How pharmacists can address knowledge gaps and health literacy challenges to help people with chronic conditions stay adherent to drug therapies
Although we still have much to learn about the coronavirus disease 2019 (COVID-19), recent studies have shown that underlying conditions among people at any age increase the risk for severe infection.1
Studies out of China, followed by 2 more recent retrospective analyses from health systems in the New York City area and a nationwide report from the US CDC, have demonstrated that patients with diabetes, heart disease, obesity, hypertension, and other chronic conditions are at the highest risk for COVID-19 complications.2,3,4
Over the years, community pharmacists have played a central role—primarily through education—in supporting patients in medication adherence. This role is more important now than ever before, especially for patients with chronic conditions. The CDC has warned Americans that if their chronic conditions are not well controlled, they are at higher risk for a negative COVID-19 outcome if they contract the virus.5
Patient education can take place with face-to-face interactions (taking standard precautions such as masks and plexiglass barriers, of course), via high-value printed or online educational materials, and/or consultations over the phone. A complete educational program should include easy-to-follow dosing instructions and information on why the medication is needed. Simplified drug information should highlight key points such as drug interactions and adverse effects to make it more easily understood.
The value of these interactions has been validated in numerous studies, including one review of community pharmacist-led interventions that demonstrated improved patient adherence to drug therapies that contributed to better management of blood pressure, hyperlipidemia, chronic obstructive pulmonary disease, and asthma.6
The High Cost of Nonadherence
Although COVID-19 attacks the respiratory system, those with hypertension, diabetes, or cardiovascular disease who acquire COVID-19 appear to be dying at rates 2 to 3 times higher than the general population. Among patients who died from COVID-19, substantial cardiac damage has been observed.7
Although adherence to treatment plans—including medication therapy—can improve outcomes, the CDC reports that the majority of patients with cardiovascular and other chronic conditions take less medication than prescribed or stop the medication altogether after only 6 months.8 Among Medicare beneficiaries, if just 25% of beneficiaries with hypertension who were nonadherent became adherent, it is estimated that the Centers for Medicare and Medicaid Services could save $13.7 billion annually and avert 100,000 emergency department visits and 7 million inpatient hospital days.9
Nonadherence is multifactorial and may be due to a patient’s reluctance to take medication or forgetting to take it. In addition, low health literacy can be a major obstacle. Research shows patients with low health literacy are more likely to forget to take their medications and more likely to take less medication than instructed compared with patients who have fewer health literacy challenges.10
Whether it is due to overall reading comprehension or English as a second language issues, patients with low health literacy often misread medication dosing. For example, in a study of seniors recently discharged from the hospital, 47.7% of participants with limited health literacy did not adhere to medication instructions due to lack of understanding about the prescription, versus 20.5% of patients with adequate health literacy who unintentionally did not adhere.11 Given this finding, it is likely no coincidence then that from 2000 through 2012, Poison Control Centers in the United States received a 100% increase in calls from patients about self-administered medication errors.12 The medication category most frequently associated with serious outcomes in these calls were cardiovascular drugs, which are also among the most challenging when it comes to patient adherence.13
Text, Images, and Video to Maximize Impact
Health IT can play an important role in helping pharmacists educate patients about their medications in order to close knowledge gaps and increase adherence. For example, community pharmacists can integrate patient education tools into their pharmacy management systems and dispensing workflows to deliver personalized medication information and education. Patients with low health literacy or language barriers also can be identified in the system so that pharmacists are alerted when educational opportunities arise.
The way the patient education is delivered matters. Patient education aimed at medication adherence should include simplified, patient-specific medication instructions, written at a 5th-to-8th grade reading level, with large font sizes to ensure readability for the elderly and visually impaired.
Education can be enhanced by visual elements as well. For example, simplified graphical calendars of all of a patient’s medications and dosing pictograms can be powerful adherence-building tools and prevent dosing errors. In addition, instructional videos can be provided for the patient to review at home for drugs that require some skill to administer, such as inhalers and injectable medications.
Fostering Health Equity
Instructions should also be available in many languages to support the large limited English proficient population in the United States who are at the highest risk for medication errors. In a study of Hispanic parents, more than 83% made dosing errors when measuring liquid medication for their children. Parents with limited health literacy and limited English proficiency had the greatest odds of making a dosing error compared with parents with adequate health literacy who were English proficient.14
I understand these challenges firsthand. As an immigrant from Korea to the United States at age 7, I witnessed family members struggle with health literacy and language barriers, which inspired me to dedicate my medical career to effective patient education focused on health literacy and language.
By recognizing and accommodating these cultural and health literacy differences, community pharmacists can build strong, trust-based relationships with their patients. After all, education about patients’ medication is one of the most important and personal roles pharmacists can perform—especially for those patients who tend to need greater assistance but might be reticent to ask for it.
For patients with chronic conditions, adherence to drug therapy plays a pivotal role in managing their conditions. With COVID-19, this priority has taken on an even greater significance. By leading the medication adherence charge through enhanced education and overcoming patients’ health literacy obstacles, community pharmacists can play an even more important disease prevention role.
Charles Lee, MD, is senior director of clinical knowledge for First Databank (FDB).
1. CDC. People with certain medical conditions. Last updated July 30, 2020. Accessed August 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
2. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China. JAMA. 2020. doi:10.1001/jama.2020.2648
3. Petrilli CM, Jones SA, Yang J, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ. 2020. doi: https://doi.org/10.1136/bmj.m1966
4. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020. doi:10.1001/jama.2020.6775
5. CDC. People who are at increased risk for severe illness. Updated June 5, 2020. Accessed August 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-increased-risk.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fpeople-at-higher-risk.html
6. Milosavljevic A, Aspden T, Harrison J. Community pharmacist-led interventions and their impact on patients’ medication adherence and other health outcomes: a systematic review. International Journal of Pharmacy Practice. 2018. doi: 10.1111/ijpp.12462
7. The American Heart Association asks your help to support the 120M people in the US living with cardiovascular disease who may be at higher risk of complications from COVID-19. News release. American Heart Association; May 4, 2020. Accessed August 10, 2020. https://newsroom.heart.org/news/the-american-heart-association-asks-your-help-to-support-the-120m-people-in-the-u-s-living-with-cardiovascular-disease-who-may-be-at-higher-risk-of-complications-from-covid-19
8. FDA. Why you need to take your medications as prescribed or instructed. Last updated February 16, 2016. Accessed August 10, 2020. https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed
9. Lloyd JT, Maresh S, Powers CA, Shrank WH, Alley DE. How much does medication nonadherence cost the medicare fee-for-service program? Medical Care. 2019. doi: 10.1097/MLR.0000000000001067
10. Mayo-Gamble TL, Mouton C. Examining the association between health literacy and medication adherence among older adults. 2017. Health Communication.https://doi.org/10.1080/10410236.2017.1331311
11. Lindquist LA, Go L, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012. doi:10.1007/s11606-011-1886-3
12. Hodges NL, Spiller HA, Casavant MJ, Chounthirath T. Smith GA. Non-health care facility medication errors resulting in serious medical outcomes. Clinical Toxicology. https://doi.org/10.1080/15563650.2017.1337908
13. Kronish IM, Ye S. Adherence to cardiovascular medications: lessons learned and future directions. Progress in Cardiovascular Diseases. 2013. doi:10.1016/j.pcad.2013.02.001
14. Harris LM, Dreyer BP, Mendelsohn AL, et al. Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency. Academic Pediatrics. 2017. https://doi.org/10.1016/j.acap.2016.10.001