On this episode of The Huddle, Wendy Mobley-Bukstein, PharmD, BCACP, CDCES, CHWC, NASM-CPT, FAPhA, FADCES and Debbie Hinnen, APN, BC-ADM, CDCES, FAAN discuss the importance of medication persistence, how to talk to clients about starting and staying on diabetes medications, and strategies to help clients stay consistent with their medication taking. This episode was made possible with support from Lilly, A Medicine Company. Learn more about the latest in diabetes technology on danatech: danatech l Diabetes Technology Education for Healthcare Professionals Learn more about the ADCES7 Self-Care Behaviors: Self-Care Tips (ADCES7) References: Kennedy-Martin, T., Boye, K. S., & Peng, X. (2017). Cost of medication adherence and persistence in type 2 diabetes mellitus: a literature review. Patient Preference and Adherence, 11, 1103–1117. https://doi.org/10.2147/PPA.S136639 McGovern, A., Hinton, W., Calderara, S. et al. A Class Comparison of Medication Persistence in People with Type 2 Diabetes: A Retrospective Observational Study. Diabetes Ther 9, 229–242 (2018). https://doi.org/10.1007/s13300-017-0361-5 Evans M, Engberg S, Faurby M, Fernandes JDDR, Hudson P, Polonsky W. Adherence to and persistence with antidiabetic medications and associations with clinical and economic outcomes in people with type 2 diabetes mellitus: A systematic literature review. Diabetes Obes Metab. 2022; 24(3): 377-390. doi:10.1111/dom.14603 Sabaté E., Adherence to Long-Term Therapies: Evidence for Action, 2003, World Health Organization, Geneva, Switzerland. https://www.ama-assn.org/delivering-care/physician-patient-relationship/8-reasons-patients-dont-take-their-medications https://www.npr.org/sections/health-shots/2017/09/08/549414152/why-do-people-stop-taking-their-meds-cost-is-just-one-reason https://www.adces.org/docs/default-source/handouts/adces7/handout_pwd_adces7_takingmedication.pdf?sfvrsn=4e3f6359_13
On this episode of The Huddle, Wendy Mobley-Bukstein, PharmD, BCACP, CDCES, CHWC, NASM-CPT, FAPhA, FADCES and Debbie Hinnen, APN, BC-ADM, CDCES, FAAN discuss the importance of medication persistence, how to talk to clients about starting and staying on diabetes medications, and strategies to help clients stay consistent with their medication taking. This episode was made possible with support from Lilly, A Medicine Company.
Learn more about the latest in diabetes technology on danatech: danatech l Diabetes Technology Education for Healthcare Professionals
Learn more about the ADCES7 Self-Care Behaviors: Self-Care Tips (ADCES7)
References:
Kennedy-Martin, T., Boye, K. S., & Peng, X. (2017). Cost of medication adherence and persistence in type 2 diabetes mellitus: a literature review. Patient Preference and Adherence, 11, 1103–1117. https://doi.org/10.2147/PPA.S136639
McGovern, A., Hinton, W., Calderara, S. et al. A Class Comparison of Medication Persistence in People with Type 2 Diabetes: A Retrospective Observational Study. Diabetes Ther 9, 229–242 (2018). https://doi.org/10.1007/s13300-017-0361-5
Evans M, Engberg S, Faurby M, Fernandes JDDR, Hudson P, Polonsky W. Adherence to and persistence with antidiabetic medications and associations with clinical and economic outcomes in people with type 2 diabetes mellitus: A systematic literature review. Diabetes Obes Metab. 2022; 24(3): 377-390. doi:10.1111/dom.14603
Sabaté E., Adherence to Long-Term Therapies: Evidence for Action, 2003, World Health Organization, Geneva, Switzerland.
Jodi Lavin-Tompkins
Hello and welcome to ADCES's podcast, “The Huddle: Conversations with the Diabetes Care Team”. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues and updates that elevate your role, inform your practice and ignite your passion. I'm Jodi Lavin-Tompkins, Director of Accreditation and Content Development at the Association of Diabetes Care & Education Specialists.
