Covid-19 as a teacher: Lessons learned in medication adherence
- The covid-19 pandemic was catastrophic for healthcare infrastructure and it has highlighted the deficiencies in the system1.
- Medication non-adherence soared during the pandemic because of virus containment measures that led to disruption in healthcare services, breakdown of support network, financial constraints, and enhancement of psychological issues 2
- Identifying the vulnerable, strengthening health infrastructure, and use of technology could mitigate some barriers to adherence.
Among all the adversities associated with the COVID-19 pandemic, one positive aspect is the knowledge it has imparted. It is a challenging situation for people living with chronic diseases, mental health illnesses, and cancers. The virus containment measures – lockdowns, social distancing, and diverted resources to tackle the pandemic – have disrupted the access to routine care and have compounded the barriers to medication adherence. It has also resulted in the early precipitation of chronic diseases and worsened the prognosis in the existing patients due to the unhealthy lifestyle, less exercise, and increase in alcohol/substance abuse2,3. Although we have learned and devised innovative strategies, several issues need to be resolved to help vulnerable patients.
Barriers to adherence during the COVID-19 pandemic
Overall, the COVID-19 pandemic has worsened adherence to medication across several health issues. A study using data from U.S. insurance claims indicated a significant drop in medicine refills for chronic diseases and an increase in therapy discontinuation3. Barriers to adherence during a pandemic stem from substantial alteration in behavior owing to lifestyle changes, social isolation, overwhelmed healthcare system, personal bereavement, and enhanced psychological issues. A survey of healthcare professionals from 47 countries reported a negative impact of the pandemic on care for chronic diseases4. Another survey reported non-adherence and worsening of symptoms in 51% of chronic disease patients in the U.S. with 19 % facing difficulty in accessing medication2.
Specific factors influencing adherence to medication during the COVID-19 pandemic are:
- Disruption to healthcare services: The pandemic has overwhelmed our healthcare systems straining facilities, personnel, and budget. As per the latest report by World Health Organization (November 2021), about 90% of surveyed countries reported ongoing disruptions in essential health services across all major health areas1.
- Restricted access to healthcare: COVID-19 containment measures had a widespread effect on accessing healthcare and prescription refills for chronic diseases. In low to middle-income countries difficulty in access to transportation hindered follow-up visits and access to pharmacies in rural areas5,6.
- Disruption in the supply chain: Pandemic has severely disrupted and strained supply chains for medicines globally. The restricted trading channels have led to a shortage of essential drugs and their active ingredients plus a scarcity of drug storing, dispensing, and delivering equipments. Stockpiling and surge in panic buying due to anticipated shortages are other factors for the non-availability of drugs influencing adherence7,8.
- Social isolation: The breakdown of the support network is a factor that fuels non-adherence behavior. Lockdown restrictions, personal bereavements, and abnormal work-life balance resulted in reduced social contacts compounding the loneliness9. For example, older adults in Italy dealing with multiple chronic diseases failed to adhere to lipid-lowering treatment during the pandemic because they were dependent on their family support for refills and reminders10.
- Enhanced psychological issues: The social isolation and heightened anxiety have contributed to a tsunami of psychological issues during the pandemic11,12. An unhealthy psychological state is an important barrier to non-adherence. A longitudinal study investigating old-age Americans suffering from chronic optic disease underscored the importance of resilience to stress for optimal medication adherence during the pandemic13.
- Reduced healthcare demand: Fear of exposure to the virus in healthcare facilities and perceptions about provider inaccessibility led to reduced healthcare demand. Missing appointments or delaying visits to healthcare services correlate negatively with adherence. A report by the Center for Disease Control and Prevention (USA) acknowledged a delay or avoidance of medical care by 41% of adults due to COVID-related concerns14. Another independent study demonstrated that missing the physician appointment increases the risk of all-cause mortality in chronic diseases (without COVID infection)15.
- Financial constraints: The pandemic brought the global economy to a grinding halt shrinking economies, lowering healthcare budgets, and widespread job loss. This has severely affected the healthcare services worldwide, especially in low and middle-income countries16. Even in high-income countries like the U.S., the surge in job loss reduced the patient’s ability to cover medication costs because healthcare for more than 50% of the population (age 0-64 years) is funded by job-associated private insurance17.
- Misinformation: Infodemic –the information epidemic- dissipated at an alarming rate on social media has risen during the pandemic18. Misinformation influences adherence behavior by affecting a patient’s belief system and threat perception19.
What is being done and what do we need further?
