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Strategies to Improve Medication Adherence Reported by Diabetes

Patients and Caregivers: Results of a Taking Control of Your Diabetes
Survey (February)

Article  in  Annals of Pharmacotherapy · February 2011

DOI: 10.1345/aph.1P322 · Source: PubMed

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 RESEARCH REPORTS
Diabetes
Strategies to Improve Medication Adherence Reported by
Diabetes Patients and Caregivers: Results of a Taking Control of
Your Diabetes Survey
Candis M Morello, Megan Chynoweth, Hoim Kim, Renu F Singh, and Jan D Hirsch
iabetes, a complex metabolic disor-
D der, typically requires multiple med-
ications to achieve glycemic control.
Long-term complications often necessi-
tate additional medications. Medication
adherence, a significant factor for suc-
cessful diabetes management, has been
defined as how well patients take their
medications in accordance with their
health-care providers’ directions.1-3 This
includes taking medications as instruct-
ed, at the correct time of day, frequency,
and dosage. Nonadherence is classified
as either intentional or unintentional. In-
tentional nonadherence is defined as a
patient’s purposeful decision to not take
a medication, such as in the event of an
adverse drug reaction.4,5 Conversely, un-
intentional nonadherence involves a pa-
tient’s forgetfulness and inability to af-
ford medications. Decreased adherence
with diabetes medication is associated
with increased health-care service utiliza-
tion.6-8 While not taking medications as
prescribed can lead to increased health-
care expenditures, improved adherence
has the opposite effect. In a study of more
than 3000 patients with type 2 diabetes,
Shenolikar and Balkrishnan showed that
increasing medication adherence by 10%
decreased the likelihood of hospitalization
and emergency department visits.6
Author information provided at end of text.
theannals.com
Downloaded from aop.sagepub.com by guest on October 11, 2013
BACKGROUND: Published studies assessing specific methods that patients with
diabetes and their caregivers perceive as helpful means of increasing medication
adherence are lacking.
OBJECTIVE: To determine methods that patients with diabetes and their
caregivers have used to improve medication adherence, investigate the
perceived helpfulness of these methods, and identify motivating factors and
medication characteristics that may positively influence adherence.
METHODS: A cross-sectional survey was distributed to patients with diabetes and
caregivers of patients with diabetes at the 11th annual Taking Control of Your
Diabetes conference in October 2005 at the San Diego Convention Center.
Outcome measures were self-reported medication adherence, perceived
helpfulness of methods employed to improve adherence, motivating factors that
may improve adherence, and medication characteristics that may improve
adherence.
RESULTS: A total of 524 (40.5% response rate) questionnaires were included in
the final analysis, 357 from patients with diabetes and 167 from caregivers.
Taking medications as part of a daily routine and using pill boxes were the most
frequently reported helpful methods for improving medication adherence. The 3
motivating factors most commonly identified as improving medication adherence
were: knowing that diabetes medications work effectively to lower blood glucose,
knowing how to manage medication adverse effects, and understanding
medication benefits. Many participants thought that newer injectable diabetes
medications resulting in weight loss or no additional blood glucose monitoring
would be helpful in optimizing adherence.
CONCLUSIONS: Participants in this study identified medication education as a key
factor in improving adherence. To empower patients to overcome medication
adherence barriers, pharmacists could perform more proactive and thorough
counseling sessions that include education on indication, mechanism of action,
and therapeutic effects of drugs. They could recommend that patients take
medications concurrently with a daily routine and use a pill box, as these actions
were reported to be likely to improve medication adherence. However, our results
also remind us that motivating factors and tools that may improve adherence
may be very patient specific and that pharmacists should incorporate an
assessment of this variance in their counseling sessions.
KEY WORDS: adherence, barriers, caregivers, diabetes, medication, pharmacists.
Ann Pharmacother 2011;45:145-53.
Published Online, 8 Feb 2011, theannals.com, DOI 10.1345/aph.1P322
The Annals of Pharmacotherapy n 2011 February, Volume 45 n 145
CM Morello et al.
Many factors contribute to decreased medication adher-
ence, including experience of adverse events (eg, weight
gain, nausea, constipation), high drug costs, and complex
and multiple medication regimens.1,9-11 On average, pa-
tients with diabetes take from 3.7 medications8 to more
than 7 medications daily,10 and adherence declines linearly
as the number of medications increases.11 Forgetfulness,
limited access to health care, and lack of patient counseling
have also been reported to hinder adherence.1
While many adherence tools exist (eg, medication
charts, pill organizers, pill box alarms), health-care pro-
viders need to know what actually works for individual pa-
tients to ensure that medications prescribed are used as di-
rected. If adherence is not assessed, treatment regimens
may be deemed unsuccessful and more drugs prescribed.
To our knowledge, this is the first study to report specific
methods that patients with diabetes and their caregivers
perceive as helpful means of increasing medication adher-
ence, rather than merely reporting reasons for nonadher-
ence. Participants in this study, attendees of Taking Control
of Your Diabetes (TCOYD) conferences, represent highly
motivated patients and caregivers of patients with diabetes
and are a unique group from whom to learn about the real
world of diabetes medication management. Knowing
which methods these motivated patients and caregivers
have—and have not— found to be helpful for improving
adherence provides pharmacists and other health-care
providers with valuable knowledge to make counseling op-
portunities with these patients more effective.
This study aimed to determine methods that patients
with diabetes and caregivers of patients with diabetes have
used to improve medication adherence, investigate the per-
ceived helpfulness of these methods, and identify motivat-
ing factors and medication characteristics that may posi-
tively influence adherence.
Methods
STUDY DESIGN
Study Sample
This study employed a cross-sectional survey distribu-
tion method. Attendees of the 11th annual San Diego
TCOYD conference in San Diego, CA, were surveyed on
October 29, 2005. Established in 1996, TCOYD is a not-
for-profit 501(c)3 charitable organization that aims to edu-
cate and empower individuals with diabetes and caregivers
of diabetes patients to take charge of their health care. Per-
sons with type 1 or type 2 diabetes, their families and
friends, and anyone interested in diabetes are encouraged
to attend the annual conferences. Approximately 10
TCOYD conferences are held across the US each year.
Health-care professionals at each TCOYD conference in-
form attendees of new therapies and technologies for man-
146 n The Annals of Pharmacotherapy n 2011 February, Volume 45
agement of diabetes and its long-term complications. Emo-
tional and psychological resources are also available.12 At-
tendees pay a nominal fee to participate in workshops, at-
tend lectures, and have opportunities to communicate with
health-care professionals in individual sessions and small
group settings. Health-care professionals available for indi-
vidual question-and-answer sessions include, but are not
limited to, pharmacists, endocrinologists, primary care
providers, ophthalmologists, dietitians, podiatrists, and dia-
betes educators. According to the TCOYD conference co-
ordinator, attendance at each conference ranges from 800
to 1300 patients and caregivers (confirmed January 2010;
e-mail communication). People who attend TCOYD con-
ferences tend to be motivated to take charge of their dia-
betes. This sample population is not representative of dia-
betes patients overall, but instead provides a unique oppor-
tunity to learn from a motivated group of patients and
caregivers.
Study Instrument
Study questionnaires, implied consent, and study de-
scription documents were included in each conference syl-
labus. All conference attendees 18 years of age or older
were eligible to participate. Three announcements were
made during general conference sessions to invite attendee
participation and explain the study process. Two different,
self-administered questionnaires were included: 1 for pa-
tients and 1 for caregivers. Participants were asked to com-
plete the questionnaire that corresponded to their status.
Hereafter, caregivers of patients with diabetes are referred
to as caregivers. Responses were anonymous and consent
was implied by returning questionnaires voluntarily to
study collection boxes located throughout the conference
venue. In appreciation for participation, 1 respondent was
randomly selected to receive a $100 gift card for a local
pharmacy. Participants were asked to separate the address
form and return it in a separate collection box. Subjects’
addresses were not linked to questionnaires. All documents
and procedures were approved by the University of Cali-
fornia, San Diego Human Research Protection Group, and
TCOYD management.
The content of questionnaires was based on published
literature regarding adherence barriers1,10,13 and the authors’
clinical judgment. Adherence, the ability to follow a pre-
scribed medication’s dosing, interval, and administration
instructions, was the main content focus. Draft question-
naires were pretested with 6 patients with chronic diseases,
such as diabetes and arthritis, and minor changes were
made to improve readability (6th grade level) and flow. A
caregiver was defined as someone (eg, family member,
friend, nurse, health-care provider) who was aware of, in-
volved in the care of, or had a close relationship with a pa-
tient with diabetes. Caregivers who may have cared for
theannals.com
 Strategies to Improve Medication Adherence