My guests today are Wendy Mobley-Bukstein, a clinical pharmacist and professor of pharmacy practice at Drake University in Des Moines, Iowa, and Debbie Hinnen, a nurse practitioner from Colorado Springs who does virtual patient consulting for the University of Colorado Health and in-person consultations for Tri-Lakes Cares Community Resource Center.
In this episode, we'll have a conversation around starting and staying on medication. I think it's an important topic right now, especially because people with diabetes don't always understand the need for long-term therapy. I would like to thank Lilly for their support of this episode. So welcome to The Huddle, Wendy and Debbie.
Debbie
Thank you.
Wendy
Thank you so much.
Jodi
Yeah, we're glad to have you both here. And to set the stage for this conversation, I want us first to distinguish the difference between what we call medication persistence and medication adherence, which are terms used in the pharmacy world. So, because you're a pharmacist, Wendy, could you fill us in on those differences?
Wendy
Sure. So medication persistence really represents the length of time a patient continues taking a prescribed medication without any kind of interruption or discontinuation. Basically this is how long the person stays on the medication versus medication adherence is the extent to which a medication is taken at the prescribed doses, intervals, and frequency. So this really emphasizes the quality of that medication-taking behavior.
Jodi
Okay, and since you mentioned medication-taking behavior, what is the language we use outside of the pharmacy world that emphasizes that patient-first, strengths-based language? I think that might be an example, but can you expand on that?
Wendy
Sure. So instead of using the word adherence, I feel like it's best to describe what the person is experiencing or doing with their medications. So for example, what I would chart would be the person can't afford their medication, so they're not taking them. Or the person reports struggling to remember to take the evening doses of their medications at least three times a week. There's no judgment rendered in those statements. I'm just paraphrasing what I was told by that person when I was speaking with them. So again, with the implementation of patient portals and what the person can see, we're not rendering any judgment there. It doesn't sound to them like I'm saying, they're just not doing what they're supposed to be doing. We're actually taking into consideration a lot of different aspects of their care when we're putting that down. And so I think one of the pieces that's really important is looking at that ADCES7 self-care behavior of taking medication. We want to make sure that we are talking with the patient about making sure they're taking the medication appropriately, but again, also understanding why they may not be.
Jodi
Well, Wendy, thanks for that clarification. And I'm really glad we're getting away from those more negative words and actually describing what a person is actually doing. I think that's the ADCS stance on that as well. So what are the barriers to medication taking that we should all be considering?
Wendy
Well, there is a World Health Organization book actually that talks about five categories of factors that contribute to inappropriate medication taking. And so those five factors include patient-centered factors, which examples of that could be age, health beliefs, perhaps lack of understanding of their disease state. The second is socioeconomic. So those would be examples of financial barriers or medication costs perhaps. We also have therapy-related factors, which would include perhaps side effects or complex dosing schedules. We have condition-related factors, where those types of examples would be presence of complications or perhaps severity of the condition. And then the last one would be health system or health care professional-related factors. And so examples of this could be continuity of care, could also be communication between the health care provider and the patient and whether or not each person in that relationship is getting the information that's necessary for them to help one another understand how they can better manage diabetes.
Jodi
Thank you for that overview. And I want to bring Debbie into this conversation. So Debbie, what do you think about all that?
Debbie
Well, I think that's very detailed and we don't always think of the WHO, but we do, I think, focus on social determinants of health. And they're all very similar. But I think what really is important for us to realize, all these issues account for over half of the person's decision-making. A lot of those are before they even decide they can get the medicine or take the medication or believe they even should. And then there are follow-up things with that as well. And so it isn't just because we said so. There are so many factors playing into it.
Jodi
Well, if we consider the WHO five categories, the overall categories, I want to do a little bit of a deeper dive into some of these barriers that Wendy mentioned. And I think if we focus on the reasons people stop their medicines, I think we'll be able to bring the other four factors from the WHO framework into the conversation as well. So Wendy, can you get us started with that?
