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

  • Nathaniel M. Rickles
  • Todd A. Brown
  • Melissa S. McGivney
  • Margie E. Snyder
  • Kelsey A. White
Keywords: Medication Adherence, Pharmacists, Education, Pharmacy, 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.


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1. Cramer J, Roy A, Burrell A, Anuja R, Burrell A, Fairchild C, Fuldeore M, Ollendorf D, Wong P. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11:44-47.

2. National Council on Patient Information and Education (NCPIE). Talk about prescriptions month newsletter. Washington, DC: National Council on Patient Information and Education, 1990.

3. Maronde R, Chan L, Larsen F, Strandberg L, Laventurier M, Sullivan S. Underutilization of antihypertensive drugs and associated hospitalization. Med Care. 1989;27(12):1159-1166.

4. Grymonpre R, Mitenko P, Sitar D, Aoki F, Montgomery P. Drug-associated hospital admissions in older medical patients. J Am Geriatr Soc. 1988;36:1092-1098.

5. Prince B, Goetz C, Rihn T, Olsky M. Drug-related emergency department visits and hospital admissions. Am J Hosp Pharm. 1992;49:1696-1700.

6. Sokol M, McGuigan K, Verbrugge R, Epstein R. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2008;43(6):521-530.

7. New England Healthcare Institute. Thinking outside of the pillbox: a system-wide approach to improving patient medication adherence for chronic disease. Cambridge, MA: New England Healthcare Institute, 2009.

8. Sackett D, Haynes R (eds.). Compliance with therapeutic regimens. Baltimore, MD: John Hopkins University Press, 1979.

9. Martin L, Williams S, Haskard K, DiMatteo MR. The challenge of patient adherence. Ther Clin Risk Manage. 2005;1(3):189-199.

10. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.

11. Burra T, Chen E, McIntyre R, Grace S, Blackmore E, Stewart D. Predictors of self-reported antidepressant adherence. Behav Med. 2007;32(4):127-134.

12. Roter D, Hall J, Merisca R, Nordstrom B, Cretin D, Svarstad B. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care. 1998;36:1138-1161.

13. Haynes R, Ackloo E, Sahota N, McDonald H, Yao X. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub3.

14. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533-543.

15. AACP Commission to Implement Change in Pharmaceutical Education. “What is the Mission of Pharmaceutical Education?” Available at: Accessed December 18, 2009.

16. Joint Commission of Pharmacy Practitioners Web Site. Pharmacy Practice in 2015. Available at: Accessed December 18, 2009.

17. Carter B, Bergus G, Dawson J, Farris K, Doucette W, Chrischilles E, Hartz A. A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control. J Clin Hypertens. 2008 ;10(4):260-271.

18. Planas LG, Crosby KM, Mitxhell KD, Farmer KC. Evaluation of a hypertension medication therapy management program in patients with diabetes. J Am Pharm Assoc. 2009;49:164-170.

19. Mehos B, Saseen J, MacLaughlin E. Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with uncontrolled hypertension. Pharmacotherapy. 2000;20(11):1384-1389.

20. Hanlon J, Weinberger M, Samsa G, Schmader K, Uttech K, Lewis I, Cowper P, Landsman P, Cohen H, Feussner J. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med. 1996;100(4):428-437.

21. Lee J, Grace K, Taylor A. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. 2006;296(21):2563-2571.

22. Rathbun R, Farmer K, Stephens J, Lockhart S. Impact of an adherence clinic on behavioral outcomes and virologic response in treatment of HIV infection: a prospective, randomized, controlled pilot study. Clin Ther. 2005;27(2):199-209.

23. Finley P, Rens H, Pont J, Gess S, Louie C, Bull S, Lee J, Bero L. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy. 2003;23(9):1175-1185.

24. Finley P, Rens H, Pont J, Gess S, Louie C, Bull S, Lee J, Bero L. Impact of a collaborative pharmacy practice model on the treatment of depression in primary care. Am J Health-Syst Pharm. 2002;59(16):1518-1526.

25. Rickles N, Svarstad B, Statz-Paynter J, Taylor L, Kobak K. Pharmacist telemonitoring of antidepressant use: effects on pharmacist-patient collaboration. J Am Pharm Assoc. 2005;45(3):344-353.

26. Capoccia K, Boudreau D, Blough D, Ellsworth A, Clark D, Stevens N, Katon W, Sullivan S. Randomized trial of pharmacist interventions to improve depression care and outcomes in primary care. Am J Health-Syst Pharm. 2004;61(4):364-372.

27. Weinberger M, Murray M, Marrero D, Brewer, N, Lykens, M, Harris, L, Seshadri R, Caffrey H, Roesner J, Smith F, Newell A, Collins J, McDonald C, Tierney W. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA. 2002;288(13):1594-1602.

