Effective medication for any disease is the foundation of prevention the progress of a disease as well as treating. However, it is only a small number of patients in Alaska who adhere to their treatment as prescribed. This has resulted in an expensive health problem not only in Alaska but in the entire United States healthcare system. Since non-adherence to medication is a complex issue with numerous contributing factors, there can never be a single solution. The main objective of this paper is to describe the policy, implemented in Alaska in order to improve medication adherence among diabetic patients. Moreover, we shall identify the key characteristics that make the policy more effective and scalable. The information provided in this research paper is intended to inform health care providers, on the effectiveness of collaborated efforts in ensuring diabetic medication adherence.
Medication is the biggest therapeutic modalities in treating diabetes. Just as patients have experience navigating the health care system, so do they have differed experiences when taking their medication. The experience is often individual’s subjective account of taking medication in his or her daily life. The experience starts soon as the patient begins the prescription. It is usually viewed as a reaction to the signs that a medication holds, the feeling that one has when using a substance to treat diseases. The experiences can either be positive or negative or have adverse implications for whether an individual patient chooses to continue with the medication. Therefore for proper management of diabetes, it is vital that healthcare practitioners work to understand the meaning of taking medication in the perspective of each patient.
The burden of medication non-adherence
Non-adherence to medication in Alaska has been a common problem, which has led to a number of public health problem. It has been reported that approximately half of the diabetes medication is not taken as prescribed. Within a year, over 50% of diabetes patients are reported to discontinue their medication. The increase in non-adherence has brought serious consequences to many patients as well as the Alaskan health care system.
Nonadherence has been connected to poor treatment outcomes and constant progression of disease symptoms. This has resulted in deterioration of health by a huge percentage. Non –adherence to diabetes has also been associated with increased hospital admissions. Moreover, the usual non-adherent patients in Alaska often require the additional medical check-ups every year, thus resulting in an average increase in the cost of treatment by $ 2,000. A recent study has estimated that the cost of non-adherence to diabetes medication has increased by approximately $ 2 billion every year.
The complex medical frameworks needed in diabetes has made this an ideal condition to examine with regard to medication adherence. A study conducted among veterans in Alaska indicated that improving medication adherence could result in savings of approximately $ 10 million to $ 50 million annually. This requires proper healthcare planning and policy design, which might impact the general population. Diabetes was selected as a model for this paper for two major reasons. First, diabetes is a complex condition that needs individual’s management with a strict focus on adherence to medication in order to accomplish the required glycaemic control. Second, intervention analysis is another context of the disease. Diabetes enables comparison of unique interventions with the common goals of improving patients’ conditions.
Medication adherence can be described as the extent at which patients comply with medical prescriptions. Today, the term “compliance” is not used often since in means that it is only responsibility of the patient to monitor his or her medical treatment. Some patients might never start medication if they are left alone. Adherence to medication has also included the concept of persistence into considering the willingness to take prescribed medication through the entire duration of drug therapy. The degree of adherence to medication by a patient and a therapist is known as a concordance.
In 54,000 new insulin users in Alaska, adherence to medication for at least 3 years was associated with 25% reduction in acute myocardial infarction with an even much better outcome of the patient taking higher doses. A similar study was conducted in a study examining the impact of medication adherence on a cohort of 25,000 Canadian diabetes patients. In another study involving 300, 000 patient in the United States mainland, the extent of reduction of diabetes mortality rate was directly associated with adherence to insulin medication. Another example of the significance of adherence outcome is the analysis of CHARM study that examined the impact of adherence to insulin medication in 8000 diabetes patients. Proper adherence was defined as 80 % intake of the prescribed dose. The extent of risk reduction associated with good adherence was remarkably great.
Role of nurses
Nurses have a big role in the implementation of the policy. A thorough discussion of the advantages with the patients is considered the foundation of improving drug concordance. Moreover, motivational interviewing might be fundamental in framing an open discussion with the choices of the patient when the policy is considered. This should include, the patient fears and social pressure. The importance of patient choices enduring policy implementation must be reinforced. Rules for the collaborative framework should be clear. The concept of reminder under the policy of care coordination involved nursing practitioners, the relatives of the patients, pharmacists. Under the policy, the patient and the healthcare practitioner not only get necessary information on proper prescription but also provided with a detailed explanation of the meaning and likelihood of potential impact. The policy was implemented in order to actively discuss various matters every time a patient returns to the caregiver. Several studies conducted after the implementation of the policy pointed out that forgetfulness is a fundamental factor that has contributed to non-adherence to medication. This is one key explanation for the observation that multiple effects of medication adherence are transient. The biggest challenge experienced along the implementation process has been the establishment of continuous strategies.
Telephone counselling as a move to improve care coordination has proven to be useful in a 3-year randomized trial. 400 non- adherent patients received more than five drugs for the treatment of diabetes. Regular calls by caregivers, clinical trials on drug adherence through electronic monitoring showed a significant increase in the number of multiple doses, which were directly associated with a dramatic increase in medication adherence. Compliance to dose-time also increased with likewise reduction in the high frequency of single doses. Less frequent dosing regimens resulted in better compliance across various therapeutic sessions.
