Adherence & Readmissions

See how adherence and readmissions are being managed with interventions, programs and strategies that are currently working.

Treatment nonadherence is widespread in chronic diseases including epilepsy and through diminished treatment benefits, may lead to an increased financial burden on patients, payers, and society. Costs associated with nonadherence and steps to improving adherence are discussed below.1

The period following discharge from the hospital is also a vulnerable time for patients. Strategies to improve transitions from hospital to home in an effort to reduce medical errors and improve patient care are also discussed below.2

Healthcare costs associated with non-adherence of AEDs1

In a 2008 study in an adult managed care population, 39% of almost 11,000 participants were shown to be non-adherent with their AED treatment, defined as less than 80% adherence. AED non-adherence was significantly associated with:

  • 48% increased risk of ER admission
  • $260 in additional annual ER costs per person
  • 11% increase risk of hospitalization
  • $1799 in additional annual inpatient costs per person
  • 44% increased risk of an unintentional injury due to a motor vehicle accident

Despite a reduction in prescription drug intake, a net increase of $1466 in total annual healthcare costs per patient remained due to this non-adherence.

A focus on improving adherence3

According to the American Medical Association, patients can often be reluctant to tell their physician that they are not regularly taking their treatment. It is essential to understand a patient’s medication-taking behavior to avoid unnecessarily escalating therapy, which can result in increased costs to the patient and health care system. Nonadherence may lead to unnecessary hospitalization and ER visits, further adding to total health care costs.

The AMA recommends these eight steps to improving medication adherence:

  1. Consider medication nonadherence as the first reason a patient’s illness is uncontrolled
  2. Develop a system to ask about medication adherence on a regular basis
  3. Create a supportive, blamefree environment when discussing medications with patients
  4. Identify why the patient is not taking their medication
  5. Respond with positive reinforcement to thank and encourage the patient for sharing information about their behavior
  6. Adapt adherence solutions to each patient’s specific needs
  7. Work with the patient to develop their treatment plan
  8. Set patients up for success with tools that make it easier to adhere to their medications

To learn more about these steps, please visit: https://www.stepsforward.org/Static/images/modules/14/downloadable
/Medication_Adherence.pdf

Promoting effective hospital discharge to curb readmissions2

After being discharged from the hospital, nearly half (49%) of patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow-up. It has also been reported that 19%-23% of patients suffer an adverse event, which is often drug-related and preventable. Typically, these errors occur due to a breakdown in communication during transition between the hospital team and primary care physician (PCP).

Recommendations to promote more effective care transitions at hospital discharge are summarized in the following table:

 

Challenges Recommended approaches
Improving physician information transfer and continuity
  • When possible, involve the PCP in discharge planning and work together to develop a follow-up plan
  • At minimum, communicate the following to the PCP on the day of discharge: diagnoses, medications, results of procedures, pending tests, follow-up arrangements, and suggested next steps
  • Provide the PCP with a detailed discharge summary within 1 week
  • In discharge summaries include: diagnoses, abnormal physical findings, important test results, discharge medications with rationale for new or changed medications, follow-up arrangements made, counseling provided to the patient and family, and tasks to be completed (eg, appointments that still need to be made and tests that require follow-up)
  • Follow a structured template with subheadings in discharge communications
  • When possible, use health information technology to create and disseminate discharge summaries
Medication reconciliation and education
  • Obtain a complete medication history by asking patients about: medications taken at different times of day; medications prescribed by different physicians; nonoral medications; over-the-counter products; dosage, indication, length of therapy, and timing of last dose of all drugs; allergies; and adherence
  • Compare and reconcile medication information obtained from patient and caregiver reports, patient lists, prescription bottles, medical records, and pharmacy records
  • Display preadmission medication list prominently in the chart
  • Reconcile medications at all care transitions, including admission, intrahospital transfer, and discharge
  • Communicate complete and accurate medication information to the next provider at discharge, including indications for new medications and reasons for any changes
  • When possible, partner with clinical pharmacists to manage medication information and reconciliation, especially for high-risk patients
Providing adequate medical and social support
  • Use multidisciplinary discharge planning teams to assess the needs of patients and their families
  • Arrange a specific follow-up appointment prior to discharge
  • Contact patients by telephone a few days after discharge to assess questions, symptoms, and medication-related issues
  • Order home health services when indicated
  • Consider home visits for frail elderly patients
More effective physician-patient communication
  • Focus discharge counseling on informing patients of major diagnoses, medication changes, dates of follow-up appointments, self-care instructions, and who to contact if problems develop
  • Ensure that staff members communicate consistent instructions
  • For high-volume conditions, consider using audiovisual recordings for discharge education, combined with an opportunity for additional counseling and questions
  • Use trained interpreters when a language gap exists
  • Provide simply written materials that include illustrations when possible to reinforce verbal instructions
  • Ensure patients and family members comprehend key points by asking them to teach back the information in their own words and demonstrate any self-care behaviors
  • Encourage patients and family members to ask questions through an open-ended invitation like, “What questions do you have?” instead of “Do you have any questions?”


 

References:

  1. Davis KL, Candrilli SD, Edin HM. Prevalence and cost of nonadherence with antiepileptic drugs in an adult managed care population. Epilepsia. 2008;49:446–454.
  2. Kripalani S, Jackson AT, Schnipper JL, Coleman, EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med. 2007;2:314-323.
  3. Brown MT, Sinsky C. Medication Adherence: Improve the health of your patients and reduce overall health care costs. American Medical Association. 2015.