7. Medication adherence of pharmacy practice
- 2. Adherence Concordance Compliance Tocomplete an action, transaction, or process and to fulfil a promise Following of instructions given by prescribers The prescriber and patient come to an agreement about the regimen patients’ views on medication-taking behaviour Persistence The ability of a person to continue taking medications for the intended course of therapy. Patient participation in treatment as a shared decision-making process.The patient is under no compulsion to accept a particular treatment
- 3. Despite the ongoing debate, adherence has been the preferred term for: • World Health Organization (WHO) • American Pharmacists Association (APA) • U.S. National Institutes of Health (NIH) “The extent to which a person’s behavior in .. taking medication, following a diet, or executing lifestyle changes .. corresponds with agreed recommendations from a health care provider” (WHO,2003)
- 4. IMPACT OF MEDICATION NON- ADHERENCE Disease progression and complications Increased health care costs Decreased quality of life Hospitals and long- term care admissions Patient’s Death
- 6. At ris k Symptom s Diagnosi s Early treatment Continue treatment Does not attend/ delays asymptomatic screening Delays or Doesn’t seek help Reluctant to accept diagnosis Reluctant to start treatment Does not follow courses as prescribed PATIENTS’ BEHAVIOR TOWARDS APPOINTMENTS AND TREATMENTS
- 7. REASONS FOR MEDICATION NON-ADHERENCE 1.Intentional medication non-adherence Decision is made by the patient to not use treatment or follow treatment recommendations 2.Unintentional medication non-adherence Unplanned behavior and is less strongly associated with beliefs, may be the result of Ho, P., Bryson, C., , & Rumsfeld, J. (2009). Medication adherence: Its importance in cardiovascular Outcomes.
- 8. Why patients have difficulty with treatment? 1. Socio-economic related 2. Patient related 3.Therapy related 4. Condition related 5. Healthcare system related
- 9. 1. Language barrier 2. Lack of family or social support network 3. Unstable living conditions; homelessness 4. Limited access to health care facilities 5. Lack of health care insurance 6. Inability or difficulty accessing pharmacy 7. Medication cost 8. Cultural and lay beliefs about illness and treatment 1. SOCIAL AND ECONOMIC DIMENSION
- 10. 2. PATIENT-RELATED DIMENSION Physical factors 1. Visual impairment 2. Hearing impairment 3. Cognitive impairment 4. Impaired mobility 5. Swallowing problems Psychological/behavioral factors 1. Knowledge about disease 2. Understanding reason medication is needed 3. Expectations or attitudes toward treatment 4. Perceived benefit of treatment 5. Confidence in ability to follow treatment 6. Fear of possible adverse effects or dependence 7. Frustration with health care providers 8. Motivation
- 11. 1. Complexity of medication regimen • (number of daily doses; number of concurrent medications) 2. Treatment requires mastery of certain techniques (injections,inhalers) 3. Treatment interferes with lifestyle or requires significant behavioral changes 4. Duration of therapy 5. Frequent changes in medication regimen 6. Lack of immediate benefit of therapy 7. Side effects 3. THERAPY-RELATED DIMENSION
- 12. 1. Chronic conditions 2. Lack of symptoms 3. Severity of symptoms 4. Depression 5. Psychotic disorders 6. Mental retardation/developmental disability 4. CONDITION-RELATED DIMENSION
- 13. 1. Provider-patient relationship and communication skills 2. Lack of positive reinforcement from the health care provider 3. Weak capacity to educate patients and provide follow-up 4. Patient information materials written at too high literacy level 5. Lack of knowledge on adherence and of effective interventions for improving it 6. Restricted formularies; changing medications covered on formularies 7. Poor system or missed appointments, long wait times 8. Lack of continuity of care 5. HEALTH CARE SYSTEM DIMENSION
- 15. • Directly observed therapy • Most accurate • Patients can hide pills in the mouth • Measurement of the level of medicine or metabolite in blood • Variations in metabolism and “white coatadherence” can give a false impression of adherence • Expensive DIRECT METHODS
- 16. INDIRECT METHODS • Patient questionnaires • Pill counts • Rates of prescription refills • Assessment of the patient’s clinical response or marker • Electronic medication monitors • Simple and inexpensive • Results are easily distorted by the patient • Data easily altered by the patient • Prescription refill is not equivalentto ingestion of medication • Inaccurate, many factors can affect clinical response. • Tracks patterns of taking drugs • Expensive