28. Lee M, Kemp J, Canning A, Egan C, Tataronis G, Farraye F. A randomized controlled trial of an enhanced patient compliance program for Helicobacter pylori therapy. Arch Intern Med. 1999;159(19):2312-2316.

29. Stevens V, Shneidman R, Johnson R, Boles M, Steele P, Lee N. Helicobacter pylori eradication in dyspeptic primary care patients: a randomized controlled trial of a pharmacy intervention. West J Med. 2002;176(2):92-96.

30. Odegard P, Goo A, Hummel J, Williams K, Gray S. Caring for poorly controlled diabetes mellitus: a randomized pharmacist intervention. Ann Pharmacother. 2005;39(3):433-440.

31. Grant R, Devita N, Singer D, Meigs J. Improving adherence and reducing medication discrepancies in patients with diabetes. Ann Pharmacother. 2003;37(7-8):962-969.

32. Solomon D, Portner T, Bass G, Gourley D, Gourley G, Holt J, Wicke W, Braden R, Eberle T, Self T, Lawrence B. Clinical and economic outcomes in the hypertension and COPD arms of a multicenter outcomes study. J Am Pharm Assoc. 1998;38(5):574-585.

33. Murray M, Young J, Hoke S, Tu W, Weiner M, Morrow D, Stroupe K, Wu J, Clark D, Smith F, Gradus-Pizlo I, Weinberger M, Brater D. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med. 2007;146(10):714-725.

34. Murray M, Young J, Morrow D, Weiner M, Tu W, Hoke S, Clark D, Stroupe K, Wu J, Deer M, Bruner-England T, Sowinski K, Smith F, Oldridge N, Gradus-Pizlo I, Murray L, Brater D, Weinberger M. Methodology of an ongoing, randomized, controlled trial to improve drug use for elderly patients with chronic heart failure. Am J Geriatr Pharmacother. 2004;2(1):53-65.

35. Nietert P, Tilley B, Zhao W, Edward, P, Wessell A, Mauldin P, Polk P. Two pharmacy interventions to improve refill persistence for chronic disease medications: a randomized, controlled trial. Med Care. 2009;47(1):32-40.

36. Faulkner M, Wadibia E, Lucas B, Hilleman D. Impact of pharmacy counseling on compliance and effectiveness of combination lipid-lowering therapy in patients undergoing coronary artery revascularization: a randomized, controlled trial. Pharmacotherapy. 2000;20(4):410-416.

37. Tavitian S, Spalek V, Bailey R. A pharmacist-managed clinic for treatment of latent tuberculosis infection in health care workers. Am J Health-Syst Pharm. 2003;60(18):1856-1861.

38. Berringer R, Shibley M, Cary C, Pugh C, Powers P, Rafi J. Outcomes of a community pharmacy-based diabetes monitoring program. J Am Pharm Assoc. 1999;39(6):791-797.

39. Bluml B, McKenney J, Cziraky M, Elswick R. Interim report from project ImPACT: hyperlipidemia. J Am Pharm Assoc. 1998;38(5):529-534.

40. Bluml B, McKenney J, Cziraky M. Pharmaceutical care services and results in project ImPACT: hyperlipidemia. J Am Pharm Assoc. 2000;40(2):157-165.

41. Gross R, Zhang Y, Grossberg R. Medication refill logistics and refill adherence in HIV. Pharmacoepidemiol Drug Saf. 2005;14(11):789-793.

42. Hess K, Goad J, Wu J, Johnson K. Isoniazid completion rates for latent tuberculosis infection among college students managed by a community pharmacist. J Am Coll Health. 2009;57(5):553-555.

43. Vivian E. Improving blood pressure control in a pharmacist-managed hypertension clinic. Pharmacotherapy. 2002;22(12):1533-1540.

44. Visnegarwala F, Rodriguez-Barradass M, Graviss E, Caprio M, Nykyforchyn M, Laufman L. Community outreach with weekly delivery of anti-retroviral drugs compared to cognitive-behavioural health care team-based approach to improve adherence among indigent women newly starting HAART. AIDS Care. 2006;18(4):332-338.

45. Hirsch J, Rosenquist A, Best B, Miller T, Gilmer T. Evaluation of the first year of a pilot program in community pharmacy: HIV/AIDS medication therapy management for Medi-Cal beneficiaries. J Manag Care Pharm. 2009;15(1):32-41.

46. Lentz N, Fons R, Gruber D, Olson N, Tschida S. Refill assistance monitoring program for HIV/AIDS patients - Community-based program enhances medication adherence. Journal of the Pharmacy Society of Wisconsin 2007;(JAN-FEB):46-47.

