We know that in the World, up to 50% of medicines in world are not taken as intended and this has also been demonstrated in the USA. Studies have shown that there is a clear relationship between medication adherence and improved outcomes and a recent report suggests that up to £500 m could be potentially saved if adherence was improved in five key health categories. Over the past 10 years, a number of comprehensive reports have been published which describe the many factors that affect medication adherence. There have been many attempts to predict non-adherence in order to allow clinicians to effectively identify patients who need support with medication adherence However, no consistent link between adherence and demographic, socioeconomic or clinical factors has been made.
Pharmacists are experienced in managing practical problems that patients may have about medicines. The evidence base for a behavioral approach to medicines adherence is growing and so are interventions. While all the interventions differ in their approach the four Es have been suggested as overarching principles which can be applied to many of the interventions. In the UK, the Royal Pharmaceutical Society promotes patient-centered communication through the recent Hospital Standards.1 The four Es principles are applicable for pharmacy consultations at admission and discharge from hospital as well as are part of the structured approach of the funded New Medicines Service (NMS), which provides guidance to community pharmacists on undertaking discussion with patients.
This is one of a number of recent headlines that acknowledge the acceptance of adherence as an under-recognized key feature in improving patient outcomes. Adherence, as compared with compliance, is used in this context to describe the fundamental change in the thinking of healthcare professionals, whose awareness of patient involvement in their care is now greater than it ever was. Adherence implies that patients agree to take a medicine/course of action, as compared with compliance where patients ‘do as they are told’. It is worth noting that compliance and adherence are measurable outcomes whereas concordance, which is sometimes used interchangeably with these terms, refers to a process of agreement about a treatment between clinician and patient. As pharmacists we strive to conduct concordant consultations that support medication adherence.
WHY ARE WE INTERESTED ? : We know that in the world, up to 50% of medicines in world are not taken as intended, and this has been demonstrated in other developed countries as well. 4 the costs to patients’ health, as well as to the health economy, are enormous. We know that adverse effects of medicines are implicated in 6–11%5 are due to hospital admissions, over half of which are preventable. However this figure does not account for the hospital admissions that are contributed to by patients taking more or less medication than prescribed. Studies have shown that there is a clear relationship between medication adherence and improved outcomes and a recent report suggests that up to £500 m could be potentially saved if adherence was improved in five key health categories. This applies to treatment as well as prophylaxis—a recent study of breast cancer survivors clearly demonstrated decreased mortality in those who took their hormonal post-treatment therapy as prescribed. While the economic reasons for improving medication adherence are clear, there is also an imperative in the world around patient-centered care and shared decision making. Shared decision making, a process by which a healthcare choice is made jointly by the practitioner and the patient, is central to patient-centered care and both empower patients to make decisions and take responsibility for implementing chosen treatment options. If we are to manage the rising demand for healthcare and the increase in availability of medication and technologies which increase life expectancy, to be effective, this must occur in conjunction with a change in patients’ attitudes to their care. We know that patients want more involvement in their care, as evidenced by the drive towards shared decision making, supported by national guidance. The advent of blogs, such as ‘e-patient dave’, 10 demonstrates the strong desire for patients to work collaboratively with clinicians and others, to optimize their care and support optimal care of others.
WHAT AFFECTS IT? Over the past 10 years, a number of reports and commentaries which describe the many factors that affect medication adherence and potential solutions. Key factors identified in the WHO (2003) report include:
▸ Social and economic factors; for example, age and race, economic status, medication cost,
▸ Cultural values health system and healthcare team-related factors;
▸ Therapy-related factors; for example, length of treatment, complexity of treatment, unwanted side effects,
▸ Condition-related factors for example, comorbidity, level of disability, acuity and severity of the condition,
▸ Patient-related factors for example, forgetfulness, treatment anxiety, misunderstood instructions, and beliefs about medicines such as fear of becoming dependent on medication.
PREDICTORS OF NON-ADHERENCE : There have been many attempts to predict non-adherence in order to allow clinicians to effectively identify patients who need support with medication adherence. As far back as 15 years ago, it was recognized that the factors affecting non-adherence were not reflected in patients’ medication-taking behavior. Clear associations have been established between adherence with regard to drug and dosage form, number of medications, elderly patients’ medication adherence and race, cost of medications, insurance coverage, and physician-patient communication. While there is a clear link between patients’ beliefs about medicines and medication adherence, factors such as patients’ age, sex, socioeconomic status, living arrangement, co-morbidity, number of physician visits and knowledge about health do not independently predict adherence. These data, much of which is evidence based, should help to direct efforts to improve non-adherence in the future.
ROLE OF THE PHARMACIST : Pharmacists are experienced in managing the numerous practical problems that patients may have about medicines. NICE guidance explores issues around necessity and concerns (perceptual issues) as well as ease and convenience of medicine taking (practical issues), referred to as the PAPA approach. The evidence base for a behavioral approach to medicines adherence is growing and interventions such as health coaching, 21 motivational interviewing, cognitive behavioral therapy and others are all being used to support the behavioral aspects of medicines adherence. Recent reviews have suggested promise with some interventions but robust evidence is still lacking. While all the interventions differ in their approach, the four Es26 have been suggested as overarching principles which can be applied to many of the interventions. They include:
▸ Explore what the patient wants to know about their medicines and follow their agenda
▸ Educate patients about what they want to know and check understanding
▸ Empower patients to take ongoing responsibility for medicines taking
▸ Enable behavioral change through discussion of practical issues around medicines taking It is clear from the evidence so far that although no single approach will solve the medicines adherence conundrum, behavioral support is one of a number of key interventions that can be used to work towards an improvement from the 50% of patients who do take their medicines as intended.
