A (3:42)

Yeah. You know, sue, as you say that, that's so. Right. Because often people want to please us and they don't tell us when they're not taking their medicine. And we want to believe in our patients. I think your point, sue, that the solutions often start with asking questions. But there's so much going on, tests. I know there's a lot of literature on this. How common is it for patients to take medicines less often than they're prescribed?

C (4:16)

So I think you're both hitting on the fact that it is very common. Right. We know that this is a clinically important issue. And roughly 50% of patients with chronic conditions do not take their medication as prescribed long term. And that's just generally. So when we start looking at like, more specific groups, adherence actually looks even worse. So, sue, you mentioned a patient taking an inhaler, that group COPD patients, asthma patients, their adherence can be lower than 30% with those as needed medications and their inhalers. And then also when we look at chronic conditions that the patient may not be feeling acutely ill. Right. They're not symptomatic. I think high blood pressure. Right. I think diabetes. Those patients can also have even lower adherence. And we know specifically with diabetes that every 10% that adherence decreases, we see an increase in A1C and an increased risk in hospitalizations.

A (5:11)

So it isn't just that this is a theoretical problem. This has very real consequences attached to it. Now, you talked about long term adherence and the differences between different disease states. How about initial prescriptions? We kind of assume we talk to someone in the office, we send in a script and they take it. Is that true?

C (5:35)

Yes. Primary non adherence is a real issue and I love what you're saying because it's clinically invisible in so many ways. You send that prescription and the assumption is that the patient has started that prescription, when in reality one in three prescriptions goes unfilled or not picked up from the pharmacy. And we know that there's a lot of different barriers that patients can experience when trying to fill that prescription for the first time. But you're exactly right. It's not just a long term use issue. It's getting them started on that first prescription as well.

A (6:04)

Yeah, that's amazing. And we'll put a link to some of those articles in the show notes below because I think that it's. Even though we all know these challenges, when we hear how big of a deal it is, it's still startling. Now Tess, you mentioned consequences. Any other consequences of non adherence we should be aware of?

C (6:27)

I mean, the short answer is with non adherence you're going to see worse health outcomes and increased health care utilization. So for diabetes specifically, I talked about the increased risk of hospitalization. If a patient is what we consider non adherent, their hospitalization risk increases two to three times. And then when we think about the healthcare spend across chronic conditions, medication, non adherence accounts for 100 to $300 billion annually in US healthcare costs. So this is a huge problem just in healthcare in general.

A (7:00)

I had no idea. Sue, your thoughts on any of that?

B (7:04)

Yeah, those numbers feel staggering, although I guess not surprising, you know, when you really hear it, you know, one of the things I think practically that not screening or not uncovering non adherence leads to too is over prescribing. Right. So if we're trying to manage a chronic condition that's appears to be uncontrolled and we're adding more medications, we're adding more options. Right. I think that probably drives a lot of this increase in hospitalizations and changes. Right. Someone goes from not taking their meds to taking all of their meds. That makes a really big difference and swing. So yeah, I mean, I think again the numbers sound staggering, but as you start to think it through clinically, you're like, that does make sense, right? Like those natural outcomes do track with what I would expect.

A (7:52)

So we've talked about what it looks like in the office, how common it is, the very real consequences. Let's now shift to thinking about what some of the barriers might be. Because when we think about what barriers are, we can then begin to address some of those barriers. Tess, I know there's some literature that talks about barriers, and then I think we all have our own thoughts, thoughts from encountering it. But first, the literature.

