|1. Engage in Outreach Activities|
| Society of Behavioral Medicine (SBM)||The SBM is a multidisciplinary organization comprising clinicians, scientists, nurses, other healthcare professionals, and educators who are dedicated to promoting the study of the interactions between behavior, biology, and the environment. Knowledge gained is then applied to improve the health and well-being of individuals, families, communities, and populations. SBM's Vision Statement captures its relevance to present discussions: Better Health through Behavior Change. Five peer-reviewed behavioral medicine journals are listed on the society's Web site.|
| Script Your Future Initiative||In May 2011, US Surgeon General Dr Regina Benjamin joined with the National Consumers League to launch the Medication Adherence Awareness Campaign entitled Script Your Future, “a new public education campaign to raise awareness among patients about the consequences of not taking medication as directed.” The initiative is supported by a coalition of more than 100 public and private partners and sponsors, including healthcare professional groups, chronic disease groups, health insurance plans, pharmaceutical companies, business organizations, consumer groups, and researchers. The organizers have indicated that they would welcome the American Society of Hypertension's (ASH's) participation.|
| Food and Drug Administration (FDA): Safe Use Initiative||The goal of the FDA's Safe Use Initiative is “to reduce preventable harm by identifying specific, preventable medication risks and developing, implementing and evaluating cross-sector interventions with partners who are committed to safe medication use.” Medication adherence is one of 14 areas in which collaboration by various stakeholders including professional societies is welcomed. (Note: the FDA is supporting the Script Your Future initiative.)|
| National medical and pharmacy organizations||The American Medical Association, the American Association of Colleges of Pharmacy, the National Association of Chain Drug Stores Foundation, and the National Community Pharmacists Association are sponsors of Script Your Future's 2012–2013 Medication Adherence Team Challenge in which students of pharmacy and other health professions campaign and raise awareness about adherence. Teaching current students about the importance of adherence is a powerful way to influence the next generation of health professionals in this regard, and ASH is well placed to participate in future events.|
|2. Engage in Advocacy Activities|
| Introduction of the flexipill to the US market||Fixed-dose combination (FDC) polypills have been marketed for some time. For patients requiring triple therapy, these options offer the possibilities of greater patient adherence, reduced treatment inertia, and better clinical outcomes (including sustained clinical and 24-hour blood pressure [BP] control) compared with multiple tablets.[37-42] The flexipill, available in some European countries, goes an important step further by allowing for flexible-dose combinations within one tablet, hence enabling physicians to increase the dosage of the component parts in a single tablet according to BP response. There now exist flexipill combinations of angiotensin receptor blockers and angiotensin-converting enzyme inhibitors with calcium channel blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors with thiazide diuretics, and β-blockers and renin inhibitors with thiazide diuretics. The flexipill will likely maintain and perhaps even further enhance improvements in patient adherence and physician adherence to treatment guidelines (decreased treatment inertia).|
|3. Increase Utilization of In-Office and Community-Based Patient Educators|
| Nurses|| |
Gindlesberger provided a case study where rooming staff (medical assistants and licensed practice nurses) played an active role in BP control with notable success. The author noted that “a model of care allowing each person on the health care team to function to the highest level of their degree will provide quality, efficient, and low-cost health care.”
Hegney and colleagues reported “the first Australian study investigating the acceptability, feasibility and sustainability of a nurse-led model of chronic disease management in general practice” in which hypertension was included. The authors observed that “Our findings showed that nurses provided chronic disease management that was acceptable, feasible and sustainable.”
Allen and colleagues reported results from a randomized, controlled trial evaluating the effectiveness of “a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner/community health worker (NP/CHW) teams vs enhanced usual care (EUC)” to improve control of various parameters including BP. The NP/CHW intervention included “aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem-solving to address barriers to adherence and control.” Compared with EUC, patients in the NP/CHW group had significantly greater 12-month improvement in BP.
Additional references are provided.[47-50]
| Pharmacists||Chua and colleagues reported results from “a large controlled trial that evaluated the outcomes of multiprofessional collaboration which involved medical general practitioners, pharmacists, dietitians and nurses in managing diabetes mellitus, hypertension and hyperlipidaemia in primary care settings.” This study demonstrated the importance of pharmacists working in collaboration with other healthcare providers including medical doctors in identifying and resolving pharmaceutical care issues, including nonadherence, to provide optimal care for patients with chronic diseases, including hypertension.|
|4. Review All Evidence Concerning Financial Incentives for Various Stakeholders|
| Physicians||Collate and critically review relevant pay-for-performance (P4P) information from multiple countries, including the United States, appropriately acknowledging differing operating characteristics of healthcare systems across countries.[52-58] Evaluate the national scalability of promising strategies. Also review the role of improvements in processes of care on patient outcomes. From a behavioral perspective, the following quotes are pertinent. Kirschner and colleagues noted that “One may assume that involvement of health care professionals in the goal setting and methods of quality measurement and subsequent payment schemes may enhance their commitment to and motivation for P4P programs and therefore the impact of these programs.” Similarly, Lee and Ferris observed that physicians “should not shy away from payment systems that introduce accountability for clinical outcomes,” since alternatives could be worse. Rather, physicians “should make it our own by adopting it, studying it, correcting its faults, and constantly seeking its improvement.”|
| Pharmacists||Koenigsfeld and colleagues discussed the initiation of a P4P project for clinic-based pharmacists in Iowa and South Dakota by a private insurer in 2009. The project focused on 4 chronic diseases, including hypertension. A high percentage of patients with these diseases achieved goal levels at clinics with clinical pharmacist services: For hypertensives, 86.2% had BP <140/90 mm Hg.|
| Patients|| |
Long and colleagues commented in 2008 that while physician- and hospital-targeted P4P can change provider behavior when payments are large enough, there are limitations to this approach since it does not directly target patients' health behavior, which is “an extremely important driver of both healthcare costs and outcomes, arguably being responsible for a much higher proportion of premature mortality than is poor quality within the health-care system.” Hence, P4P for patient (P4P4P) programs have been initiated in the United States to directly provide monetary and nonmonetary incentives for healthy behaviors, eg, losing weight, participating in wellness programs, and offering nonsmokers lower health insurance premiums than smokers.
A more recent paper by Wu also advocated for P4P4P, noting that patient rewards could be in the form of discounts towards copayments for doctor's visits, procedures, and medications, thereby potentially reducing costs and improving adherence. The author noted that “A pilot study recruiting patients with diabetes or hypertension, diseases with clear and objective outcome measures, would be useful to examine true costs, savings, and health outcomes of such a reward program.”
| Payers|| |
In contrast to the traditional principle that all services must cost the same for all patients, ie, all patients pay the same out-of-pocket costs for health care services whose benefits are nonetheless dependent on individual patient characteristics, value-based insurance design (VBID) “encourages the use of services when the clinical benefits exceed the cost and likewise discourages the use of services when the benefits do not justify the cost,” thus leading to a high-value health system. Farley and colleagues examined whether participation in a population-based VBID program was associated with improved medication adherence to various drugs for several indications including hypertension 2 years after implementation. A pre-post quasi-experimental study design with a retrospective cohort of 75,000 enrollees was employed. VBID was associated with improved medication adherence, with changes being most notable among patients who were less adherent before VBID implementation.
Additional references are provided.[65-70]