Therefore it is important to reduce the number of single doses, independent of the content in order to improve medication adherence among diabetic patients. Ineffective medication might cause a lot of harm by reducing the concordance for the effective medications.
Review of literature
The first study on insulin adherence in Alaska was published in 1980. Later on, a number of papers have been published on this specific topic, with the objective of measuring medication adherence, factors associated with poor adherence and policy recommendations that would improve adherence. However, every effort by the Alaskan government was almost ineffective, and poor adherence continues to be a huge problem among the diabetes patients. Currently, non-adherence to diabetes treatment ranges from 40% to 50% and the rate is even higher in Alaska alone. Such huge rates of non-adherence have resulted in increased number of diabetes patients who do not accomplish the advantages of prescribed drugs. As a consequence, they often have a deteriorating quality of life, and also the cost of health care increases. As indicated earlier, improvement in medication adherence has a strong influence on health outcome, as compared to the development of new treatments.
Xxx points out that “non-compliance is a problem in all illnesses. It is independent of the kind of medication and whether the treatment is long-lasting.” Poor adherence is a complex concept. The emphasis should not only be directed to taking medications but also on timing and termination. XXX adds that “non-adherence is not only associated with individuals behaviors, but also the disease itself, duration of medication and probable adverse effects of the treatment.” Medication adherence is also affected by the relationship between a patient and a caregiver.
According to WHO, the various determinants of non-adherence can be divided into several dimensions: healthcare system, social and economic, therapy, condition and the patient.Another study by xxx was conducted to make a comparison of different reminders of medication of type 2patients. The first set was supported by coordinated care management, such as daily telephone calling while the second group received a monthly care coordination through telephone calls. Both sets received monthly calls. The control for glycaemia in the first group increase also the blood levels improved.
Another study conducted in Bartlett Regional Hospital, in which nurses call patients twice every month for 3 years demonstrated that drug compliance increased by 10% compared to a group that did not have support. This system is easy to implement, and the study shows that a policy like this has the capability to be spread in the entire United States.
Another study by xxx on telephone-based coordination, in Cordova community medical center, examined the benefits of regular phone calls after diagnosis of diabetes In comparison to the typical care by a doctor. The main objective of the research was a 3-month prescription. Xxx showed that patients who received regular reminders improved their compliance to the medication. During the study, a state-wide program that motivated the use of insulin treatment also begun. The author believes that such kind of initiative will help in the wide implementation of the policy.
Policy
Reflecting on the ongoing commitment to improving the overall healthcare in Alaska, the coordinated policy highlights the key area of quality improvement. Some of the recommendations under the policy have been debated in the context of reforms in the healthcare system and might have been incorporated in some of the proposals now being reviewed.
About half of Alaska diabetes patients fail to comply with their prescriptions, which has significantly reduced the quality of care while increasing health expenditures, according to a study by Alaska Journal of medicine in 2005. Increased cost due to medical non-adherence might approach $ 32 billion annually according to results from a study conducted by xxx.
Xxx points out that, “Not only is medical non-adherence expensive, but also very risky. Because patients don’t take their prescription for different reasons, such as adverse effects, fear about the medication, problems with dosing, and cost to utilize multiple strategies to improve adherence.” The efforts of the caregivers in identifying the key opportunities to minimize the barriers need to be mediated.
More that 50legislator and experts in medication adherence, including clinicians, researchers and employers met in June 20th, 2017 in Central Peninsula General hospital. At the conference, RAND cooperation provided there study on diabetes medication adherence, and Lead Johnson provided a practical strategy to improve diabetes medication adherence, based on the outcome of the study. Non-adherence to medication is a huge health problem in Alaska Dr. Gerald Walled, the lead author of the review. He further pointed out that “finding formidable solutions to the issue should be part of reform in Alaska.”
Care Coordination:
Strategies focusing on improving care need to consider the fundamental role of medication in disease management and treatment. This includes specified criteria for qualification as a medical center, including care teams comprising of a wide range of healthcare providers involved in patient care. Moreover, it should be active in involving patients and caregivers in creating and implementing the policy.
Care strategies to be used in care coordination, including initial medication of the patients, use of all prescription, and use of information from the review to establish and reach the clinical objectives and adopt a medication reconciliation process across different healthcare providers, in order to ensure that medication is accurate.
The policy also utilizes the appropriate incentives to support coordination activities and improve medication adherence, delivered by various healthcare experts.Coordinated care has long been described different in different ways in various studies and a set of methods or organizational models implemented to enhance connectivity, and collaboration with healthcare providers at different levels. Among the key factors incorporated in the coordinated care include multidisciplinary system. Reminders, education to healthcare, professionals, support for self-management, patient education and finally case management.
The policy of care coordination aims at increasing the quality of care by improving healthcare satisfaction and efficiency for patients with chronic illnesses. Despite the advantages, using the policy has proven to be a challenging process, Due to the complexity if the Alaska health care system, healthcare providers sometimes may have difficulties when coordinating their work and actions in an integrated framework for the patients. However, in order to achieve high-quality care for the diabetes patients requires collaboration among healthcare professionals.
