title: Seeing the Forest Through the Trees: Improving Adherence Alone Will Not Optimize Medication Use.
abstract: Medication adherence is a problem that has received widespread attention in the medical literature and health policy circles. With the increased emphasis on recognizing and rewarding quality in the U.S. health care system, medication adherence measures are increasingly being adopted to assess quality of medication use. However, when adherence is discussed in the literature or evaluated via quality measures, there is rarely any dialogue surrounding adherence in the context of patient-centered issues such as clinical status, individualized medication needs, or personal expectations and social situation. When nonadherence is identified via a comprehensive assessment of all of a patient's medication-related issues, it typically is recognized as only the third most frequent type of medication-related problem. Issues such as requiring a medication that has not been prescribed or receiving a medication prescribed at a dose too low to achieve the intended clinical goal are more frequently experienced. Furthermore, if a patient is nonadherent to a medication because of adverse effects or if the medication prescribed is not appropriate considering the patient's individual clinical situation, promoting adherence can create unintended harm. Therefore, achieving medication adherence as typically evaluated via existing quality metrics such as proportion of days covered is only valid if the medication is first deemed to be indicated, effective, and safe for the patient. Medications are the most common medical intervention for chronic illnesses. As a result, success in achieving the Triple Aim of health care is highly dependent on optimizing medication use. When quality measures for medication use narrowly focus on measuring adherence, the resulting programs of payers and providers will likely ignore the most frequent types of medication problems that prevent improved health, create unnecessary costs, and could negatively impact patients' experience with the health care system. Strong leadership and advocacy on the part of agencies in the position to influence the quality measurement landscape in the U.S. health care system will be critical to achieve widespread awareness of medication nonadherence in the context of the full scope of medication-related problems in health care.
  
  
  BACKGROUND
  No outside funding supported this research. Brummel provides consulting services to other health systems; has received grants from Sanofi and speaking fees from AMCP, APhA, and ASHP; and is on the faculty at the University of Minnesota and employed by Fairview Pharmacy Services. Ekstrand provides consulting services for Alliance for Integrated Medication Management and has received speaking fees from International Diabetes Center and MN Alliance of Physician Assistants. The authors report no other conflict of interest, potential or otherwise. Study concept and design were contributed primarily by Sorensen, Brummel, and Rehrauer, along with the other authors. Rehrauer, Brummel, and Ekstrand collected the data, which were interpreted by Sorensen, Brummel, Rehrauer, and Ekstrand. Pestka and Sorensen wrote and revised the manuscript, with assistance from the other authors.
authors.affiliation: 1 Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis.
authors.forename: Todd D
authors.initials: TD
authors.lastname: Sorensen
authors.affiliation: 2 Social and Administrative Pharmacy, College of Pharmacy, University of Minnesota, Minneapolis.
authors.forename: Deborah L
authors.initials: DL
authors.lastname: Pestka
authors.affiliation: 3 Clinical Ambulatory Pharmacy Services, Fairview Pharmacy Services, Minneapolis, Minnesota.
authors.forename: Amanda R
authors.initials: AR
authors.lastname: Brummel
authors.affiliation: 4 Medication Therapy Management Program, HealthPartners, Bloomington, Minnesota.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Rehrauer
authors.affiliation: 5 Medication Management Program, Park Nicollet Health Services, St. Louis Park, Minnesota.
authors.forename: Molly J
authors.initials: MJ
authors.lastname: Ekstrand
mesh_terms: D003695:Delivery of Health Care / Q000379:methods; D006291:Health Policy; D006801:Humans; D054539:Medication Therapy Management; D010604:Pharmacy; D055553:Prescription Drugs / Q000627:therapeutic use*; D016903:Drug Monitoring
chemical_list: D055553:Prescription Drugs