As is commonly said, “We cannot stop natural disasters but we can arm ourselves with knowledge”. Rising chronic health issues and worsening patterns of medication adherence warrant focused interventions. The innovative use of digital technology in medicine has helped to some extent. ENABLE survey (European Network to Advance Best practices & technoLogy on medication adherencE) has provided specific recommendations for healthcare services to tackle non-adherence in chronic diseases during the pandemic20. In addition, we need to address the financial and social concerns for suboptimal adherence. Listed below are some interventions to tackle non-adherence for chronic diseases during the pandemic.
- Identify people in high-risk group: Studies have identified a few risk categories for non-adherence during the pandemic like young age, female gender, obesity, multimorbidity, and psychological issues2. Predictive modeling to identify and stratify people in different risk categories will help develop focused interventions for medication adherence.
- Digital medicine: Alternatives to in-person visits, for example, telemedicine is essential to extend healthcare. Even with increased telemedicine, reports suggest at least a 30% reduction in practitioner-patient contact21. Employing multiple communication channels – tele, in-person and digital – is required. The use of electronic prescriptions by both providers and pharmacists aided with the provision of home medical services has increased medication accessibility for the vulnerable22,23.
- Fixing supply chain: To ease the drug supply chains, prioritizing the imports of life-saving medication is important. Additionally, ramping up local manufacturing will be crucial to combat this problem24. Australian strategy of cooperation between the drug wholesalers and pharmacies as well as a purchase embargo on essential medicines have ensured a consistent supply. Prescribing substitution drugs for the unavailable medication can help in specific cases22. A publicly available database tracking drug shortages is also a useful resource to tackle drug shortages.
- Combating misinformation with effective communication: Coping strategies to deal with misinformation easily accessible on public platforms are important for medication adherence. We can partially mitigate it using effective communication through publicly available guidelines. State-authorized interactive healthcare applications similar to Stop-the-Spread (a WHO/UK government initiative) providing authentic healthcare information is crucial. Enhanced tele-counseling and wide use of digital technology will also help to tackle the psychosocial factors limiting adherence.
- Revitalize existing healthcare services: Strengthening and training the workforce to deal with the increased workload is crucial for revitalizing healthcare. The system can use other resources like pharmacists and nurses to prescribe routine medication for chronic diseases. Providing e-prescriptions for a longer duration is an important step in reducing the frequency of care required. Planning and implementing healthcare financing strategies is essential for the devastated infrastructure. A WHO survey reported that 70% of countries have committed additional governmental funding for healthcare recovery1.
The COVID-19 pandemic has significantly altered human behavior and has magnified the deficiencies of our healthcare system1. It has severely affected medication adherence for chronic diseases that required persistent care2. Fortifying gaps in the healthcare system will bring access to care and medication to everyone enhancing adherence. The spectrum of digital initiatives is currently limited in its use for the underprivileged and a substantial population in the developing world. Adapting and expanding the digital health strategies for such populations is important for enhancing medication adherence globally. Similarly, effective communication and curbing misinformation is immensely important. Addressing the aforementioned issues will help knock down the barriers to non-adherence in patients with chronic diseases during the current and any potential future pandemics20.
- Organization WH. Third round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic. electronic. 2022. 7 Feb 2022.
- Ismail H, Marshall VD, Patel M, Tariq M, Mohammad RA. The impact of the COVID-19 pandemic on medical conditions and medication adherence in people with chronic diseases. J Am Pharm Assoc (2003). May-Jun 2022;62(3):834-839 e1. doi:10.1016/j.japh.2021.11.013