Wendy
What I see mostly, I work in a federally qualified health center. So what I see a lot are those financial barriers. You know, if our 340B formulary doesn't have a medication on it and the person goes to a pharmacy to try and obtain a medication and the cost is too much for them to afford, they're going to have to make a decision of buying groceries or buying medication. Every day of the week I think most of the individuals in my clinic are probably going to buy the groceries for their family versus buying their medications. Additionally, I think health literacy plays into this as well. A lot of times the patients don't understand that chronic nature of the disease and the fact that even if they continue taking their medications and we get them to a goal range, then sometimes they don't continue taking the medication because they think that they're quote, quote, cured, if you will. So I think that there is definitely some factors there in making sure that we understand where those patients are in their health literacy. Additionally, you have pharmacy deserts. You know, the access to a pharmacy, we're seeing pharmacy deserts in all areas of the country. So not only rural areas, but also now metro areas where the pharmacy is closing, which brings me to my next point, access to transportation. Perhaps your patient doesn't have transportation. So it's hard for them to get to a pharmacy in order to get their medications. I think that ultimately, especially type 2 diabetes, most of our patients don't have symptoms until their diabetes is much more progressed perhaps than what it would have been if we had been able to diagnose them early on because they just don't feel bad. They don't really have symptoms. They may be having symptoms, but they don't know that those symptoms are related to their diabetes until they're very overt. And then the last part is just fear of side effects. And so I have a lot of individuals, again, being in the type of clinic that I am, I have a lot of refugee patients. And they come in with a lot of different fears about medications. And so sometimes those fears of hypoglycemia, that fear of, “is it going to hurt if I have to inject something?” Those are ways that I have to try and kind of talk with a patient about why it's important for them to take the medication and help them try and get over some of those fears by sometimes practicing just here in the office where they can get an idea of what it's really going to be like for them to be able to use the devices.
Debbie
Wendy, you know, in addition to that, mistrust in the medical care or the clinician, I think is a big issue. So I think we have to work hard to build that trust early on. But we also have, I think, examples of people who rely on Dr. Google or their friend even more than they do us. And one of the recent things that happened at our food bank was that a gentleman who's on a sulfonylurea plus once a week GIP-GLP medication said to me, I've got to stop this GIP-GLP injection because it's burning out my pancreas. My friend told me so. And I said, "oh no, no, no, no, that one kicks in when you need it. It's activated when you eat. And then when the blood sugars come back to normal, it shuts off. So it's like thermostat. It kicks in, it shuts off.” So that information credibly delivered, hopefully, helps build that trust. But I think our treatment very often is too difficult and people have polypharmacy. People complain “I'm taking so many pills.” Well, you know there may be one or two that are prescriptions, but in our diabetes folks, we have often multiple diabetes, plus hypertensives, plus lipids. And so people are taking a handful of pills. And the more difficult that becomes when we add thyroid, please take it at a different time, or an oral GLP, stagger that from a totally different time on an empty stomach, it's overwhelming for people. And as you pointed out, those cultural and religious beliefs very strongly dictate health care decisions that people make. And we have to know the cultures. And Jodi, I know you've worked with some different cultures in your clinical experience.
Jodi
Yes, we had a refugee clinic in our health system and I learned so much from people from other backgrounds and places around the world. And it's so important to get to know what they believe about medications because Western medicine is often foreign to them. Now that we've covered a lot about the reasons people stop their medication or don't want to start them, I think it's important for us to discuss some strategies for overcoming those barriers. And one major strategy involves effective communication and education with the person. So let's talk about what that looks like. And maybe you could each give some examples you've seen in your practice for our listeners.
Wendy
I personally try to take as much time as necessary to make sure that the person understands the disease process. I talk with them, obviously I'm a pharmacist, so I talk about the way the meds work, but I'm just very curious by nature, so I ask a lot of questions to make sure that I can address any kind of knowledge gaps that may exist that could directly affect how they're going to care for themselves in the future. So I have lots of analogies for diabetes, especially type 2 diabetes. I talk about the basketball and the hoop. The basketball hoop is the receptor and the basketball is the insulin. And I talk about how the hoop's not round anymore. The hoop is some odd shape that the ball doesn't go into and it bounces out. So now we're not able to have the insulin get in. And when the insulin doesn't get in, then the sugar can't get in either. So then the sugar stays in their blood for a long period of time. And I talked to them about how sometimes you don't have symptoms with diabetes. And so then we start medications and they're like, “I feel terrible.” So then I talked to them about like, well, kind of like being in a car and you're on the interstate. When you're on the interstate and you're driving 75 and all of a sudden you got to get off at the exit and you're stomping on the brakes and trying to slow it down. That's kind of what it's like when we start putting that medication in there is your body's so used to running with a high blood sugar. And now we're trying to bring it down into a more normal range that it's gonna take a little bit of time for your body to kind of adjust to that new speed that you're trying to put it on.