C (8:21)

So the two that rise to the top time and time again are access and affordability. When you think about pharmacy access, pharmacy deserts are a growing problem. In addition to pharmacy deserts, you also have patients that may not have reliable transportation to make it to the pharmacy, or their work hours don't coincide with the pharmacy hours being open. There's so many different, just general access issues, getting to a pharmacy, getting that prescription. And then with affordability, we know that 30% of patients cite that price is the reason that they don't take their medications as prescribed. So they either may be skipping doses intentionally to make that supply last or delaying refills of medications, but that affordability is the main concern. And then I also think of things like treatment complexity, forgetfulness. And I think what's important to remember here is that these barriers are not isolated. Right? They can layer on top of each other. So a patient may have transportation issues, but they also can't afford that medication and they have a new diagnosis. They're feeling overwhelmed and maybe skeptical about taking the medication to begin with. So this is just such a complex and difficult problem to find solutions for.

A (9:31)

Interesting. Sue, your thoughts?

B (9:33)

Yeah, and I alluded to this in the opening, but I really do think, like diagnosing nonadherence. Right. If we're going to use that word. Like, I think finding it is really, really challenging when we think about all of those issues you just cited. They're very sensitive issues. Right. Patients don't often want to disclose if they're having barriers to care due to social determinants of health, they don't want to disclose. They're not doing what we asked of them because they want to please us. So I think really the trusting relationship that someone has with their primary care clinician becomes really important here because diagnosing it is really challenging because it's complex and the issues are very sensitive and it's really nuanced to ask those questions. And I think there's other pieces of this for clinicians, right? Sometimes just figuring out which medicine is covered in a particular formulary, getting to the right answer. We've all been on the phone, we've all had those back and forth conversations with patients, with their pharmacy, with people doing the prior authorization. It's really complicated. And so of course, patients have nonadherence. I think this assumption to go into every visit assuming that this patient is having some issues with adherence and trying to explore that in a nonjudgmental, sensitive way is really important.

A (10:55)

I think it is. And I think that when we ask questions, by asking questions, we respect where patients are coming from and it enhances trust. In thinking about it, I divide adherence issues into three. Three buckets. And one bucket would be structural things like Tess, you said access and affordability. Those are structural issues. Another is interactional, and that's sue, you and I in a room with a patient establishing trust, asking them do they understand why they're taking their medicine, taking the time to explain to them how important it is, and then the patient, patient level, on their personal level, their trust in a system separate from what we can affect their belief model, there are patients, Tess, you mentioned asthma. This has been studied. Where patients don't believe that asthma is a chronic disease. They believe they only have it when they're short of breath. So there are those belief systems. And Tess, I think you alluded to it, all of our lives are different. Some of us are just very organized people. We can take, organize our medicines. Some of us life is chaos. It is very hard to get through the day, to get the kids to school or grandkids to school and cook a meal and also remember to take all those different medicines that we have to take. So things happen at all those levels. So let's now focus at a structural level and test. This is an area that you're very involved with, which is access and affordability. And can you discuss different choices that are available for patients to fill their medicines? You mentioned some of the challenges with different pharmacies. And start with kind of talking about traditional pharmacies in someone's neighborhood and then talking about what else is now available with mail order and online pharmacies.

C (13:04)

Absolutely. So with community pharmacies, I think that's kind of what we all first think of when you're getting a prescription running to that community pharmacy. But the reality is that since 2019, 7,000 pharmacies have closed, and the result is that nearly half of the US Counties have a pharmacy desert. So, as I mentioned, pharmacy deserts are a growing problem. And that's an important conversation that a prescriber can have with their patient. Are you able to get to the pharmacy? Is there a pharmacy in your neighborhood that you're able to use? And if not, there are other options, one being mail order, as you said. And so we think of mail order as a great solution for patients on established therapy that are taking those extended day supply. So the 90 day prescriptions, and the one consideration there is that it can take a little bit longer to get that prescription to the patient. So it might be a week to 10 days before they receive that prescription. And then the third class that you discussed there is digital pharmacies or online pharmacies that have fast home delivery. And the barrier here today is that there's not a lot of patients that are aware of the option and there's many providers that aren't comfortable with those solutions yet. So just becoming more familiar and aware with digital pharmacies and their options can be so important for patients when we're trying to figure out other ways that they can access their medications. And to me, that's what it boils down to is how do we make sure that patients have options that they're able to get to a pharmacy, whether digitally or down the street that's able to take care of their needs and also have a clinical resource that's available for them. So are they able to talk to a pharmacist and get their questions answered? That's so important as well when we think about pharmacy access.