The key stakeholders who often sit together to deliberate about medication adherence for patients are the most important ones. Insurers began to show concern in various disease management strategies, as they understood that, they strategies minimise dispersal and achieve greater outcomes through affordable costs. Various studies have shown that coordinated care offered by interdisciplinary teams can minimize the menace of worsening conditions or prolonged hospitalization. Moreover, collaboration among healthcare practitioners can be imperative to the achievement of a certain intervention and might impact the overall usefulness of a care strategy.
Successful management of diabetes requires patients to use complex medical frameworks into their daily medication process, make significant changes in the lifestyle, track progress and challenges among others. Even though such complex frameworks, managing diabetes is not a “do it yourself” thing. It is a process that requires constant guidance from experts and collaboration between the patient and the healthcare providers. The relationship between healthcare providers and patients lies at the core of patient-centred care. A great relationship fosters regular communication, improve the understanding of the patients regarding their condition and treatment. This allows patients to have a comfortable process and participating in medication adherence as well as the overall health outcome. The relationship between the patients and healthcare providers has shown a great adherence and positive outcomes. For instance, a study conducted at Fairbanks Memorial hospital including 500 diabetes patients from 7 hospitals in Alaska found a strong relationship between the patient-provider relationship and medication adherence to medication. Access to healthcare providers was not solely associated with medication adherence, suggesting that the quality of patient-provider exchange and not the amount of time spent is very important.
Alaska Overview
Alaska presents a unique challenge in diabetes medication adherence most notably because if the huge size of the state, the number of isolated communities, and the size of the area that is medically underserved. Other factors such as cultural and linguistic variation have also contributed to these challenges. With an area of 663,268m2, Alaska is approximately a fifth of the entire size of the United States. However, it has the lowest population density. The population of Alaska is approximately 800, 625, with the most populated areas being anchorage and Matanuska –Susistna. Alaska does not have counties as are other states. Rather the state is divided into Borough with the largest one being the North Slope Borough. The unorganized borough of Alaska covers approximately 78149 square miles. The boroughs are divided into census areas for the purpose of statistical analysis and record keeping.
Key Legislators
Policy interventions are very important and can be very effective for the community, with the focus on improving public health. Public health policy intervention has a huge impact on system development, social and organizational reforms in order to promote improvement in health care. Alaska state health department chronic disease programs are well positioned to connect with other public health departments programs. The programs have primarily focused on various issues such as affordable care, transport and chronic disease control in larger societal level efforts where necessary.
Policy interventions on medication adherence are important it is system based and has a huge impact on the entire population by transforming the context in which diabetes patients take actions or make their decisions. They have a huge influence on decisions or creating an environment or structure in which everyone is safer. While the policy intervention focuses on Behavioral change at the individual level, the policy has also established the parameter for the choices of many individual choices, thus taking more direct actions at the population level. This kind of population-based approach is often less expensive. However, the ultimate effectiveness of the policy intervention depended on numerous factors such as compliance, education, and awareness of the policy as well as the necessary resources that can support the implementation of the policy.
While most state health departments are used to playing the biggest role in identifying challenges, some programs might involve other important domains during the policy process. Involving legislators in the process of policy implementation, help in ensuring that public health policies are founded on the best available evidence, reflecting the needs of the audience and are improved as evidence evolves.
Methodology
The APCA executive directors invited 88 participants who represented a range of practices and locations. 46 of the entire group had a positive response regarding the policy. Apparently, 35 interviews were completed. Reason being potential interviewees declined invitations due to the length of the interview, conflicts in scheduling, and some of the participants changed their minds. However, the Alaska PCOE retains the consent of participating.
A review of the information provided by the 35 respondents helped in identifying a number of themes. The open-ended questions together with the follow-up questions provided the required themes in response to medical non-adherence, while at the same time focusing on broader topics. Therefore, the findings are presented by general theme rather that the specific questions. Legislators together 2 Alaska PCO reviewed and organized all the detailed notes individually and then met to discuss the themes that came out of the interviews. Rural, as used in the research means, areas of Alaska that are outside Anchorage, Wasilla, Juneau, and Fairbanks.
Findings
A majority of the respondents pointed out that care coordination is fundamental services in healthcare practice and medication adherence among diabetes patients. A review of the study shows that 28 interviewees indicated that care coordination is either being offered by the facilities or it would be very important to the facility. Seven respondents pointed out that care coordination is needed and is very supportive of increasing quality. One respondent provided that “a case manager is very important as they help with all the details of the patient, ensuring that medication is running effectively.” Care coordination is very important in the diabetes management. The value is reinforced in the response from a majority of the respondents. Of the 35 respondents who answered all the questions indicates that the common challenge in offering care coordination for diabetes patients is that it is not usually reimbursed by the payers.
Two key respondents reflected on this matters, indicating that lack of sufficient reimbursement is a huge challenge in offering coordinated care in various facilities. However, in spite the various issues, a third of the respondents provided that their respective facilities are yet to offer coordinated care. The respondent indicated that care coordinators or case managers only offer support in addressing several issues. They help with facilitating referrals, providing important information, and coordinating with the healthcare team. However, most don’t focus on working with patients towards medication adherence.