more than 1 patient were instructed to answer based on 1 summarized with descriptive statistics. Differences be-
particular patient. Questionnaires included 3 main sections: tween the adherent and nonadherent groups and differ-
(1) helpfulness of methods used to improve adherence, (2) ences between “good” versus “poor” diabetes control sub-
top 5 motivating factors to promote adherence to diabetes jects were explored with Pearson’s χ2 or Fisher’s exact
medication regimen, and (3) evaluation of potential help- tests in STATA 9.0 (StataCorp LP, College Station, TX),
fulness of new diabetes medication characteristics to in- with an a priori p value of <0.05 considered significant.
crease adherence. In addition, self- or caregiver-reported
medication adherence, diabetes treatment information (pa- Results
tients only), and demographics were collected. Helpfulness
of 5 common methods to improve adherence was rated on RESPONSE
a scale of 1 (not at all helpful) to 4 (extremely helpful), and
Of 1295 individuals who attended the TCOYD confer-
space was provided for subjects to write other methods.
ence, 539 (41.6%) returned questionnaires. Five patient
Subjects indicated their top 5 motivating factors to adhere
questionnaires were excluded from analysis: 2 from indi-
to a diabetes medication regimen by choosing from a list of
viduals younger than 18, 1 from an individual who only
9 possible factors or writing in their own factor. The possi-
completed demographic information, 1 from a patient who
ble helpfulness of new diabetes medication characteristics
only completed gift card entry information and did not sep-
was rated on a scale of 1 (not at all helpful) to 4 (extremely
arate it from the unanswered questionnaire, and 1 from a
helpful). Medication characteristics were based on novel
person who completed the wrong questionnaire. Ten care-
therapeutics recently marketed or in drug development.
giver questionnaires were excluded from analysis: 6 from
The Morisky et al. medication adherence scale was used
persons who were not caregivers of patients with diabetes,
to assess self- or caregiver-reported medication adher-
and 4 from individuals who only completed gift card entry
ence.14 This scale has been used previously in patients with
diabetes, and a classification of good adherence (score >3) information. In total, 524 questionnaires (357 patients, 167
has been shown to be associated with a 10% lower hemo- caregivers) were utilized for an overall response rate of
globin A1c (A1C) level.15 The Morisky scale contains 4 40.5%. Caregiver and patient questionnaires were analyzed
questions, each answered with yes or no. A “no” response separately.
represents medication adherence. For example, a “no” re-
sponse to “do you ever forget to take your medication?” DEMOGRAPHICS
would indicate that a patient is adherent. Thus, a higher
Responding diabetes patients were predominantly fe-
number of “no” answers (each scored as 1 point) indicates
male (62.5%), white (76.4 %), and non-Hispanic (84.3%),
greater adherence. A subject’s score can range from zero to
with a mean age of 56.4 ± 13.6 years (Table 1). Similarly,
4 points, with zero corresponding to the lowest adherence
caregivers were primarily female (75.9%), white (75.3%),
(zero “no” responses) and 4 corresponding to the highest
and non-Hispanic (75.9%), with an average age of 51.5 ±
(4 “no” responses). For evaluation purposes, patients were
categorized as either adherent (score ≥3) or nonadherent 13.3 years.
(score ≤2). Caregivers, who rated their patients’ adherence,
were categorized either as caregivers of adherent patients DIABETES AND MEDICATION PROFILE
or caregivers of nonadherent patients, using the same
Most (74.4%) patients had type 2 diabetes and took only
method.
oral medications (54%).The next most common (26.2%)
Diabetes and treatment questions, including type of dia-
medication regimen was insulin as monotherapy (Table 2).
betes and current medication regimen, and demographic
The vast majority (86.8%) of diabetes patients reported
information (age, sex, race, ethnicity) were collected. Fi-
taking medication (for diabetes or other chronic condi-
nally, patients rated themselves or caregivers rated their pa-
tions) 2 or more times per day. Twice daily dosing was the
tients for level of diabetes control using a 5-category scale
most common (46.3%) dosing frequency but, notably, one
(poor, fair, good, very good, or excellent control). For eval-
quarter of the patients indicated that they took medications
uation purposes, study patients and patients of caregivers
were categorized as having either “good” diabetes control more than 3 times per day. Almost two thirds (63.6%) of
(good to excellent) or “poor” diabetes control (poor or patients believed that they had good to excellent glycemic
fair). control, and 64.4% of patients were categorized as adher-
ent. Analogous to patient results, the majority (63.8%) of
caregivers believed that the person with diabetes for whom
STATISTICAL METHODS
they cared had good to excellent glycemic control. Nearly
The questionnaire data were entered in Microsoft Office 60% (57.9%) of these caregivers’ patients were catego-
Excel 2003 (Microsoft Corp., Redmond, WA). Data were rized as adherent.