A (14:48)

That's interesting. And you answered in some ways the question that I was about to ask. One of the nice things about a neighborhood pharmacy is you go in, you have a question, there's someone there. Obviously Amazon is one of the online pharmacies. Are there pharmacists there? It's. It's a. What goes on there?

C (15:12)

Absolutely. There's hundreds of pharmacists. And actually the thing that's probably most important to me is that there's 24,7 pharmacist support. So a patient can either call or chat with a pharmacist literally anytime, day or night. So if they have that question at 2:00am that they just really need to ask, then they're able to get that clinical reassurance that they need. And I think that that is something that is so important. It is. Pharmacy is not just prescription fulfillment or prescription delivery. The pharmacist is the heart and soul of a pharmacy.

A (15:43)

Oh, interesting. So it's not just an automated. You put in a question that gives a standard like wiki page response. There are people there that you can.

C (15:54)

Chat with for clinical questions. You're absolutely talking to a licensed pharmacist, a pharmd, somebody that has their doctorate in pharmacy. And so we want to continue to make pharmacists the most accessible community resource for patients. That's traditionally been their role in the community like you described, you walk in and you talk to your pharmacist, you're able to ask that question. And in an online or digital pharmacy, we need to kind of meet the moment and meet the time and make that pharmacist available digitally for patients as well.

A (16:22)

That's interesting. This is something that I haven't thought a lot about, Sue.

B (16:28)

Yeah, no, agreed. I think I've been practicing long enough that there have been the reduction of mom and pop pharmacies, right. Of that place that, that everyone knows their name. They can find a pharmacist right away. They're not waiting in a big line to talk to someone. And, you know, I think, I don't go to the hardware store anymore, right. I order it online because someone's there to like, respond immediately. And I think if we can give that to patients to like, give them the information that they need, even if it's digital, right, like, is better than not getting the information at a lot of pharmacies anymore because they're just not staff to provide that counseling. And, you know, those community resources really do matter. Having that one on one conversation with someone with the appropriate training does matter.

A (17:14)

It's interesting, as I'm listening, I'm thinking, I went to a neighborhood pharmacy actually last week. You probably could guess that from my voice. And I stood in line and I mean, I don't have questions, I'm a doctor. But it occurred to me that if I had questions, I would have felt somewhat pressured about that because there was a line of people behind me. And I would have felt inconsiderate if I kept other people waiting because, you know, I didn't know about something in particular. And I'm guessing that doesn't actually happen when I contact a pharmacist digitally because there isn't the same feeling of a cue there. Even if there is, when it's your turn, it's your turn. Is, is my sense of that test accurate?

C (18:17)

You're spot on from a couple of different senses. You know, I come from a background as a community pharmacist and feeling that pressure of wanting to be that resource for my patients, but at the same time, trying to talk to a doctor on the phone, pulling up an immunization, getting ready to like, give a flu shot at the same time, all while checking a prescription and like, trying to acknowledge the person at the register who's like, having trouble with their credit card. There's just so much going on in that moment for those community pharmacists. They're really doing everything that they can. But patients are so perceptive, and they understand she doesn't have time to answer my questions. And that's scary because then those questions aren't being asked. And so for me, having a digital resource where that pharmacist is dedicated to answering patient questions is so important. That is their sole job. And when you have a workflow like that, you're able to kind of divide out the tasks so that the pharmacists that are focused on answering patient questions are solely doing that. They're not tacking prescriptions at the same time or doing other tasks. They're devoted to answering that patient's questions from the privacy of their own home, too. They're not necessarily having that private conversation on what can be a public stage, like, in front of your neighbors and your community friends.

