PATIENT MEDICATION ADHERENCE

PATIENT MEDICATION ADHERENCE

ADHERENCE

Defined by the World Health Organization as ‘the extent to which a person's behavior [in] taking medication...corresponds with agreed recommendations from a health care provider’

- World Health Organization

•       The Term COMPLIANCE has come into disfavor because it suggests that a person is passively following a doctor's orders, rather than actively collaborating in the treatment process.

•       Adherence, on the other hand, requires the person’s agreement to the recommendations for therapy.

•       PERSISTENCE is defined as the ability of a person to continue taking medications for the intended course of therapy.

•       In the case of chronic diseases, the appropriate course of therapy may be months, years, or even the person's lifetime.

•       A person is classified as non-persistent if he or she never fills a prescription or stops taking a prescription prematurely.

•       Discussing the intended course of therapy when medications are first started has been shown to be an important factor in keeping people persistent with a medication regimen.

Adherence is a multidimensional phenomenon determined by the interplay of five sets of factors, termed "dimensions" by the World Health Organization:

1. Social/economic factors
2. Provider-patient/health care system factors
3. Condition-related factors
4. Therapy-related factors
5. Patient-related factors

1. SOCIAL AND ECONOMIC DIMENSION

1. Limited English language proficiency
2. Low health literacy
3. Lack of family or social support network
4. Unstable living conditions; homelessness
5. Burdensome schedule
6. Limited access to health care facilities

7. Lack of health care insurance
8. Inability or difficulty accessing pharmacy  9.Medication cost

10. Cultural and lay beliefs about illness and  treatment
11. Elder abuse

2. HEALTH CARE SYSTEM DIMENSION

1. Provider-patient relationship
2. Provider communication skills (contributing  to lack of patient knowledge or understanding  of the treatment regimen)
3. Disparity between the health beliefs of the  health care provider and those of the patient
4. Lack of positive reinforcement from the health  care provider
5. Weak capacity of the system to educate  patients and provide follow-up
6. Lack of knowledge on adherence and of  effective interventions for improving it
7. Patient information materials written at too  high literacy level
8. Restricted formularies; changing medications  covered on formularies
9. High drug costs, copayments, or both 
10. Poor access or missed appointments 
11. Long wait times
12. Lack of continuity of care

3. CONDITION-RELATED DIMENSION

1. Chronic conditions
2. Lack of symptoms
3. Severity of symptoms
4. Depression
5. Psychotic disorders
6. Mental retardation/developmental disability

4. THERAPY-RELATED DIMENSION

1. Complexity of medication regimen (number of  daily doses; number of concurrent medications)
2. Treatment requires mastery of certain techniques  (injections, inhalers)
3. Duration of therapy
4. Frequent changes in medication regimen
5. Lack of immediate benefit of therapy
6. Medications with social stigma attached to use
7. Actual or perceived unpleasant side effects 
8. Treatment interferes with lifestyle or requires significant behavioral changes

5. PATIENT-RELATED DIMENSION

PHYSICAL FACTORS:

1. Visual impairment
2. Hearing impairment
3. Cognitive impairment
4. Impaired mobility or dexterity
5. Swallowing problems

Psychological/Behavioral Factors:

1. Knowledge about disease
2. Perceived risk/susceptibility to disease
3. Understanding reason medication is needed
4. Expectations or attitudes toward treatment
5. Perceived benefit of treatment
6. Confidence in ability to follow treatment  regimen
7. Motivation
8. Fear of possible adverse effects 
9. Fear of dependence
10. Feeling stigmatized by the disease 
11. Frustration with health care providers 
12. Psychosocial stress, anxiety, anger 
13. Alcohol or substance abuse

MEASURING ADHERENCE

There are several ways to measure medication adherence.

1. Medication event monitoring systems (MEMS):-

These are the most accurate method of measuring adherence because they record the date and time the medication bottle was opened through microprocessor technology embedded in the cap.

Advantages with microprocessor:-

1. erroneous/not faith/falls., because pt may  remove more than one dose
2. Very expensive & different devices are needed  for each medication
3. Therefore it is an impractical way to determine adherence in clinical practice.

2. Patient self-reports is easiest method when adherence is being assessed, open-ended questions should be asked.

Instead of asking, “Are you taking your medications?” the HCP should phrase the question along the lines of, “How many times in the past week (month) have you skipped your medications?”

3. Pill counts

4. Pharmacy databases or refill rates, and 

5. Blood levels which also are employed in research, are more feasible options for clinical practice

6. Morisky’s Medication Adherence Scale (MMAS) It was designed to distinguish poorly adherent patients from those with medium- to-high adherence to their antihypertensive regimen

MMAS consists of questions addressing multiple reasons for non-adherence..

e.g., because regimen complexity can lead to noncompliance.

The scale contains a question assessing whether the patient feels hassled (trouble/Tense) about his or her regimen

•       Since patients tend to give their HCPs positive answers to please them, the questions in Morisky’s study were phrased to avoid this bias.

•       Each question measures a specific medication- taking behavior rather than adherence or compliance behavior.

Methods Can Improve Medication Adherence by Pharmacists

1. Use Kitchen Table Consults
2. Improve Pharmacy Work Flow
3. Simplify Patients’ Medications
4. Identify Reasons for Medication Non-  adherence
5. Ask Patients Specific Questions About Their  Medication

ROLE OF THE PHARMACIST

•       While medication dispensing is the best- known function of the pharmacist,

•       Pharmacists—through counseling, medication therapy management (MTM), disease-state management, and other means—can play a pivotal role in patient care.

•       There are opportunities in every type of pharmacy practice to improve patients’ adherence and therapeutic outcomes, and pharmacists must embrace and act on them.

1. Patient Education

2. Dosing simplification and minimization of adverse effects are extremely successful strategies for improving adherence.

3. Preparing a dosing cardcontaining only the most essential elements of the patient’s medications can be highly beneficial

•       It can be extremely helpful for patients who take many medications or who have cognitive barriers.

Dosing cards

4. Reminder calls, texts, or e-mails are helpful for many patients, especially those with busy lifestyles. Automatic refills are a useful strategy

•       Whatever the barriers to adherence may be, the only way to assess them is to talk to the patient.

•       The pharmacist needs to be diligent (pay attention) about including the patient in the treatment experience.

•       The more trust the patient has in the pharmacist, the more he or she will open up and disclose any apprehensions or difficulties about taking his or her medication. Only then can the pharmacist play an integral role in improving a patient’s adherence.

•       Dim. Of Med. Adh

•       Diff Med. Adh, compl and per.

•       Meth. for measuring Med. Adh.

•       Role of Pharmacist ******

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