Table 14.1 Consequences of poor adherence to prescribed medicine regimens
Reference Reason for medication How adherence Consequences of poor adherence was assessed
Vik et al., 2004 Multiple conditions Unknown 8–11% of hospital admissions in older patients were attributed to poor adherence to medication
Simpson et al., Multiple conditions Unknown Patients with poor adherence to active or 2006 comparing active placebo medication were twice as likely
and placebo to die as patients with good
medication adherence
Kimmel et al., Anticoagulation Percentage of bottle Poorly adherent patients (those with 20% 2007 openings compared with fewer or 10% more bottle openings than
prescribed frequency prescribed) were more than twice as likely to have a subtherapeutic INR, and nearly twice as likely to have a supratherapeutic INR
Hope et al., Congestive cardiac Percentage of prescribed Poor adherence was associated with 2004 failure doses collected from more frequent emergency hospital visits
pharmacy and percentage for cardiovascular disease of bottle openings
compared with prescribedf requency
Ho et al., Diabetes mellitus Percentage of prescribed Poorly adherent patients were 1.6 times 2006a doses collected from more likely to be hospitalised and 1.8
pharmacy times more likely to die than patients with good adherence (defined as those who collected ⬎ 80% of their prescriptions)
Nachega et al., HIV Percentage of prescribed Poor adherence to medication was 2007 doses collected from associated with fewer patients achieving
pharmacy suppression of HIV load. With each 10% increase in prescription collection above 50%, an additional 10% of patients achieve viral load suppression Ho et al., Post-MI Percentage of prescribed Patients who stopped taking aspirin,
2006b doses collected from beta-blockers or statins after an MI were pharmacy nearly 4 times more likely to die than
patients who continued treatment. Rasmussen Post-MI Percentage of prescribed Patients with poor adherence to beta-
et al., 2007 doses collected from blockers or statins were 25% more likely pharmacy to die than patients with good
adherence
No difference was found in mortality between patients with good or poor adherence to calcium channel blockers.
Patient education
Educating patients about their medicines is unlikely to be effective on its own (Schroeder et al., 2004; Haynes et al., 2005) although it has been successful in some patient groups (Clark et al., 2007). Indeed, the traditional model of a pharmacist counselling about medication (without assessing patients’ existing knowledge or desire for information) has been found to alienate patients (Salter et al., 2007). This does not mean that educating patients about their medicine is not important, but it needs to be combined with an attempt to elicit what patients want from their treatment, how their beliefs will affect their medication taking, their current level of understanding, and to help patients decide whether or not to take the recommended medication (RPSGB, 1997).
Multicompartment compliance aids
Multicompartment compliance aids (MCAs) (also known as monitored dosage systems (MDSs)) such as dossett boxes, NOMAD systems
and Medidos, are generally considered to be overused (Nunney and Raynor, 2001). Patients using them often think they would remember their medicines without them, and some have difficulties opening the medicine compartments. This may be because patients are rarely asked which MCA they would prefer (often pharmacies only keep one type of MCA). In addition, using MCAs reduces patients’ knowledge about the medicines they take. However, MCAs do help patients in some groups to remember their medicines and are likely to be beneficial.
Regular contact with health professionals Haynes et al. (2005) argue that maintaining contact between health professionals and patients is likely to be the most effective strategy to improve adherence to medication. This view is supported by Brookhart et al. (2007), who found that patients who had stopped taking their medication after a myocardial infarction were most likely to start taking it again if they had had recent contact with a doctor, and particularly if this was with the prescribing doctor.
How can adherence to medication be improved?
1 4 5
Table 14.2 Examples of interventions that have improved patient adherence
Patient group Successful interventions Reference
Patients with tuberculosis Pharmacist education about medication Clark et al., 2007 Multiple patient groups Medication reminder packaging Heneghan et al., 2006 Patients with hypertension Dispensing medicines in blister pack; pharmacist-led Lee et al., 2006
or hyperlipidaemia education about medicines; regular follow-up with a pharmacist
Multiple patient groups Motivational interviewing Rubak, 2005 Patients with HIV/AIDS Improving practical medication management skills Rueda et al., 2006
with individual patients over at least 12 weeks
Patients with hyperlipidaemia Simplified medication regimens; improved patient Schedlbauer et al., 2004 information and education; reminders
Patients with hypertension Simplifying dosage regimens; medicine reminder Schroeder et al., 2004 charts; social support and family support
Is improving adherence to medication always beneficial to patients?
Health professionals assume that improving patient adherence to medication will be benefi- cial to patients, but this may not always be true. In some cases, increased adherence may have no impact on clinical outcomes, whilst in others it may lead to more adverse effects. For example:
• a pharmacy care programme improved patient adherence to statins, but did not improve lipid control (Lee et al., 2006)
• directly observed therapy for tuberculosis (where patients take three-times weekly doses of medication under health profes- sional observation) and standard therapy (where patients take daily therapy at home) showed no differences in terms of course completion or clearance of tuberculosis infection (Volmink & Garner, 2006)
• patients with gastrointestinal bleeding associ- ated with NSAIDs are more likely to have taken the prescribed dose of NSAID than patients without gastrointestinal bleeding (Wynne & Long, 1996)
• good adherence in clinical trials to medica- tion that was subsequently found to be harmful tripled the risk of death (Simpson et al., 2006).