B (19:32)

Yeah, it makes me think, too. I mean, I'm sure it's not. I guess it's not been done in this space because it's so new, but we know that patient entered histories, like patient entered questionnaires, like, have a lot more truth and honesty to them. And I also think that this space gives them, you know, we're talking about adherence. Right. So it also gives them that. That safe space and probably elicits a little more honesty than they would in other settings, too. So I think that's really useful for them.

C (19:57)

And chat actually comes in importantly there if someone has, like, a question that they feel is embarrassing or they don't even want to talk about it over the phone, but they're comfortable, you know, sending in a message and asking that question. So, again, just providing those different resources and options to patients to. To get the questions that they need answered to feel comfortable taking their medication, which is, again, going to circle back to medication adherence.

A (20:20)

Yeah. You know, it strikes me also timing is important. When do. When do a lot of people come up with questions? It's always after they leave the doctor's office. It is after you leave the pharmacy, you get home, you're ready to take the prescription, and there's, you know, often a little bit of fear, a little bit of uncertainty. I know with inhalers, I have a family member who recently was prescribed a new inhaler, and you had to put a canister into the device.

C (20:52)

And.

A (20:55)

Between myself and the family member, it took two of us. And I think those questions often aren't there when someone's picking up the medicine and that availability at any time, Tess, as you said, seems actually to really meet someone's needs when it's relevant.

C (21:17)

And that's exactly what we need to be able to do as pharmacists is be there for the patient when they need us. And as you know, well, sometimes we can't check out at 5pm unfortunately we have to be there to be able to answer those questions. And when a patient is motivated and feels encouraged to take that medication and has their questions answered, they're so much more likely to start their medication and stay on that therapy. It's when we're not able to meet that moment and provide that reassurance that we may see those primary non adherence issues. And they say, you know what, I'm not going to take this medication, I don't want to start it or I'll wait. And then they kind of lose that motivation.

A (21:58)

Yeah, that's interesting. So Tess, in your opinion, do you think this helps with adherence?

C (22:06)

I think the key, well, one of the keys to adherence is optionality that a patient has the different options to meet where they are. And if we can do that, getting their medication in their hand is the first step. So if we can at least do that, we're helping with medication adherence and continuing just to make patients aware of different options and ways that they can, they can get their medication to stay healthy.

A (22:34)

That sounds good. We're about out of time. Sue, do you have any final thoughts as you've listened to everything?

B (22:41)

Yeah, I mean I think the answer, especially with that data that is saying how often this happens and how impactful this is is one, assume it's happening. Two, I would say lead with a very non judgmental curiosity of what the drivers are so you can really uncover all those drivers and we should really be educated to employ all of the resources out there to help patients with this. And you know, I think in our new digital era like that includes what their options are for, you know, getting their medications through a digital source and we should be familiar with that.

A (23:17)

Fantastic. Tess, your final thoughts?

C (23:21)

I think medication adherence is so complex, there's so many layers of this and it really is going to take us working together as a team to help problem solve. So that's providers, pharmacists, patients working together, having those conversations, being able to help provide options and just appreciate being a partner with you both in this conversation.

A (23:45)

This was such an Excellent conversation. Dr. Susan Kuchera, thank you so much for joining us.

B (23:52)

My pleasure to be here. Thanks.

A (23:54)

Thank you. Thank you for joining us. And most of all, of course to our listeners. I really am reflecting on our conversation. Solutions often start with asking questions. And I feel I've learned a lot because I've not thought a lot about digital pharmacies and I've particularly not thought about the ability for patients to ask questions. Questions. Obviously, we're all aware you can order something, it shows up at your doorstep. But, boy, that support is something that I haven't given a lot of thought to and now need to reflect on. This special series of Diabetes Core Update is sponsored by Amazon. We thank everyone for listening and for the American diabetes association, I'm Dr. Nick Skolnik. Till next time, stay safe and keep learning.