Jodi
I love your use of analogies. I think they're so helpful in teaching, and both of you are really good at that. So thank you for sharing.
Wendy
Yeah. Again, I describe how the drugs work to help fix the different, I refer to them as quote, problems in the body, but you know, the dysregulation or dysfunction that might be going on. And then I give them realistic expectations from what they should see with the medications. So I'm letting them know that yes, you might see your blood sugar dip a little bit lower than it's been, and you might feel that, but give it a couple of weeks in order for it to really kind of adjust to that before we're gonna make more changes if the blood sugar obviously isn't coming down to where we'd like to see it. And then I do talk with them about complications. I think that that's probably the area that's the hardest to talk about because of course I don't want to scare anyone. I don't tell people that, you know, there's this higher risk you're gonna have a heart attack or higher risk you're gonna have a stroke. But I think that it's important for them to know that the longer that their blood sugar remains high that we have these increased risks for all of these other things to happen and so why it's so important for us to work to get their blood sugar down over a pretty decent amount of time. I don’t know, Debbie, what are the things you talk to people about?
Debbie
Well, I love the basketball hoop idea and I will be using that one. I think it's really important to lead with questions. What questions do you have today? What questions specifically do you have about your medications? And I think that really kind of opens up that conversation. And whatever people ask about is where you start. May not be on starting or staying on the medication, which is top of mind for us. But we can't get there until we tackle what they're worrying about the most. And correcting misinformation, I think, is very hard, but a constant job that we have to do, as well as all the education and filling those gaps. But, you know, I mentioned Dr. Google earlier, and I think it's really important that we give people good websites. You know, the CGM companies are using YouTube videos and I have endocrinologist friends that are putting that in the after-visit summary note. Use this YouTube to help start your CGM at home. And so we need to give those good websites. The websites for healthy eating, the websites for the medications, those are all patient and professional sections that people can use and can access. In fact, when we do patient classes, we have a whole list of resources after every topic. And so people who don't make it to class or don't listen in class or they forgot, they've got someone saying pretty much the same thing we said, maybe in a better way. And they can hear it as many times as they want to. Our ability, though, to have shared decision-making is what really is going to help close the deal.
And so once we've gotten through a lot of the education, the discussion, the agreement, “okay, maybe I need that”, we then need to take that to the next level as we do with motivational interviewing. To what degree do you think you can do this on a scale of one to 10? And if someone says six, we've missed something in our conversation. So we have to dig a little deeper and find out what are the barriers or the problems that we haven't uncovered in our conversations and then help kind of problem solve that with people. But the other thing then I think that we always do is try to have our notes be careful. And I've gotten so many after-visit summaries that say nothing. I think people don't read the AVS. And so I love that your charting is very patient friendly. You know, that language is patient friendly. And so if we can do that, then we are truly giving people something useful in that after visit summary. People go to the portal and have to communicate that way now. So those things can be accessed by and large by people after the visit.
Wendy
I love that you are utilizing those websites for reinforcement. When we're talking with a patient, I feel like we're kind of brain dumping. Like, here's all this stuff. And I often talk with the students when they come, like, we have to set a ground level first, and then we're going to have to build on top of that afterwards. Because if we throw everything at them today, they're not going to remember it when they get home. So having that ability to have those resources. And so I'm going to plug danatech here really quick. But there are so many things out there that are no cost for people to be able to access and to be able to utilize that. And so I think that as a DCES, we have the opportunity to take some of those resources that are on danatech and pull those out for patients to be able to see and use as well.