theannals.com The Annals of Pharmacotherapy n 2011 February, Volume 45 n 147

CM Morello et al.

HELPFUL METHODS TO IMPROVE MEDICATION tients, a larger percentage of caregivers of adherent patients
ADHERENCE believed that pill boxes (52.5% vs 24.3%) and automatic re-
fill reminders from pharmacists (38.5% vs 22.5%) were ex-
The majority of patients had tried incorporating medica-
tremely helpful (p = 0.004 and p = 0.01, respectively). Simi-
tion dosing reminders into their daily routine and using pill
lar to patients, a larger percentage of caregivers of nonadher-
boxes (93.3% and 76.8%, respectively) (Table 3). These
ent patients, compared with caregivers of adherent patients,
methods were viewed as extremely helpful by more than
indicated that having someone remind the patient to take his
half of the patients who had tried them (53.5% and 54.7%,
or her medications was very to extremely helpful (64.3% vs
respectively). Fewer patients (<50%) had tried the remain- 40.0%; p = 0.01). No significant differences were detected
ing methods, and helpfulness ratings varied, ranging from between caregivers of patients with “good” versus “poor” di-
“not at all helpful” (15.9% to 30.2%) to “extremely help- abetes control (p > 0.05).
ful” (16.8% to 39.4%). Although the overall utilization of
various methods to increase adherence was similar be-
MOTIVATING FACTORS TO INCREASE MEDICATION
tween adherent and nonadherent patients (p > 0.05), com-
ADHERENCE
parison of helpfulness ratings from adherent versus nonad-
herent patients revealed that more adherent patients (58.8% Of the 357 patients whose questionnaires were ana-
vs 41.6%) reported a daily routine to be extremely helpful lyzed, only 270 (75.6%) identified motivating factors to
in increasing medication adherence compared with nonad-
herent patients (p = 0.01). A larger percentage of nonad-
herent patients than adherent patients (56.1% vs 34.6%)
Table 2. Patient Profiles
thought that having someone remind them to take their
medications was very to extremely helpful (p = 0.02). No Diabetes Pts.,a Caregivers,b
Characteristic n (%) n (%)
other statistical differences existed between adherence
Type
groups, and no significant differences were detected be- type 1 88 (24.4) NA
tween patients classified as having “good” versus “poor” type 2 268 (74.4) NA
diabetes control (p > 0.05). not sure 4 (1.2) NA
Similar to patients, the majority of caregivers believed that Medication (current)
administering medications as part of a daily routine and using oral only 195 (54.0) NA
pill boxes would be very to extremely helpful for their pa- insulin only 94 (26.2) NA
tients (87.8% and 69.1%, respectively) (Table 3). Opinions other injectable 1 (0.3) NA
regarding the 4 remaining methods were mixed, with helpful- oral and insulin 59 (16.2) NA

