Adherence: a review of education, research, practice, and policy in the United States

OBJECTIVE To describe the education, research, practice, and policy related to pharmacist interventions to improve medication adherence in community settings in the United States. METHODS Authors used MEDLINE and International Pharmaceutical Abstracts (since 1990) to identify community and ambulatory pharmacy intervention studies which aimed to improve medication adherence. The authors also searched the primary literature using Ovid to identify studies related to the pharmacy teaching of medication adherence. The bibliographies of relevant studies were reviewed in order to identify additional literature. We searched the tables of content of three US pharmacy education journals and reviewed the American Association of Colleges of Pharmacy website for materials on teaching adherence principles. Policies related to medication adherence were identified based on what was commonly known to the authors from professional experience, attendance at professional meetings, and pharmacy journals. RESULTS RESEARCH AND PRACTICE: 29 studies were identified: 18 randomized controlled trials; 3 prospective cohort studies; 2 retrospective cohort studies; 5 case-controlled studies; and one other study. There was considerable variability in types of interventions and use of adherence measures. Many of the interventions were completed by pharmacists with advanced clinical backgrounds and not typical of pharmacists in community settings. The positive intervention effects had either decreased or not been sustained after interventions were removed. Although not formally assessed, in general, the average community pharmacy did not routinely assess and/or intervene on medication adherence. EDUCATION National pharmacy education groups support the need for pharmacists to learn and use adherence-related skills. Educational efforts involving adherence have focused on students' awareness of adherence barriers and communication skills needed to engage patients in behavioral change. POLICY Several changes in pharmacy practice and national legislation have provided pharmacists opportunities to intervene and monitor medication adherence. Some of these changes have involved the use of technologies and provision of specialized services to improve adherence. CONCLUSIONS Researchers and practitioners need to evaluate feasible and sustainable models for pharmacists in community settings to consistently and efficiently help patients better use their medications and improve their health outcomes.