon further questioning, he
  states “I don’t feel any different if I take it, so why bother?”
• How do you respond to the patient?

Case #2
CM is a retired 78 yo African American female with PMH of CHF,
• BP: 148/86, EF: 30%, LDL: 160, HDL: 38, TG: 172, HbA1c: 7.4%
• Medications: Entresto 49mg/51mg BID, carvedilol 6.25mg BID,
  rosuvastatin 10mg daily, metformin 1,000mg BID, Januvia
  100mg daily
• At the appointment, you notice that some of CM’s pill bottles are
  empty. Upon further questioning, she states “I can’t afford to all
  of the medications and I know how important it is to take them.
  In order to save money, I pick up half of them one month and
  pick up the rest the next month.”
• How can we improve the patient’s adherence?
Case #3
TA is a 62 year-old Caucasian female with a PMH of T2DM,
HTN, and depression
• BP: 124/84, HR: 70, A1c 6.9%, TG: 100, Total cholesterol 110, LDL:
  70, HDL 51
• Medications: metformin 1000 mg BID, Lantus 15 units QHS, lisinopril
  40 mg daily, atorvastatin 40 mg daily and citalopram 20 mg daily
• She presents to clinic complaining of left hip pain that extends
  through her left thigh. Her sister told her it was probably the “statin
  drug” because she no longer takes hers due to muscle pain. She
  states, “I have enough aches and pains, I do not need a medication to
  make it worse.”
• How do you respond to the patient?

Case #4
SR is a 52 year-old caucasian male with a PMH of HTN, CAD, and anxiety
• BP: 142/90 mmHg, HR: 75, FLP within normal limits
• Medications: lisinopril 40 mg daily, HCTZ 25 mg daily, metoprolol tartrate 25
  mg BID, atorvastatin 80 mg daily, ASA 81 mg daily and fluoxetine 20 mg
• During the visit, the patient admits that he often forgets to take his second
  dose of metoprolol. He often falls asleep before remembering the dose.
• How can we improve this patient’s adherence?

Adherence Chart Example 1

Drug                       For:         Dose:   Breakfast/Lunch   Supper/Bedtime

Aspirin 81mg daily         Heart
                                        1 tab          X
Metoprolol tartrate        Blood
                                        ½ tab          ½                ½
25mg twice daily

Multivitamin daily         Supplement
                                        1 tab          X
Tradjenta 5mg daily        Diabetes
                                        1 tab          X
Lisinopril 5mg daily       Blood
                                        1 tab          X

Caduet 5/20mg daily        Blood
                                        1 tab          X
(contains Amlodipine 5mg                                                           24
and atorvastatin 20mg)
Adherence Chart Example 2
Drug                               Dose:      Breakfast       Lunch      Dinner      Bed

Terazosin 2mg twice daily          1 cap         X                                     X

Sertraline 100mg twice daily                  X (1 tab)                              X (1.5

Omeprazole 20mg twice daily        1 cap         X                         X

Mirtazapine 15mg daily at          1.5 tabs                                            X

Atorvastatin 20mg daily            1 tab                                               X

Lyrica 25mg 3 times daily          1 tab         X              X          X

Warfarin 2.5mg (0.5-1 tab) daily                          Dosed by Anticoag Clinic
Adherence Chart Example 3

Drug                              Dose:   Breakfast   Lunch   Dinner   Bed

Losartan 25 mg twice daily        1 tab
Omeprazole 20mg twice daily       1 cap
Zolpidem 5 mg daily at bedtime    1 tab
Atorvastatin 20mg daily           1 tab
Gabapentin 100 mg 3 times daily   1 cap
Baumgartner PC, Haynes RB, Hersberger KE, Arnet I. A systematic review of medication adherence thresholds dependent on clinical outcomes. Front Pharmacol. 2018; 9:1290.

Crowe M. Do you know the difference between these adherence measures. Pharmacy times. 2015. Accessed 19 March 2019. Available from: https://www.pharmacytimes.com.

Hinson J, Garofoli G, Elswick B. The impact of medication synchronization on quality care criteria in an independent community pharmacy. J Am Pharm Assoc. 2017; 57(2): 236-240.
Hugtenburg JG, Timmers L, Elders P, Vervloet M, Dijk LV. Definitions, variants and causes of nonadherence with medications: a challenge for tailored interventions. Patient Preference and
Adherence. July 2013. 7:675-682.

Kefale B, Tadesse Y, Alebachew M, Engidawork E. Management practice, and adherence and its contributing factors among patients with chronic kidney disease at Tikur Anbessa
Specialized Hospital: A hospital-based cross-sectional study. PLoS One. 2018;13(7):e0200415.