Debbie
Right. And we know from adult teaching principles that people have to see it, hear it, and write it to really make that retention up high enough in the 80s to have a chance of it maybe actually being able to start implementation and then do it 30 times to build the habit. So I appreciate the suggestions and all the brainstorming that you're sharing with patients.
Jodi
Let's talk about health professionals now. We've been talking a lot about the person with diabetes, but I'm sure you have some tips or strategies you'd like to share for easing the burden of prescribing and ensuring access to medications on behalf of other health professionals. So Wendy, can you start us off with that?
Wendy
Sure, so I'm first going to talk about kind of what I do with the patient and then I'll talk a little bit more about, I work with internal medicine residents, I work with pharmacy students and so talk a little bit more about how we do that on the professional side. But for patients, I write out explicit instructions for them. So I'll say it's going to be take one tablet twice a day for one week and then on 5/29, which would be a week from today. I'm going to tell them to increase the two tablets and I'm probably going to call them and ask them, hey, did you remember today is the day you're going to have to increase the two tablets twice a day and then tell them, you you'll continue this dose until you see your clinician the next time or until they tell you differently. So that way they understand that this is going to be something. And sometimes I will say this is a long-term medication, something that you're going to be taking for a long time. And that way they understand that even if they run out, they need to go to the pharmacy and get more refills. Or I might explicitly say, when you run out of this medication, make sure a couple of days before it's gone, that you call the pharmacy and make sure that they can refill it for you. So I do a lot of education around that. Our electronic health records are all different. We use Epic. And so I free text a lot of the instructions in. So even if it's a twice daily, you know, I put it in there, take one tablet by mouth twice daily and then in parentheses, in the morning, at breakfast time, and in the evening, at dinner time. And so sometimes I'm a little bit more explicit with the patient than maybe what they need, but I think that it's important to make sure that you're putting in all that information. Working with the students, working with the internal medicine residents, you know, we spend a lot of time on how should I put those prescriptions in or how are we going to titrate it? And I think that that's where we are able to augment our services with the medical services that are provided in the clinic because we're able to be that extra set of hands to be able to call people and say, “hey, did you titrate that medication?” Or like even this morning we had someone who's on a GLP-1 GIP. They just finished the 2.5 milligram dose. We had them come in, we weighed them, we talked about how they were feeling and all of that before we said, “okay, today, we'll send that prescription for the five milligram because you took your last dose of the 2.5 yesterday. So the five milligram will be available for you next week when you're ready to start taking that.”
Debbie
I think it's really important to use a formulary lookup tool. Our Epic has some formulary preference information embedded in it, but we know every Epic is different. So sometimes it's right, sometimes it isn't. And one of my favorites is coverage search. Use it on my phone, can kind of confirm what Epic says or maybe it isn't in Epic and I've got something to go on. Or fingertip formulary. Those are just a couple of them. There's more out there. But that gives you a good starting place because the thing we don't want to happen is that we write the wrong one. And when the person gets to the pharmacy and they're told, oh yes, here you go, that's $800 or $1,100, there's no way they'll do it. Obviously we've written the prescription for the wrong one. Now on the 340B, of course, sometimes you don't have GLPs or you may have the original one from 20 years ago that's twice a day injection. So there are some struggles, but getting the right medication. And I think all our newer medications, particularly the once a week injections, we need to anticipate a prior auth. And the standards of care from ADA are pretty clear that the GLP family is very much indicated for people at risk of cardiovascular disease, which covers almost our entire population, right? So if we can quote the standard of care, I think that helps a bit in the prior auth as well. But quite frankly, that first review of the PA is done by an AI bot, so it's going to deny very often, and we're going to have to be ready to go back in with a denial. We can't quit just because we're told once. So getting that prior auth help, hopefully someone in your office is doing all the prior auths. I can't tell you how many lunch hours I've had to do it without help. But the people who do prior auths are experts, oh my gosh. And if we charted carefully enough to include the requirements as we know them, then that lets whoever's doing that PA for us be able to dig back in, do the original, do the appeal. Maybe with some additional information. But I do think it's also really important if we get pushback that we ask for a peer-to-peer or we ask to talk to the medical director. That pharmacist who's the peer-to-peer can override that problem. The medical