Counseling for Improved Medication Adherence
(Pharmacists have the tools and expertise to deliver personalized adherence coaching that improves therapeutic outcomes and reduces health care costs.)
Globally, the prevalence of chronic disease is increasing, yet adherence to treatment regimens remains persistently low. In developed countries, only about 50% of all patients treat their chronic disease according to the instructions. Non-adherence is associated with poorer clinical outcomes, and ageing populations in particular experience negative effects of poor adherence. Multiple diseases and poly-pharmacy among older adults further challenge the good coordination of care.
Non-adherence appears to be a difficult problem to resolve and remains a global concern for healthcare. A Cochran review included almost 200 randomized controlled trials (RCTs), and it was evident that in only a minority of the lowest risk of bias, RCTs improved both adherence and clinical outcomes. Despite the fact that intervention studies in optimal circumstances may show some results, their effectiveness is even more limited in real-life clinical settings. The difficulties in measuring the adherence further complicate the matter. Healthcare professionals also tend to overestimate patients’ adherence in routine clinical practice.7
The Cochran review concluded that one explanation for non-effectiveness is the lack of a thorough understanding of the adherence problems. Overall, non-adherence is a complex process and more understanding is needed from the qualitative research perspective. So far, qualitative studies have focused on the viewpoint of patients, healthcare professionals and the interactions between different professionals. Type of interaction, communication and trust appear to be among the essential themes in these studies. The Cochran review advised that shifting medication counseling to allied healthcare providers seems a reasonable and potentially cost-effective strategy. Although there is no clear evidence that inter-professional interventions are more effective than single-handed ones, they appear to offer the best opportunity to improve clinical outcomes. Patients do not self-manage alone and they would benefit from different types of support by different healthcare professionals.
General practitioners (GPs) are responsible for much of the medication prescribing and counseling for chronic diseases. The aim of this study was to explore GPs’ insights into medication adherence and to assess the perceived barriers, facilitators and ideas for improving patients’ adherence in routine clinical practice. Our study sought to broaden understanding of the primary care doctors’ struggle against the multifaceted phenomenon of non-adherence. We also aimed to study GPs’ attitudes towards having pharmacists as team members in primary care and the need for pharmacists’ involvement in patient education and counseling services.
Barriers to good medication adherence according to the general practitioners (GPs)
- Poor knowledge of the illness and medication.
- Administering and dosage of the medication.
- Independent pausing, stopping or controlling of the medication.
- Lack of competence in self-management.
- Hiding the drug information (eg, drugs prescribed by private doctors).
- Fear towards drugs.
- Media and neighbors as a source of medication information.
- Diseases where poor control does not yet present symptoms.
- Challenges with lifestyle changes.
- Replacing prescription drugs with self-administered drugs.
- Reviewing the full medication information is challenging and time-consuming.
- Accurate knowledge of the actual home medication is difficult to attain.
- Sometimes a too authoritative role for doctors.
- Unsatisfactory skills in coaching self-management.
- Complex medications.
- The duration of the medication (temporary, permanent) and withdrawing the medication.
- Adverse effects.
- Shortage of GP appointments.
- Poor access to care.
- Problems with keeping the medication lists up to date.
- IT systems and poor communication within healthcare systems.
Patient-related factors of self-management
According to the focus group discussions, the GPs were quite burdened with non-adherence to medication. The patients managed their chronic disease poorly and it was easy for the GPs to agree that probably at least half of their patients experienced difficulties with their medication adherence. The GPs also noticed that problems accumulated in certain patient groups.
According to the GPs, there was a huge variation in the self-management in general as well as in medication management among different patient groups. A few treated their disease exactly as ordered using their own Excel tables to document the outcome of the care. Others did not attend GP’s appointments or manage their disease as agreed. The GPs thought that these patients were confused with their medication and often did not know how the medicines should be taken.
In all four focus group discussions, the GPs wanted to talk about their especially problematic patients, who had many diseases and multiple medications.
The challenge often was with the instructions. When a new drug was commenced, the GP explained the medication to the patient. On the other hand, the patients often decided for themselves how they should take their medication, and this was not always in accordance with the GP’s instruction.
Patients did not necessarily understand why the medication had been prescribed for them. Patients might regard the GP’s questions on adherence as interference even though the purpose was to clarify the issues and to find the best alternative to treat their disease. The GPs knew the patients made independent decisions on their treatment and they hoped those decisions would not be detrimental.
The role of the doctor
According to the GPs, the authoritative role taken by doctors may demotivate patients from taking responsibility for their medication management. The doctors were aware that patients did not always tell them the truth about their use of medicines.
Facilitators to better medication adherence according to the GPs
- Focus on health outcomes of self-management and drug therapies.
- Support for patients to better understand their disease and its management.