Lycett H, Wildman E, Raebel E, et al. Treatment perceptions in patient with asthma: synthesis of factors influencing adherence. Resp Med. 2018; 141:180-189.

Measuring adherence. American Pharmacist Association. https://www.pharmacist.com/measuring-adherence?is_sso_called=1. Accessed March 13, 2019.
Naqvi AA, Hassali MA, Aftab MT, Nadir MN. A qualitative study investigating perceived barrier to medication adherence in chronic illness patients of Karachi, Pakistan. J Pak Med Assoc.
2019; 69 (2):216-223.

Patton DE, Cadogan CA, Ryan C, et al. Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported
barriers and facilitators. Health Expect. 2017;21(1):138-148.

Sabate, Eduardo. Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organization; 2003.

2018 Medicare-Medicaid Plan Performance Data Technical Notes. Centers for Medicare and Medicaid Services. Updated April 2018.https://www.cms.gov/Medicare-Medicaid-
Office/FinancialAlignmentInitiative/Downloads/MMPPerformanceDataTechNotesCY2018_04252018.pdf. Updated April 2018. Accessed March 13, 2019.
Thank you!
Bree Meinzer, PharmD

Sarah Aldrich, PharmD
Health Literacy
        The Medical Imperative
               Joseph K. Daprano, MD, FAAP, MACP
 Assistant Professor, Internal Medicine & Pediatrics, Case Western
                         Reserve University
               Physician, The MetroHealth System

                      Joseph J. Sudano, PhD
Assistant Professor of Medicine, Population and Quantitative Health
            Sciences, Case Western Reserve University
           Senior Researcher, The MetroHealth System
The Bottom Line
• Only 12 percent of adults have Proficient health literacy. In
  other words, nearly 9 out of 10 adults may lack the skills
  needed to manage their health and prevent disease.

• Fourteen percent of adults (30 million people) have Below
  Basic health literacy. These adults are more likely to report
  their health as poor
  (42 percent) and are more likely to lack health insurance
  (28 percent) than adults with Proficient health literacy.

Measuring Health Literacy
Measures of health literacy at the individual level were largely
developed in the 1990s:
 • Rapid Estimate of Adult Literacy in Medicine (REALM)
 • Test of Functional Health Literacy in Adults (TOFHLA and S-TOFHLA)

Recently developed for Spanish speakers:
 • Short Assessment of Health Literacy–Spanish and English (SAHL-
   S&E) (2010)
 • Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)
Measuring Health Literacy
• Health literacy measures based on functional literacy do not capture the
  full range of skills needed for health literacy.

• Current assessment tools (for populations and individuals) cannot
  differentiate among:
   •   Reading ability
   •   Lack of health-related background knowledge
   •   Lack of familiarity with language and materials
   •   Cultural differences in approaches to health
• However, these measures are the best we have at this time for research
  purposes involving populations. In the clinical setting, single item
  measures are often used for quick screening for health literacy issues.

• From the 1991 National Literacy Act, as
     defined by the U.S. Congress:

  “…an individual’s ability to read, write, and
   speak in English, and compute and solve
   problems at levels of proficiency necessary
   to function on the job and in society, to
   achieve one’s goals, and to develop one’s
   knowledge and potential.”
Literacy Statistics
• Average American reads at the 8th grade level
• One out of five read below grade level five
• 9% of Ohio’s population lack basic literacy skills
• Varies from county to county:
   •   Adams county 13%
   •   Logan 10%
   •   Hamilton 7%
   •   Delaware 4%

https://nces.ed.gov/naal/estimates/StateEstimates.aspx 2003
Low Literacy
Adults who cannot read or cannot read well:
  • Rely on oral sources for information: TV, radio, friends, family
  • May be reluctant to ask questions of those they do not know
  • May feel embarrassed
  • Do not self-identify
  • Cannot be identified by appearance
  • Exemplify perseverance in life

Examples of Literacy Levels and
  Tasks People with Level 1 Literacy                         Tasks People with Level 2 Literacy
         (Grade level K-2)                                           (Grade level 2-6)
        Usually Can Perform:                                       Usually Can Perform:

• Locate 1 piece of information from a                    • Read the gross pay year-to date
  short article                                             from a pay stub
• Read current net pay from a pay                         • Calculate total costs from
  stub                                                      items on an order form
• Add 2 numbers on a bank deposit
      Initial Findings, Prepared by the Center on Urban Poverty and Social Change CWRU
Health Literacy
Health Literacy is defined in the Institute of Medicine report
Health Literacy: A Prescription to End Confusion as:

“The degree to which individuals have the capacity to obtain,
process, and understand basic health information and
services needed to make appropriate health decisions."
           - Institute of Medicine. 2004. Health Literacy: A Prescription to End Confusion.
           Washington, DC: The National Academies Press