Simpson et al. (2006) also found that patients with poor adherence to placebo and active medication were both twice as likely to die as patients who had good adherence. This suggests that the positive benefit of good adher- ence to medication is likely to be due to good overall healthy behaviour. Rasmussen et al. (2007), however, found that patients with good adherence to beta-blockers and statins (both known to reduce mortality after a myocardial infarction) had better outcomes than patients with good adherence to calcium channel blockers (medicines for which there is no evidence that they reduce mortality risk after a myocardial infarction). This study suggests that good adherence to effective and safe medica- tion is beneficial irrespective of other health behaviours.
What does concordance mean, in practice, for pharmacists?
So far this chapter has described the different meanings of compliance, adherence and concor- dance, why patients do not adhere to prescribed regimens and the potential consequences of this. In addition, it has introduced some of the interventions that may help patients adhere to their medication. But what does concordance mean, in practice, for pharmacists?
It is clear from multiple studies that the tradi- tional approach to medicine taking, which expects patients to adhere to the prescribed medication regimen, is ineffective. Pharmacists therefore need to adopt a more concordant approach to their interactions with patients. At first glance, it may be difficult to see how the traditional pharmacist role lends itself to concordant consultations. However, every time a pharmacist interacts with a patient they have an opportunity for a concordant consultation. Some of these opportunities, and how they can be used, are described below.
Dispensing medication
When pharmacists dispense medication for patients, they are ideally placed to identify any practical problems that patients might experi- ence with their medicines. Such practical prob- lems could include not knowing when or how to take their medication, and inability to open medicine containers or to read labels. Pharma- cists can ask patients about these issues when dispensing medicines for the first time, and also when patients present with a repeat prescrip- tion. In addition, patients’ understanding of information provided by the doctor can be checked. This can provide patients with an opportunity to ask their pharmacist questions about medicine efficacy or side-effects. When answering such questions, it is important to identify what the patient has been told by the doctor, to avoid giving conflicting information. Pharmacists can also take the opportunity to talk to patients about their expectations for the
medicine and their perspective on whether or not to take the medicine.
Repeat dispensing
Pharmacists are increasingly involved in repeat dispensing systems. In this case, the pharmacist may be the only contact the patient has with a health professional for up to 6 months. It is therefore important that the pharmacist asks simple questions such as, ‘How are you getting on with your medicines?’, to help identify any practical problems the patient may be experi- encing, or symptoms that could be adverse effects of the medication. In addition, pharma- cists can use this opportunity to discuss with the patient whether they are taking the medication as prescribed; if not, why not; and if the level of non-adherence is likely to pose a risk to the patient.
Medicine use reviews
Under the new Pharmacy Contract, pharmacists can provide medicines use reviews (see Box 6.7). These provide an ideal opportunity to sit down with a patient in private and talk with them about their medicines as part of a concordant consultation. This allows pharmacists to iden- tify any problems that a patient is experiencing, talk to them about their understanding of their medicines and why they take (or do not take) them.
Prescribing
Pharmacists can now qualify as supplementary or independent prescribers (see Chapter 2), which provides an ideal opportunity for a concordant consultation. Pharmacists can discuss patients’ health beliefs, and the benefits and risks of the available treatment options, in order to agree with patients their preferred treatment strategy. This can also include anticipating (and resolving) practical problems with treatment, such as administering medication several times a day.
Taking medication histories when patients are admitted to hospital
Hospital pharmacists are increasingly involved in making accurate records of what medications a patient who is admitted to hospital has been taking at home. This is an ideal time for a concor- dant consultation, which can help to inform how the patient is treated throughout their admis- sion. Pharmacists can identify whether patients take their medicine as prescribed, why they may choose to alter the prescribed regimen, what practical difficulties they may experience, and their beliefs about their medicines. This infor- mation can then be used to help doctors agree suitable treatment regimens with patients during the admission, and on discharge from hospital.
Counselling patients about medicines on discharge from hospital
Hospital pharmacists are often involved in medication counselling before patients are discharged home. This provides an opportunity to discuss patients’ beliefs and understanding about their medicines and conditions, their intention to take the medication, and any prac- tical difficulties they may anticipate when they return home.
Developing a concordant approach Pharmacists need to develop new skills in order to have concordant consultations with patients (Weiss, 2004). The skills required at each stage of a concordant consultation are described in Box 14.6. In addition, pharmacists must carefully examine their attitudes to patients and the impact these attitudes could have on a consul- tation. It is important that pharmacists care for, respect and trust the patient (Weiss, 2004). Pharmacists should also be aware of their own values, beliefs, history, needs and culture, and how these can influence interactions with different patients. This awareness should allow