ness ratings ranging from not at all helpful (11.7% to 20.6%) oral and other injectable 3 (0.9) NA
insulin and other injectable 5 (1.5) NA
to extremely helpful (20.4% to 37.0%). Comparing care-
oral, insulin, and other injectable 3 (0.9) NA
givers of adherent patients with those of nonadherent pa-
Medication frequencyc
once daily 47 (13.2) NA
twice daily 167 (46.3) NA
3 times daily 53 (14.7) NA
Table 1. Demographics of Study Participants >3 times daily 93 (25.8) NA
Pts. Caregivers Self-reported level of glycemic controld
Demographic (n = 357) (n = 167) poor 20 (5.5) 13 (8.0)
Age (y), mean ± SD 56.4 ± 13.6 51.5 ± 13.3 fair 111 (30.9) 47 (28.2)
Sex, n (%) good 128 (35.5) 62 (36.8)
female 225 (62.5) 126 (75.9) very good 80 (22.3) 28 (16.6 )
male 135 (37.5) 40 (24.1) excellent 21 (5.8) 17 (10.4)
Race, n (%) Self-reported adherence levele
American Indian 5 (1.5) 1 (0.6) adherent 222 (64.4) 77 (57.9)
Asian 17 (4.7) 13 (8.0) nonadherent 123 (35.6) 56 (42.1)
African American 31 (8.6) 11 (6.8)
NA = not applicable.
native Hawaiian/Pacific Islander 6 (1.8) 2 (1.2) a
N = 357.
white 275 (76.4) 122 (75.3) b
N = 167.
c
other 26 (7.1) 13 (8.0) Includes diabetes medication and medication(s) for other chronic con-
ditions.
Ethnic background, n (%) d
Caregivers self-reported the level of glycemic control of their patients
Hispanic 49 (15.8) 38 (24.1) with diabetes.
non-Hispanic 264 (84.3) 120 (75.9) e
Caregivers reported adherence level of their patients with diabetes.

148 n The Annals of Pharmacotherapy n 2011 February, Volume 45 theannals.com

 Strategies to Improve Medication Adherence

improve medication adherence. The other 24.4% failed to
answer the question or completed it incorrectly (ie, an-
swered more than 5 motivating factors). Of those complet-
ing the question correctly, knowing that a diabetes medica-
tion effectively reduces blood glucose level was the most
frequently reported motivating factor (81.3%; Table 4). Al-
most three quarters (71.6%) reported that understanding
the benefits of their specific diabetes medications motivat-
ed them to adhere to their medication regimen. Having
easy access to a physician with whom to discuss diabetes
issues and knowing how to manage adverse effects of dia-
betes medications were the third and fourth most frequent-
ly reported motivating factors for patients (64.2% and
60.5%, respectively). Understanding the risks of uncon-

Table 3. Helpfulness of Methods Used by Patients with Diabetes to Improve Medication Adherence: Patient and Caregiver Views
Tried Helpfulness, n (%)
Method,
Method n (%) Not at all Somewhat Very Extremely

Pt.
Daily routine 333 (93.3) 9 (2.7) 31 (9.3) 115 (34.5) 178 (53.5)
Pill box 274 (76.8) 15 (5.5) 45 (16.4) 64 (23.4) 150 (54.7)
Have someone remind pt. to take medications 173 (48.5) 50 (28.9) 49 (28.3) 45 (26.0) 29 (16.8)
Medication chart 139 (39.0) 42 (30.2) 23 (16.5) 40 (28.8) 45 (24.5)
Use combination medications 132 (37.0) 21 (15.9) 28 (21.2) 31 (23.5) 52 (39.4)
Automatic refill reminder from pharmacist 121 (33.9) 28 (23.1) 21 (17.4) 27 (22.3) 45 (37.2)
Caregiver
Daily routine 164 (98.2) 4 (2.4) 16 (9.8) 75 (45.7) 69 (42.1)
Pill box 162 (97.0) 18 (11.1) 32 (19.8) 49 (30.2) 63 (38.9)
Use combination medications 154 (92.2) 18 (11.7) 32 (20.8) 47 (30.5) 57 (37.0)
Automatic refill reminder from pharmacist 161 (96.4) 21 (13.0) 38 (23.6) 53 (32.9) 49 (30.4)
Medication chart 155 (92.8) 32 (20.6) 41 (26.5) 40 (25.8) 42 (27.1)
Have someone remind pt. to take medications 162 (97.0) 31 (19.1) 50 (30.9) 48 (29.6) 33 (20.4)

