Managing medications

Developing new interventions in medication management

by Stephanie Stemmler   • March 17, 2022

Jaclyn Schwartz, PhD, OTR/L (right), reviews a research participant’s medications and supplements..

Jaclyn Schwartz, PhD, OTR/L, a 2010 graduate of the Program in Occupational Therapy, was working in her first job after earning her master’s degree when she noticed a common recurrence in patients with cardiac conditions.

“I was rotating in acute care services at Barnes-Jewish Hospital in St. Louis, and I noticed that there was big problem with medication adherence, which brought many patients back into the hospital,” she recalls. “Medication instructions were explained in detail at discharge, but adherence at home was a completely different issue.”

Medication adherence is a huge health problem. Studies have found that half of all older adults fail to take their medications as prescribed.¹ It becomes a critical health issue if a patient is discharged with impairments, such as with the effects from a stroke, because they may not be able — or understand how and when — to take medications at home.

“With long-term medications for chronic conditions, such as high blood pressure, 80 percent of the medication must be taken each month to obtain a real benefit,²” says Schwartz. “That means missing six pills of a daily medication over 30 days is a big deal.”

Compound that with cases where patients take multiple medications daily, and you rapidly realize why poor medication adherence is estimated to cause 125,000 avoidable deaths and between $100-300 billion annually in preventable health- care costs.³

Schwartz, who earned her doctorate from the University of Wisconsin after leaving St. Louis, moved to Miami, Fla., in 2015 to serve as an assistant professor at Florida International University. There, she not only focused on minority health and health disparities, she also delved further into the problem of medication adherence. “This is where occupational therapists can add value on the frontlines of care,” she says. “We can actively monitor adherence and address barriers to taking medications.”

Schwartz is the recipient of a two-year, R03 grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development to serve as principal investigator for a study examining medication adherence in stroke survivors. Called the Medication Adherence after STroke (MAST) project, the goal is to better understand stroke survivors’ issues around medication adherence, with the long-term goal of improving both medication management and, ultimately, adherence.

“As many as half of all stroke survivors fail to take their medications as prescribed, resulting in unnecessary hospitalizations, morbidity and mortality,”⁴ says Schwartz. “This is often because they not only have to manage a complicated medication regimen, they also must overcome both motor and cognitive impairments associated with stroke, and these impairments compromise activities of daily living.”

Physicians, pharmacists and nurses are the initial point for patient information, which Schwartz says can be characterized as directive. “The patient is sitting and listening while someone goes over all of the medications and how to take them. Occupational therapists are in a leading role to continue asking the patient, ‘Did you understand the instructions? Can you do this at home? What is difficult in handling the medications at home?’”

Her research has a two-pronged approach focusing on both behavior modification and simplified technology. With behavior modification, she first investigated factors that impact the ability of a patient to take medications. Then she developed a behavioral intervention process, which she’s calls iMeds, to see if a battery of tailored behavior change approaches could enhance medication adherence. Pilot studies completed while Schwartz was in Milwaukee and Florida proved it was a missing intervention.

Then she listened to what her study participants requested. “People really want simple fixes that can easily be integrated into their daily lives,” she explains.

She created 3D-printed, customizable pillboxes designed to easily identify how and when to take medications. In two separate small studies, she combined iMeds and the pillboxes to see if both would improve adherence. “What we found is that pillboxes are a low-cost, scalable intervention that can be used to globally impact the public health crisis of medication adherence,” she notes.

Schwartz has now brought her research back to Washington University School of Medicine, where she plans to expand her studies through use of the Stroke Registry overseen by Washington University and the Barnes-Jewish Stroke and Cerebrovascular Center. The registry currently has information on more than 30,000 stroke survivors.

Within the Program in Occupational Therapy, she serves as an assistant professor, with plans to mentor students by this fall. Her lab includes occupational therapist researcher Katherine Aylmer, OTD, OTR/L, as well as Sami Tayeb, MA, a clinical research coordinator.

“There are not a lot of people looking at medication adherence in the rehabilitation setting,” Schwartz notes. “But for people with chronic disabilities such as traumatic brain injury and stroke, we as occupational therapists have a prime opportunity to effect positive change and address what is truly a public health crisis with medication adherence.”

1. World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. World Health Organization; 2003.
2. Wirbka L, Haefeli WE, Meid AD. Estimated Thresholds of Minimum Necessary Adherence for Effective Treatment with Direct Oral Anticoagulants: A Retrospective Cohort Study in Health Insurance Claims Data. Patient Prefer Adherence. 2021;15:2209-2220. doi:10.2147/PPA.S324315
3. Benjamin RM. Medication adherence: helping patients take their medicines as directed. Public Health Rep. 2012;127(1):2-3.
4. Zhang J, Gong Y, Zhao Y, Jiang N, Wang J, Yin X. Post-stroke Medication Adherence and Persistence Rates: A Meta-analysis of Observational Studies. J Neurol. 2021;268(6):2090-2098. doi:10.1007/s00415-019-09660-y