▸ Limited English language proficiency
▸ Low health literacy
▸ Lack of family or social support network
▸ unstable living conditions; homelessness
▸ burdensome schedule
▸ Limited access to healthcare facilities
▸ Lack of healthcare insurance
▸ Inability or difficulty accessing pharmacy
▸ Medication cost
▸ Cultural and lay beliefs about illness and treatment
▸ Elder abuse
▸ Provider-patient relationship
▸ Provider communication skills (contributing to lack of patient knowledge or understanding of the treatment regimen)
▸ Disparity between the health beliefs of the healthcare provider and those of the patient
▸ Lack of positive reinforcement from the healthcare provider
▸ Weak capacity of the system to educate patients and provide follow-up
▸ Lack of knowledge on adherence and of effective interventions for improving it
▸ Patient information materials written at too high literacy level
▸ Restricted formularies; changing medications covered on formularies
▸ High drug costs, copayments, or both
▸ Poor access or missed appointments
▸ Long wait times
▸ Lack of continuity of care
▸ chronic conditions
▸ Lack of symptoms
▸ Severity of symptoms ▸ Depression ▸ Psychotic disorders ▸ Mental retardation/developmental disability
▸ Complexity of medication regimen (number of daily doses; number of concurrent medications)
▸ Treatment requires mastery of certain techniques (injections, inhalers)
▸ Duration of therapy
▸ Frequent changes in medication regimen
▸ Lack of immediate benefit of therapy
▸ Medications with social stigma attached to use
▸ Actual or perceived unpleasant side effects
▸ Treatment interferes with lifestyle or requires significant behavioral changes 5. Patient-related dimension
▸ Physical factors
▸ Visual impairment ▸ Hearing impairment
▸ Cognitive impairment ▸ Impaired mobility or dexterity
▸ Swallowing problems
▸ Psychological/Behavioral Factors
▸ Knowledge about disease
▸ Perceived risk/susceptibility to disease
▸ Understanding reason for medication is needed
▸ Expectations or attitudes towards treatment
▸ Perceived benefit of treatment
▸ Confidence in ability to follow treatment regimen
▸ Fear of possible adverse effects
▸ Fear of dependence
▸ Feeling stigmatised by the disease
▸ Frustration with healthcare providers
▸ psychosocial stress, anxiety, anger
▸ Alcohol or substance abuse
PHARMACY IN PRACTICE : The focus of many clinical consultations is around identifying a diagnosis, which will be followed by discussion of treatment options and often, the prescriber-patient consultation will end with a prescription being handed to the patient. It could be surmised that this, for the prescriber, is the physical and psychological end to the consultation which may explain why, apart from time constraints, adherence issues are rarely discussed in a prescribing consultation. In the UK, we have had nearly a decade of experience with pharmacist prescribers and the skills of the pharmacist, combined with the prescribing role are an ideal opportunity to open up conversations with patients to include beliefs about medicines, prior to prescribing. Discussion of adherence issues would seem to be a natural subject for inclusion in a pharmacist-prescriber consultation, however pharmacist training until recently has rarely included support with behavioral change together with exploration of beliefs about medicines. With the introduction of the NMS and Medicines Use Reviews, community pharmacists have an opportunity to support adherence for patients with long-term conditions. The structured approach to consultations provides the pharmacist with guidance on key areas for discussion to support adherence. There are tools to assess adherence that can be used to identify patients at risk, such as the more risky scale and comprehensive online medication adherence support tools are also available. The use of the four Es offers potential for behavioral and practical support around medicines in a short consultation at admission and discharge pharmacy consultations with patients in hospital and to support the structured approach to Medicines Use Reviews and NMS. Indeed these principles can be applied to patient consultations in care homes, patients’ own homes and the general practice setting.
SUPPORT FROM THE MEDICINES USE AND SAFETY:
Medicines Use and Safety teams at East and South-East England Specialist Pharmacy Services have been working to raise awareness of medicines adherence issues among pharmacists. This has included delivery of learning events, publications; contribution to the Department of Health-led national consultation framework and participation in other national adherence events. Ongoing work includes contribution to research around adherence support for patients receiving oral anticancer agents, supporting providers who wish to commission adherence support training and working with community pharmacy and secondary care to promote integration of adherence support skills into clinical pharmacy practice. Future learning events will showcase best and emerging practice in medication adherence, targeted at education leads and clinical pharmacy managers, aiming to encourage attendees to consider what can be done differently in their workplace to improve adherence.
Improving medication adherence has the potential to improve patient outcomes, reduce medicines waste and increase National Health Service return on investment of medicines as part of an overall program of pharmacy support. There are many factors affecting adherence of which some are currently addressed through pharmacy support. In order to address behavioral issues, a change to the pharmacy consultation paradigm is required and this can be achieved through a multifaceted, long-term strategy, working with practitioners, academics and the wider profession to explore new ways of consulting with patients. The Medicines Use and Safety team had developed a strategy to contribute to this aim