Table 4. Motivating Factors to Increase Medication Adherencea,b

Pts. (n = 268) Caregivers (n = 138)
Factor n (%) Factor n (%)

Knowing that diabetes medications are effectively 218 (81.3) Having a better understanding of the benefits of each of 96 (69.6)
reducing my blood glucose the pt.’s diabetes medications
Having a better understanding of the benefits of each of 192 (71.6) Knowing that diabetes medications are effectively 93 (67.4)
my diabetes medications reducing pt.’s blood glucose
Having easy access to a doctor to discuss my diabetes 172 (64.2) Having easy access to a doctor to discuss pt.’s diabetes 93 (67.4)
and other health issues and other health issues
Knowing how to manage adverse effects of my diabetes 162 (60.5) Taking fewer pills or injections for diabetes each day 85 (61.6)
medications, if they occur
Understanding my risk for negative effects of poorly 156 (58.2) Knowing how to manage adverse effects of pt.’s diabetes 84 (60.9)
controlled diabetes (eg, amputations, blindness, medications, if they occur
impotence, kidney failure)
Taking fewer pills or injections for diabetes each day 134 (50.0) Understanding pt.’s risk for negative effects of poorly 76 (55.1)
controlled diabetes (eg, amputations, blindness,
impotence, kidney failure)
Paying less for diabetes medications 118 (44.0) Paying less for pt.’s diabetes medications 67 (48.6)
Having easy access to a pharmacist to discuss issues 104 (38.8) Having easy access to a pharmacist to discuss issues 51 (37.0)
about my diabetes (eg, how best to take and use about pt.’s diabetes (eg, how best to take and use
diabetes medications) diabetes medications)
Providing a more convenient way to pick-up my 59 (22.0) Providing a more convenient way to pick-up medications 39 (28.3)
medications from the pharmacy from the pharmacy
Other 17 (6.3) Other 5 (3.6)

a
Motivating factor results are listed in descending order, from most frequently cited.
b
Participants were asked to rank only their top 5 motivating factors.

theannals.com The Annals of Pharmacotherapy n 2011 February, Volume 45 n 149

CM Morello et al.

trolled diabetes—such as amputation, blindness, and kid-
ney failure—was the fifth most frequently reported
(58.2%) motivator cited by diabetes patients. The remain-
ing motivating factors were chosen by less than 50% of pa-
tients. Notably, only one third (38.8%) of patients indicated
that having easy access to a pharmacist with whom to dis-
cuss issues about diabetes (eg, how best to take and use di-
abetes medications) was an important motivator to help
them improve adherence. No significant differences were
detected between adherent and nonadherent patients (p >
0.05) or between patients with “good” diabetes control ver-
sus those with “poor” control (p > 0.05).
Caregiver choices of motivating factors that would like-
ly improve their patients’ adherence were very similar to
patient responses and there were no differences found be-
tween adherent and diabetes-control groups (Table 4).
HELPFULNESS OF NEW DIABETES MEDICATION
CHARACTERISTICS
The majority of patients who answered these questions
believed that all of the new medication characteristics
could be very or extremely helpful in improving adherence
(Table 5). Significantly more patients who were already us-
ing an injectable medication believed that an injectable
drug that does not require extra glucose monitoring would
be helpful, and they also indicated that they would be will-
ing to try it, when compared with patients taking only oral
diabetes medications (94.8% vs 84.1%; p = 0.01 and
92.7% vs 67.3%; p < 0.001, respectively). More patients
who were taking only oral diabetes medications perceived
that an inhaled medication instead of a pill would be help-
ful in increasing adherence, compared with patients using
an injectable diabetes medication (p = 0.01). No other sig-
nificant differences were seen when patients using only
oral diabetes medications were compared with patients us-
ing a regimen including an injectable diabetes medication.
The majority of caregivers also rated all new medication
characteristics as very to extremely helpful (Table 5). Fa-
vorable responses ranged from 71.7% to 80%.
Discussion
Using a motivated population, this study determined
methods that patients and caregivers use to improve adher-
ence, the perceived helpfulness of these methods, and other
motivating factors and medication characteristics that may
positively influence adherence. The percentage of patients
in our study population with type 2 diabetes using insulin
and multiple oral agents for diabetes and other related con-
ditions was similar to that of the overall US diabetes popu-
lation.12 It has been reported that medication adherence de-
creases as the number of medications and times per day
that a patient needs to take a medication increase.1,13 In this
study, 86% of patients and caregivers reported that they (or
their patients) took medications more than once daily; thus,
patients in this study were at higher risk for nonadherence.
Yet, the majority of patients and patients of caregivers were
classified as adherent to their diabetes medication regimens
(65.6% and 57.9%, respectively) and reported that they (or
their patients) had good to excellent control of their dia-
betes (64.0% and 63.8%, respectively). The rates of adher-
ence in previous studies vary significantly based on type of
therapy (acute vs chronic) and regimen complexity. On av-

Table 5. Helpfulness of New Diabetes Medication Characteristics: Patient and Caregiver Views
Helpfulness, n (%)
Medication Characteristic Not at all Somewhat Very Extremely