Why is Health Literacy Important?
Poor health literacy is a stronger predictor of a person's health
than age, income, employment status, education level, and race

             Health Literacy and Patient Safety: Help Patients
2007 American Medical Association Foundation & American Medical Association

• Lower health literacy scores were associated with higher
  mortality rates within a Medicare managed care setting. -
 Baker 2007

• People with low health literacy have a lower likelihood of
  getting flu shots, understanding medical labels and
  instructions, and a greater likelihood of taking medicines
  incorrectly compared with adults with higher health literacy.
 -Bennett IM, 2008

Health Literacy and Hypertension

In multivariate analyses that did not make an adjustment for
the other variable, both lower educational attainment and
more limited literacy were found to be significant independent
predictors of poorer hypertension knowledge and control. -Pandit,
AU 2009

Health Literacy and Healthcare Cost

 • $106-$238 billion is lost every year on health care costs
   due to a disconnect in the delivery of health information.
  Vernon, J.(2007). Low Health Literacy: Implications for National Health Policy

 • In a study of 92,749 veterans with service utilization from
   2007–2009, average per patient cost for those with
   inadequate and marginal health literacy was significantly
   higher ($31,581) than for patients with adequate health
   literacy ($23,508).
  Huan,J. BMC Health Serv Res. 2015; 15: 249

What do we know about our
communications with patients?
• Up to 80 percent of medical information provided by
  healthcare providers is forgotten immediately by patients.
• Almost half of the information that is remembered is
• Even though approximately 20 percent of American adults
  read at or below the fifth grade level, most health
  information materials are written at the tenth grade level or
  above. - National Assessment of Adult Literacy 2003

Health Literacy Levels
The National Assessment of Adult Literacy (NAAL) measures the
health literacy of adults living in the United States. (2003)
  • Health literacy was reported using four performance levels: Below
    Basic, Basic, Intermediate, and Proficient
     • 36% of adults in the United States have limited health literacy
     • 22% have Basic and 14% have Below Basic health literacy
     • The majority of adults (53 percent) had Intermediate health literacy
     • An additional 12 percent of adults had Proficient health literacy

Health Literacy Live
Health Literacy includes the ability to understand:
  • How to negotiate complex health insurance and health care
  • Appointment slips
  • Doctor's directions and consent forms
  • Instructions on prescription drug bottles
  • Medical education brochures
  • Pre-surgical and post-surgical instructions
  • Research assent / consent forms

Skills Needed for Health Literacy
• Visually literate - able to understand graphs or other visual
• Numerically or computationally literate - able to calculate
  or reason numerically
• Information literate - able to obtain and apply relevant
• Computer literate - able to operate a computer

The Single Item Literacy Screener
• "How often do you need to have someone help you when
  you read instructions, pamphlets, or other written material
  from your doctor or pharmacy?"

     • 1-Never, 2-Rarely, 3-Sometimes, 4-Often, 5-Always

     • Scores greater than 2 were considered positive, indicating
       some difficulty with reading printed health related material
           - Morris et al. BMC Family Practice 2006 7:21

Five Steps to Improve Health
1. Conduct patient-centered visits
  •   Engage in a dialogue with the patient
  •   Listen more and speak less
  •   Encourage patient questions -
      (ASK Me 3)
      •   What is my main problem?
      •   What do I need to do?
      •   Why is it important for me to do this?
              - National Patient Safety Foundation

Five Steps to Improve Health
2. Explain things clearly using plain language
   • Slow down the pace of your speech
   • Use analogies:
     o “Arthritis is like a creaky hinge on a door.”
  • Use plain, non-medical language:
     o “Pain killer” instead of “analgesic”

Five Steps to Improve Health
3. Focus verbally on key messages and repeat
  • Limit information by focusing on 1-3 key messages per
  • Review each point and repeat several times
  • Have other staff reinforce key messages

Five Steps to Improve Health
4. Use “teach back” or “show me” techniques
  • Asking patients to repeat in their own words what they
    need to know or do, in a non-shaming way
  • Not a test of the patient, but of how well you explained a
  • A chance to check for understanding and, if necessary, re-
    teach the information

Five Steps to Improve Health
5. Use Patient –friendly educational materials to enhance
  • Evaluate reading level of written health education

  • Focus only on key points in educational material
  • Emphasize what the patient should do

Discussion in Groups of Two
• How can I implement the         Who will ask the question?
  Single Item Literacy Screener
  into my practice?
                                  How will the result be
                                  communicated confidentially
• What would a                    to all staff?
  Plan/DO/Study/Act quality
  improvement effort on Health
  Literacy look like in my        How will we mitigate patient
  office?                         embarrassment?

Thank you!
Joseph K. Daprano, MD, FAAP, MACP

Joseph J. Sudano, PhD
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