- Pharmacists as coaches for drug therapies.
- Medication counseling for caregivers.
- Peer groups for chronic conditions and training in peer groups.
- Inter professional practices for updating the drug lists before yearly check-ups.
- Continuity of care and permanent doctor–patient relationships.
- Equal relationships with patients, with a coaching attitude.
- Setting achievable goals.
- Inter professional interventions: medication reconciliation (nurse or pharmacist), medicines optimization (pharmacist) and medication review (pharmacist).
- Combination of products to minimize the number of medicines.
- Checking and teaching the right use of medical devices.
- Inter professional practices.
- Inter professional interventions: medication reconciliation, medicines optimization and medication review.
- Healthcare wide shared patient information and better IT systems.
Medication adherence—the extent to which patients take medications as prescribed by their providers and agreed upon in the treatment plan—is essential for optimizing health outcomes. The term previously used, “medication compliance,” has fallen out of favor, because it suggests the patient is passively following orders, as opposed to being actively involved in treatment planning.
Non-adherence takes many forms and statistics on the number of unfilled prescriptions are stunning. One large-scale study found 22% of prescriptions go unfilled, a statistic that climbs to 28% for new prescriptions. Non-adherence rates were even higher for pain medications, where only 45% of new prescriptions were filled.
Non-adherence rates were the lowest for prescriptions written by the patients’ primary care physicians (16%) and prescriptions written for patients 18 years and younger (13%). Despite these and other research findings reporting that only 50% to 60% of patients are medication adherent, only 8% of patients acknowledge non-adherence. Medication non-adherence is linked to disease worsening, increased mortality, and increased health costs. It is estimated, for example, that improved adherence to antihypertensive treatment could prevent 89,000 premature deaths in the United States annually. Furthermore, 33% to 69% of all medication-related hospital admissions stem from poor medication adherence.
Adherence rates are generally defined as the percentage of correct doses taken over a period of time. Currently, however, there is no definitive benchmark for acceptable adherence; some clinicians consider 80% as acceptable, whereas others use a 95% benchmark. To a large extent, acceptable adherence rates vary by disease. For example, because poor adherence is linked to increased viral load, those working with HIV patients emphasize 95% to 100% medication adherence. Studies suggest, however, that average adherence among HIV patients is 75%.
Currently, no gold standard exists for measuring adherence. Biological assays, pill counts, weight of topical medications, electronic monitoring, pharmacy records, prescription claims, and patient interviews have all been used to measure adherence, but each is accompanied by methodological disadvantages. Although pill counts are the most common measure employed, studies suggest pill counts underestimate adherence. Patients, for example, may miss a dose, and then double up the dose later on.
Factors Impacting Adherence
Adherence rates are generally higher for patients with acute conditions compared with adherence for those with chronic conditions. Adherence drops significantly after the first 6 months of treatment. For some conditions, the drop comes sooner—up to 50% of patients treated for depression discontinue treatment within the first 3 months of therapy.
Patient characteristics impacting adherence include advanced age, cognitive impairment, depression, substance abuse, asymptomatic disease, belief systems about medications, lack of trust for health care providers, poor literacy, language, religion, socioeconomic level, culture, and race. Hispanics and African Americans, for example, have lower adherence rates compared with Caucasians.
Along with patient characteristics, other factors that impact adherence include poly-pharmacy and medication regimen complexity, lack of immediate treatment effect, high medication costs and co-payments, lack of support systems, adverse effects, and poor communication between provider and patient. Typical reasons cited by patients for not taking medications include forgetfulness (30%), other priorities (16%), a decision to skip a dose (11%), lack of information (9%), and emotional factors (7%). For those 50 years and older who fail to fill a prescription, cost was a factor in 40% of the cases.
A Cochran review concludes that no single strategy exists for improving adherence across all diseases, populations, or settings. Strategies with the strongest evidence include self-monitoring and self-management, simplified dosing, and direct pharmacy involvement. Other strategies, such as reminders, education combined with self-management skills training, counseling, support, and financial incentives, show promise, but current evidence is lacking regarding their effectiveness for improving long-term adherence.12 Electronic medication event monitoring systems are effective, but they are costly and somewhat cumbersome to use.13
Understanding risk factors for non-adherence provides the basis for effective counseling. Predictors of poor adherence include visual problems, inability to open child-proof caps, complex medication regimens, poor understanding of the disease being treated, the impact of the side effect profile, depression, asymptomatic disease, high costs or co-payments, and cognitive impairment.
Researchers are constantly evaluating improved treatments, but in the absence of new treatments, medication adherence has a significant impact on improving patient outcomes. Direct pharmacy involvement definitely improves adherence and patient outcomes. Each patient must be evaluated to understand the barriers preventing the patient from adherence. Multiple strategies work best Highlights useful counseling tips.