Pt.
An injectable medication that may result in weight loss (n = 255) 24 (9.4) 25 (9.8) 55 (21.6) 151 (59.2)
A medication that can be inhaled through the mouth, instead of given as an injection (n = 254) 20 (7.9) 42 (16.5) 50 (19.7) 142 (55.9)
An injectable medication that does not need dose adjustments based on blood glucose 19 (8.1) 33 (14.1) 58 (24.8) 124 (53.0)
readings (n = 234)
An injectable medication pen device that does not require separate vials or syringes (n = 236) 17 (7.2) 39 (16.5) 63 (26.7) 117 (49.6)
A medication that can be inhaled through the mouth, instead of swallowed as a pill (n = 254) 44 (17.3) 49 (19.3) 46 (18.1) 115 (45.3)
An injectable medication that does not require extra glucose monitoring (n = 233) 23 (9.9) 43 (18.5) 71 (30.5) 96 (41.2)
Caregiver
A medication that can be inhaled through the mouth, instead of given as an injection (n = 155) 12 (7.7) 19 (12.3) 45 (29.0) 79 (51.0)
A medication that can be inhaled through the mouth, instead of swallowed as a pill (n = 152) 18 (11.8) 25 (16.5) 41 (27.0) 68 (44.7)
An injectable medication that may result in weight loss (n = 150) 11 (7.3) 30 (20.0) 43 (28.7) 66 (44.0)
An injectable medication pen device that does not require separate vials or syringes (n = 151) 12 (8.0) 20 (13.3) 55 (36.4) 64 (42.4)
An injectable medication that does not need dose adjustments based on pt.’s blood glucose 11 (7.3) 25 (16.7) 51 (34.0) 63 (42.0)
readings (n = 150)
An injectable medication that does not require extra glucose monitoring (n = 152) 16 (10.5) 27 (17.8) 58 (38.2) 51 (33.6)