director's harder to get to, but those are the really important steps, I think, to be sure we've done our due diligence on helping get that medication in the patient's hands. So I think the troubleshooting really is probably most important. Your follow-up, though, after you start something, I agree. Even if it's a quick phone call and not an official telehealth, has really made a big difference. People are surprised, first of all, that you reach out in just a few days. You don't have 20 minutes to do telehealth always. But just a quick phone call. “I know you're supposed to start today. How did the injection go? Any questions or problems?” Boom. So copays and deductibles are another thing that I think as clinicians, we need to be sure we're putting on the table. We may not know the copay amount, but we need to give people a heads up. The first of the year, there's going to be a deductible. If people are on Medicare, it's $2,000 till they reach the cap now and enter into catastrophic, not $5,000. And that can be partitioned out over the year. So if someone is going for one of the newer once a week medications and they have to pay $2,000, that sounds overwhelming in January. But if they think, that could be actually less than $200 a month if I spread it out over the year, that may sound more doable. and really help people be able to access it. And of course, there's direct purchase from the pharma companies for people to buy the medication directly, the real medication, not the compounded. But I think we forget sometimes to talk about the direct access, and that's fairly new for us. The other thing I would just close with is when people have been on the medication, they're doing well, they've reached weight goals, A1C goals, and we know from research out there they can't stop the medication or they lose all those metabolic benefits. We have to be ready to do continuation of therapy prior auth. And the tip I would share there is to be sure you've included the original baseline A1C and baseline weight, because what you have today, a year later, may be marvelous and wonderful. And the insurance company says, “oh good, they don't need it anymore.” Well, this is not strep throat. You have not cured the diabetes. You may have it in remission as long as they maintain this medication and all the healthy eating and higher protein resistance work, all of those strategies as well. So I would just say that is kind of the wild card we're not always prepared for.
Jodi
Alright, well, this conversation has been very informative. Thank you both. And I want to wrap up with a key question for both of you. What do you think is the best way to explain to a person with diabetes, especially those with other conditions and comorbidities, why it's important for them to continue their medication even if they've reached their treatment goal?
Wendy
I often talk about the fact that this is a chronic disease that even once we reach whatever that treatment goal looks like for that individual person, that we have to stay there. And perhaps the medication is what helped to get us there. So if we stop the medication, then the disease itself can start to progress again. And then we're going to be back to kind of square one where we were before. So really talking about how this is a lifelong journey with the medication perhaps. Sometimes we're able to, to Debbie's point a little bit ago, we're able to pull back on the medications a little bit and maybe not need as much, but knowing that we need to do that continuous follow-up to make sure that things are not progressing. Debbie, do you have other things to add?
Debbie
I agree those are indeed the most important things. But I think, for instance, in obesity literature, it's very clear that it's a chronic disease. You continue to need medication to help with satiety and hunger. And so those are huge parts of diabetes management. And I think people don't understand that ongoing need. And of course, when they stop the medication, they don't just lose that satiety and hunger. They lose the other metabolic benefits. And we know that the GLP world has many more indications than just diabetes. Heart, cardiovascular, kidney, sleep apnea, now Alzheimer's research is going on. So we want to help people remain on, start and stay, because maybe they'll benefit from many other things besides what we're thinking of today.
Jodi
Well, Wendy and Debbie, thank you so much for taking the time to join us for this episode of The Huddle and for sharing your expertise on this topic. As practicing clinicians who deal with this every day and in a teaching capacity, I'm sure our listeners have gained some new knowledge and strategies from you both that they can take away from our conversation. So thank you so much.
Debbie
Thank you, Jodi.
Wendy
Thank you.
Jodi
I would like to thank Lilly again for their support of this podcast. And thank you all for listening to this week's episode of The Huddle. Make sure to download the resources discussed in today's episode. You can find them linked in the show notes at adces.org/podcast. And remember, ADCES membership gets you free access to resources, education, and networking that improve your practice and optimize outcomes for your clients. Learn more about what ADCES can do for you at adces.org/join.
The information in this podcast is for informational purposes only and may not be appropriate or applicable to your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a health care professional. Please consult your health care professional for any medical questions.