- Clement J, Jacobi M, Greenwood BN. Patient access to chronic medications during the Covid-19 pandemic: Evidence from a comprehensive dataset of US insurance claims. PLoS One. 2021;16(4):e0249453. doi:10.1371/journal.pone.0249453
- Chudasama YV, Gillies CL, Zaccardi F, et al. Impact of COVID-19 on routine care for chronic diseases: A global survey of views from healthcare professionals. Diabetes Metab Syndr. Sep – Oct 2020;14(5):965-967. doi:10.1016/j.dsx.2020.06.042
- Subathra GN, Rajendrababu SR, Senthilkumar VA, Mani I, Udayakumar B. Impact of COVID-19 on follow-up and medication adherence in patients with glaucoma in a tertiary eye care centre in south India. Indian J Ophthalmol. May 2021;69(5):1264-1270. doi:10.4103/ijo.IJO_164_21
- Singh K, Kondal D, Mohan S, et al. Health, psychosocial, and economic impacts of the COVID-19 pandemic on people with chronic conditions in India: a mixed methods study. BMC Public Health. Apr 8 2021;21(1):685. doi:10.1186/s12889-021-10708-w
- Alexander GC, Qato DM. Ensuring Access to Medications in the US During the COVID-19 Pandemic. JAMA. Jul 7 2020;324(1):31-32. doi:10.1001/jama.2020.6016
- Fox ER, Stolbach AI, Mazer-Amirshahi M. The Landscape of Prescription Drug Shortages During the COVID-19 Pandemic. J Med Toxicol. Jul 2020;16(3):311-313. doi:10.1007/s13181-020-00786-4
- Hwang TJ, Rabheru K, Peisah C, Reichman W, Ikeda M. Loneliness and social isolation during the COVID-19 pandemic. Int Psychogeriatr. Oct 2020;32(10):1217-1220. doi:10.1017/S1041610220000988
- Degli Esposti L, Buda S, Nappi C, Paoli D, Perrone V, Network Health DB. Implications of COVID-19 Infection on Medication Adherence with Chronic Therapies in Italy: A Proposed Observational Investigation by the Fail-to-Refill Project. Risk Manag Healthc Policy. 2020;13:3179-3185. doi:10.2147/RMHP.S265264
- Jia R, Ayling K, Chalder T, et al. Mental health in the UK during the COVID-19 pandemic: cross-sectional analyses from a community cohort study. BMJ Open. Sep 15 2020;10(9):e040620. doi:10.1136/bmjopen-2020-040620
- Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatr. Nov 1 2021;175(11):1142-1150. doi:10.1001/jamapediatrics.2021.2482
- Racette L, Abu SL, Poleon S, Thomas T, Sabbagh N, Girkin CA. The Impact of the Coronavirus Disease 2019 Pandemic on Adherence to Ocular Hypotensive Medication in Patients with Primary Open-Angle Glaucoma. Ophthalmology. Mar 2022;129(3):258-266. doi:10.1016/j.ophtha.2021.10.009
- Czeisler ME, Marynak K, Clarke KEN, et al. Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns – United States, June 2020. MMWR Morb Mortal Wkly Rep. Sep 11 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4
- McQueenie R, Ellis DA, McConnachie A, Wilson P, Williamson AE. Morbidity, mortality and missed appointments in healthcare: a national retrospective data linkage study. BMC Med. Jan 11 2019;17(1):2. doi:10.1186/s12916-018-1234-0
- Kaye AD, Okeagu CN, Pham AD, et al. Economic impact of COVID-19 pandemic on healthcare facilities and systems: International perspectives. Best Pract Res Clin Anaesthesiol. Oct 2021;35(3):293-306. doi:10.1016/j.bpa.2020.11.009
- Robin A. Cohen AEC, Emily P. Terlizzi, and Michael E. Martinez. Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2021. Health survey. Services CfDCaPaUSDoHaH; 2022:1-24. National Health Interview Survey Early Release Program. 05/2022
- Tagliabue F, Galassi L, Mariani P. The “Pandemic” of Disinformation in COVID-19. SN Compr Clin Med. 2020;2(9):1287-1289. doi:10.1007/s42399-020-00439-1
- Schulz PJ, Nakamoto K. The perils of misinformation: when health literacy goes awry. Nat Rev Nephrol. Mar 2022;18(3):135-136. doi:10.1038/s41581-021-00534-z
- Kardas P, van Boven JFM, Pinnock H, et al. Disparities in European healthcare system approaches to maintaining continuity of medication for non-communicable diseases during the COVID-19 outbreak. Lancet Reg Health Eur. May 2021;4:100099. doi:10.1016/j.lanepe.2021.100099
- Baum A, Kaboli PJ, Schwartz MD. Reduced In-Person and Increased Telehealth Outpatient Visits During the COVID-19 Pandemic. Ann Intern Med. Jan 2021;174(1):129-131. doi:10.7326/M20-3026
- Bell JS, Reynolds L, Freeman C, Jackson JK. Strategies to promote access to medications during the COVID-19 pandemic. Aust J Gen Pract. Aug 2020;49(8):530-532. doi:10.31128/AJGP-04-20-5390
- Agh T, van Boven JF, Wettermark B, et al. A Cross-Sectional Survey on Medication Management Practices for Noncommunicable Diseases in Europe During the Second Wave of the COVID-19 Pandemic. Front Pharmacol. 2021;12:685696. doi:10.3389/fphar.2021.685696
- Choo EK, Rajkumar SV. Medication Shortages During the COVID-19 Crisis: What We Must Do. Mayo Clin Proc. Jun 2020;95(6):1112-1115. doi:10.1016/j.mayocp.2020.04.001