150 n The Annals of Pharmacotherapy n 2011 February, Volume 45 theannals.com


erage, adherence rates are 50%,1,16 and chronic treatment
adherence rates range from 43% to 78%.1 Our study popu-
lation, with chronic, complex medication regimens, falls
within this range.
Previous studies report a significantly lower rate of ad-
herence for females compared with males with diabetes
(68% vs 74%; p = 0.01).17 Since the majority of our dia-
betes patient population was female, this may have influ-
enced the adherence rate seen for the entire population.
Our analysis did not further assess sex as a confounding
variable.
Two commonly recommended methods of improving
adherence were viewed as very to extremely helpful by the
majority of respondents: incorporating medication admin-
istration into a daily routine and utilizing pill boxes.
Taking medications every day without missing doses
can be challenging; therefore, when counseling patients, a
pharmacist should consider each patient’s lifestyle and dai-
ly schedule to promote adherence. Since pill boxes were
rated as very helpful by the majority of patients and care-
givers, creating the time and opportunity for pharmacists
(or other support staff) to demonstrate filling a week’s
worth of medications could be a simple, yet important, step
toward increasing adherence. Interestingly, more nonad-
herent patients, and caregivers of nonadherent patients, in-
dicated that “having someone else remind them to take
medications” was helpful, compared with adherent patients
and caregivers. This finding suggests that, although some-
one reports that a method is helpful, it does not mean that it
is effective (ie, that the person is adherent) and that more
than 1 adherence support method may be needed for some
patients. Pharmacists should be aware that having a pa-
tient indicate that a method is helpful may not equate to ad-
herence. Adherence should be specifically assessed, and
the 4-question Morisky scale used in this study could be a
quick and easy assessment tool for any practice setting.
There was wide variation in the ratings of helpfulness for
the remaining methods listed in the questionnaire, under-
scoring the need to assess each patient’s individual needs
to determine which method, or methods, might work best
for him or her.
The most frequently cited motivating factors were relat-
ed to knowing more about the specific benefits of medica-
tions and management of adverse effects associated with
them. The majority of patients and caregivers believed that
all of the new medication characteristics would be very to
extremely helpful in improving adherence. Not surprising-
ly, patients already using an injectable diabetes medication
reported being more willing to try an injectable drug that
does not require extra glucose monitoring than were pa-
tients taking only oral diabetes medications. However, pa-
tients only on oral diabetes medications were also willing
to try injectable diabetes medications.
theannals.com The Annals of Pharmacotherapy
Strategies to Improve Medication Adherence
Although having easy access to a pharmacist was in-
cluded in the list of motivating factors to improve medica-
tion adherence, it was not a frequently selected motivator
by patients or caregivers. This was an interesting finding
because pharmacists are known to be the most accessible
health-care providers. Although this may be true, pharma-
cists should realize that patients and caregivers may not
perceive pharmacists as a motivating factor in increasing
adherence, and thus may not seek them out. Educating the
public (and payors) of pharmacists’ willingness and capa-
bilities to effectively provide education and a broad range
of medication therapy management services remains a pri-
ority. With their pharmacotherapy expertise, training in
communication skills, and close proximity to patients,
pharmacists should use a proactive approach in medication
counseling to improve adherence and fully equip patients
with diabetes to overcome adherence barriers. For exam-
ple, pharmacists could assess medication adherence, using
the Morisky scale, and then focus medication counseling
on identified factors that would support adherence.
Limitations
This was an observational study of a convenience sam-
ple of subjects; thus no conclusions of causality can be made.
Due to survey method constraints, diabetes control and ad-
herence were necessarily self-reported and measured subjec-
tively. Objective measures (eg, A1C or medication posses-
sion ratio from refill records) would have allowed for more
definitive estimates. The study population does not reflect the
overall diabetes population. Instead, these patients were stud-
ied specifically because, simply by having attended a
TCOYD conference, they were assumed to be actively en-
gaged in controlling their diabetes and thus represented an in-
teresting sample from which to learn about the helpfulness of
a variety of adherence methods that they may have tried.
Several limitations are related to the questionnaires used.
Questionnaires were only available in English, which resulted
in a predominantly non-Hispanic cohort, despite a relatively
large Hispanic population that reportedly attends San Diego,
California, TCOYD conferences. The questionnaire used the
term doctor to refer to physicians, which had potential to add
confusion since other health professionals are referred to as
doctor. Future questionnaires should contain the term physi-
cians. The questionnaires also included a few lengthy phrases
that may have impaired subjects’ full understanding of cer-
tain questions, resulting in unanswered questions. While the
Morisky scale has been validated for patients, it has not been
for caregivers. Finally, response bias may be particularly like-
ly for results related to helpfulness of new medication charac-
teristics, since a fairly large proportion of subjects chose not
to answer questions related to that topic. Subjects who were
not interested or who thought the characteristics were not
helpful may have been those who chose not to respond.
n 2011 February, Volume 45 n 151
CM Morello et al.
Knowing which methods patients with diabetes and care-
givers of patients with diabetes have reported that they feel
are helpful for improving adherence provides pharmacists
and other health-care providers with valuable knowledge
with which to make counseling opportunities more effective.
Participants in this study believed medication education to be
a key factor in improving medication adherence, particularly
counseling on how prescribed medications work, benefits of
each medication, how to manage adverse effects, and the im-
portance of glycemic control. Having a daily routine and us-
ing pill boxes were the 2 methods most frequently reported as
being helpful for improving adherence. However, our results
also remind us that the motivating factors and tools that may
improve adherence may be very patient specific and pharma-
cists should incorporate an assessment of this variance into
their counseling sessions.
Candis M Morello PharmD CDE FCSHP, Associate Professor of
Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceuti-
cal Sciences, University of California–San Diego, La Jolla, CA; Am-
bulatory Care Pharmacist Specialist, Veterans Affairs of San Diego
Healthcare System, San Diego, CA
Megan Chynoweth PharmD, at time of writing, PharmD student,
Skaggs School of Pharmacy and Pharmaceutical Sciences, Uni-
versity of California–San Diego; now, Pharmacy Practice Resident,
Kaiser Permanente, Kern County, CA
Hoim Kim PharmD, at time of writing, Pharmacy Practice Resident,
University of California, San Diego Medical Center; now, Clinical
Pharmacist, City of Hope National Medical Center, Duarte, CA
Renu F Singh PharmD, Associate Clinical Professor, Skaggs School
of Pharmacy and Pharmaceutical Sciences, University of Califor-
nia–San Diego
Jan D Hirsch BPharm PhD, Associate Professor of Clinical Phar-
macy, Skaggs School of Pharmacy and Pharmaceutical Sciences,
University of California–San Diego; Clinical Pharmacist Specialist,
Veterans Affairs of San Diego Healthcare System
Correspondence: Dr. Morello, candismorello@ucsd.edu
Reprints/Online Access: www.theannals.com/cgi/reprint/aph.1P322
Conflict of interest: Authors reported none
We thank student pharmacist volunteers from the University of California, San Diego
Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) Class of 2009
and SSPPS student pharmacists Mehrnaz Farrokhi, Shawna Kobayashi, Jennifer
Lai, Sarah McCoy, Lisa Mueller, Diem Nguyen, Ali Rezaei, Yunnie Song, and Julia
Harder; and University of California, San Francisco School of Pharmacy student
pharmacist Anh Dao Nguyen for helping with questionnaire distribution and collec-
tion as well as data entry. We also thank Marissa Reid for her help with study ques-
tionnaires and Dr. Steven Edelman and the Taking Control of Your Diabetes orga-
nization for their cooperation throughout the process of this study, as well as the
patients and caregivers who participated in the study.
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Estrategias para Mejorar el Cumplimiento con la Terapia de
Medicamentos reportadas por Pacientes Diabéticos y Proveedores
de Servicios de Salud: Resultados de una Encuesta Tomando el
Control de su Diabetes
CM Morello, M Chynoweth, H Kim, RF Singh, y JD Hirsch
Ann Pharmacother 2011;45:145-53.
EXTRACTO
TRASFONDO: Se carece de estudios publicados evaluando métodos
específicos que los pacientes diabéticos y los proveedores de servicios
de salud perciben como medios útiles para incrementar el cumplimiento
con la terapia medicamentosa.
OBJETIVO: Determinar métodos que los pacientes diabéticos y sus
proveedores de servicios de salud han usado para mejorar el
cumplimiento con la terapia medicamentosa, investigar la utilidad
percibida de estos métodos, e identificar factores de motivación y
características de medicamentos que pueden influir positivamente en el
cumplimiento con medicamentos.
theannals.com