47. Bozovich M, Rubino C, Edmunds J. Effect of a clinical pharmacist-managed lipid clinic on achieving National Cholesterol Education Program low-density lipoprotein goals. Pharmacotherapy. 2000;20(11):1375-1383.

48. Lai L. Community pharmacy-based hypertension disease-management program in a Latino/Hispanic-American population. Consult Pharm. 2007;22(5):411-416.

49. Cipolle R, Strand L, Morley P. Pharmaceutical Care Practice: The Clinician’s Guide. 2nd ed. New York: McGraw-Hill;2004.

50. American Association of Colleges of Pharmacy Web Site, Center for the Advancement of Pharmaceutical Education. Educational Outcomes 2004. (Accessed December 18, 2009).

51. 2005-06 AACP Educational Outcomes and Objectives Supplement Development Task Force. Pharmacy Practice Supplemental Educational Outcomes. March 2007. Available at: (Accessed December 18, 2009).

52. 2005-06 AACP Educational Outcomes and Objectives Supplement Development Task Force. Social and Administrative Sciences Supplemental Educational Outcomes. March 2007. (Accessed December 18, 2009).

53. Kimberlin CL. Communicating with patients: skills assessment in US colleges of pharmacy. Am J Pharm Educ. 2006;70: Article 67. Available at: (Accessed December 18, 2009).

54. Adamcik B, Airmet D. Multi-cohort learning: teaching pharmacy students about compliance, counseling, and mentoring. Am J Pharm Educ. 1998;62: 342-346. Available at: (Accessed December 18, 2009).

55. Singla D, MacKinnon G, MacKinnon K, Younis W, Field B. Interdisciplinary approach to teaching medication adherence to pharmacy and osteopathic medical students. J Am Osteopath Assoc. 2004;104:127-132.

56. Slain D, Casdorph D, McIntire T. Assessment of an antiretroviral adherence sensitivity training exercise in the doctor of pharmacy curriculum. Am J Pharm Educ. 2002;66: 277-280. Available at: (Accessed December 18, 2009).

57. Divine H, Cain J. Assessing the effect of a polypharmacy medication adherence simulation project in a geriatrics course in a college of pharmacy. J Am Geriatr Soc. 2009;57:1487-1491.

58. Villaume W, Berger B, Barker B. Learning motivational interviewing: scripting a virtual patient. Am J Pharm Educ. 2006;70: Article 33. Available at: (Accessed December 18, 2009).

59. Rickles N, Tieu P, Myers L, Galal S, Chung V. The impact of a standardized patient program on student learning of communication skills. Am J Pharm Educ. 2009;73(1):4.

60. National Alliance of State Pharmacy Associations Limited Time Opportunity To Join The Patient Centric Model—A Synchronized Prescription Refill Pilot Program. Accessed at (Accessed January 13, 2009).

61. Mirixa, Corp. About us. Accessed at (Accessed December 19, 2009).

62. PurpleTeal. About us. Accessed at (Accessed February 7, 2010).

63. Aprexis Health Solutions, Inc. Services. Accessed at (Accessed February 7,2010).

64. Outcomes Pharmaceutical Health Care. Accessed at (Accessed February 11, 2010).

65. Medication Management Systems, Inc. Accessed at (Accessed February 11, 2010).

66. Centers for Medicare & Medicaid Services. Medicare Prescription Drug Benefit Final Rule: 42 CFR Parts 400, 403, 411, 417, and 423 Medicare Program. Federal Register, vol. 70, no. 18. January 28, 2005. Available at: (Accessed February 10, 2010).

67. Centers for Medicare & Medicaid Services. Higher quality care through Medicare’s modernization benefits. Accessed at (Accessed December 19, 2009).

68. Bluml B. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc. 2005;45:566-572.

69. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service. Version 2.0. J Am Pharm Assoc. 2008;48:341-353.

70. Centers for Medicare & Medicaid Services. Medicare Part D Medication Therapy Management (MTM) Programs 2009 Fact Sheet. Accessed at December 19, 2009.

71. Boyd ST, Boyd LC, Zillich AJ. Medication Therapy Management Survey of Prescription Drug Plans. J Am Pharm Assoc 2006;46(6):692-699.

72. Humana, Inc. Pharmacists. Accessed at (Accessed December 19, 2009).

73. Centers for Medicare & Medicaid Services. Issuance of the 2010 Call Letter dated March 30, 2009.

74. Centers for Medicare & Medicaid Services. Medicaid Program-General Overview. (Accessed December 19, 2009).

75. American Society of Health-System Pharmacists. ASHP Policy Analysis: Pharmacist Provider Status in 11 State Health Programs. Available at: (Accessed January 17, 2010).

76. Pharmacy Quality Alliance. Accessed at (Accessed February 12, 2010).

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