MÉTODOS: Se distribuyó una encuesta transversal a pacientes diabéticos y
a proveedores de servicios para pacientes diabéticos que asistieron a la
11ra Conferencia Anual– Tomando el Control de su Diabetes– llevada a
cabo en el Centro de Convenciones de San Diego. Las medidas de los
resultados fueron: el auto-reporte del cumplimiento con el tratamiento de
medicamentos, la utilidad percibida de los métodos empleados para
mejorar el cumplimiento, los factores de motivación que pueden mejorar
el cumplimiento, y las características de fármacos que pueden mejorar el
cumplimiento.
RESULTADOS: Se incluyeron 524 cuestionarios (40.5% respuestas) en el
análisis final, 357 de pacientes diabéticos, y 167 de proveedores. La
toma de medicamentos como parte de una rutina o práctica diaria y la
utilización de cajitas de píldoras o pastilleros fueron los métodos
reportados con más frecuencia como útiles en mejorar el cumplimiento
con la terapia medicamentosa. Los 3 factores de motivación más
comunes identificados para mejorar el cumplimiento fueron: el saber
que los medicamentos para la diabetes funcionan efectivamente para
disminuir la glucosa en sangre, el saber cómo manejar los efectos
secundarios de medicamentos, y el entender los beneficios de los
fármacos. Muchas personas pensaron que fármacos para la diabetes
inyectables, más nuevos que resulten en pérdida de peso o en ningún
monitoreo adicional de glucosa serían beneficiosos en optimizar el
cumplimiento con la terapia.
CONCLUSIONS: Los participantes en este estudio identificaron la
educación de medicamentos como un factor clave en mejorar el
cumplimiento con la terapia de fármacos. Los farmacéuticos pueden
realizar sesiones de orientación más pro-activas y minuciosas que
incluyan educación sobre la indicación, el mecanismo de acción y los
efectos terapéuticos de fármacos con el propósito de facultar o habilitar a
los pacientes para superar barreras del cumplimiento con la terapia
medicamentosa. La recomendación de que los pacientes tomen
medicamentos al mismo tiempo que una práctica diaria y que usen un
pastillero también fue reportada con probabilidad de mejorar el
cumplimiento con la terapia. Sin embargo, los resultados de este estudio
nos recuerdan que los factores de motivación y los instrumentos que
pueden mejorar el cumplimiento con la terapia medicamentosa pueden
ser bien específicos para cada paciente y los farmacéuticos deberían
incorporar una evaluación de esta variación en sus sesiones de
orientación.
Traducido por Brenda R. Morand
theannals.com The Annals of Pharmacotherapy
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Strategies to Improve Medication Adherence
Stratégies pour Améliorer l’Adhésion au Traitement chez des
Patients Diabétiques et Leurs Soignants
CM Morello, M Chynoweth, H Kim, RF Singh, et JD Hirsch
Ann Pharmacother 2011;45:145-53.
RÉSUMÉ
OBJECTIF: Déterminer les différentes méthodes que les patients
diabétiques et leurs soignants utilisent pour améliorer l’adhésion au
traitement; investiguer la valeur ajoutée de ces différentes méthodes, et
identifier les facteurs motivants et les caractéristiques des médicaments
qui peuvent influencer l’adhésion.
MÉTHODES: Un questionnaire a été distribué aux patients diabétiques et
leurs soignants lors de la 11e conférence “Annual Taking Control of
Your Diabetes” au centre des congrès de San Diego. Les résultats
thérapeutiques comprenaient une auto-évaluation de l’adhésion aux
médicaments, la perception de l’utilité de ces méthodes, les facteurs
motivants qui améliorent l’adhésion, et les caractéristiques des
médicaments qui peuvent faciliter l’adhésion.
RÉSULTATS: Un nombre de 524 questionnaires ont été inclus dans
l’analyse finale soit 357 des patients diabétiques et 167 des soignants. La
prise des médicaments sur une base journalière et l’utilisation de
piluliers étaient les méthodes les plus utilisées pour favoriser l’adhésion
au traitement. Les 3 facteurs qui ont été identifiés pour favoriser
l’adhésion étaient le fait que les patients savaient que les
hypoglycémiants oraux étaient efficaces pour diminuer la glycémie;
qu’ils savaient comment gérer les effets indésirables et comprenaient les
effets positifs des médicaments. Plusieurs patients avaient la perception
que les injections d’insuline entraînaient une perte de poids ou que le
monitorage de la glycémie n’était plus nécessaire et que ces facteurs
faciliteraient l’adhésion au traitement.
CONCLUSIONS: Les participants de cette étude ont identifié que
l’information sur les médicaments a été un facteur important dans
l’adhésion au traitement. Afin de responsabiliser les patients à l’adhésion
à leur traitement, les pharmaciens pourraient être proactifs et les sessions
d’information devraient inclure des informations sur l’indication, les
mécanismes d’action et les effets thérapeutiques des médicaments.
L’utilisation d’une routine journalière ou l’utilisation d’un pilulier sont
des facteurs favorisant également l’adhésion au traitement.
Traduit par Louise Mallet
n 2011 February, Volume 45 n 153