- 17. MEDICATION EVENT MONITORING SYSTEMS (MEMS) – TRACK-CAP 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. • Impractical way to determine adherence in clinical practice 1. Easily manipulated (patient may remove more than one dose, open more than once) 2. Very expensive & different devices are needed for each medication. 3. Inaccurate
- 18. Measures Equations Medication Possession Ratio (MPR) Days’ supply obtained/refill interval or fixed interval Dichotomous variable (arbitrary cutoff value) Continuous, Multiple Interval Measure of Medication Acquisition(CMA) Cumulative days’ supply obtained over a series of intervals/total days from the beginning to the end of the time period Continuous, Multiple Interval Measureof Medication Gaps (CMG) Cumulative days without any medication over a series of intervals/total days from the beginning to the end of the time period Continuous, Single Interval Measureof Medication Acquisition(CSA) Days’ supply obtained in each interval/total days in the interval Continuous, Single Interval Measureof Medication Gaps (CSG) Number of days without any medication/total days in the interval Pill count (Number of dosage units dispensed − number of dosage units remained)/(prescribed number of dosage unit per day × number of days between 2 visits) Equations of medication adherence measures involving secondary database analysis and pill count
- 19. Questionnaire and scales Target population(s) Advantages Disadvantage(s) Brief Medication Questionnaire Diabetes Depression Self-administration Evaluate multidrug regimes Reduce practitioner’s training Time-consuming Hill-Bone ComplianceScale (Hill-Bone) Hypertension specific, black patients High internal consistency in both primary and outpatient setting Limited generalizability 8-item Morisky Medication Adherence Scale (MMAS-8) All validated conditions Higher validity and reliability in patients with chronic diseases than MAQ MedicationAdherence Questionnaire (MAQ) All validated conditions Quickest to administer Validated in the broadest range of diseases Validated in patients with low literacy Comparatively short, mainly suitable for initial screening The Self-Efficacy for Appropriate MedicationUse Scale (SEAMS) All validated chronic conditions High internal consistency in patients with high or low literacy Time-consuming MedicationAdherence Report Scale (MARS) Chronic mental illness, especially with schizophrenia Simplistic scoring Strong positive correlations compared to DAI and Limited generalizability Summary of self-report questionnaire and scales
- 20. IMPROVING MEDICATION ADHERENCE Intentional nonadherence Unintentional nonadherence Long-termTreatments Short-termTreatments Elderly Several interventions have been reported in the literature to improve nonadherence
- 21. ASSESSMENT Assess all medications INDIVIDUALIZATION Individualize the regimen DOCUMENTATION Provide written communication EDUCATION Provide accurate and continuing education tailored to the needs of the individual A I D E S SUPERVISION Provide continuing supervision of the regimen Bergman-Evans B. AIDES to improving medication adherencein older adults. Geriatr Nurs 2006; 27: 174–82 Adherence in older adults
- 22. INTENTIONAL AND UNINTENTIONAL NONADHERENCE • Unintentional nonadherence – Technology (Mobile apps) – Simplification of regimen – Drug packages – Proper counseling Directing Supporting Motivational interviewing • Motivational interviewing for improving intentional nonadherence – Method used to explore the reasons for barriers to medication intake – Intended to stimulate behavioral change. – Increasing knowledge about the disease and its treatment – Explore patient concerns or fears about potential side effects – Motivate them to resolve their problems and prevent future intake problems. Encouragin g Advising
- 24. • The best known function of the pharmacist is (Medication Dispensing) BUT • Pharmacists through patient counseling, medication therapy management, disease management, have important role in patient care. • As social pharmacy links clinical pharmacy, basic sciences and social sciences, pharmacy practice able to improve patients’ adherence and therapeutic outcomes • Enhancing pharmacist-prescriber and pharmacist-patient communication can lead to significant breakthroughs in adherence
- 25. PHARMACIST-PRESCRIBER RELATIONSHIP • Pharmacists collaborate with providers in: – Community settings – Ambulatory settings – Hospital settings. • Prescriber acceptance rates vary greatly between patient care settings
- 26. • Ambulatory care and inpatient pharmacist medication recommendations are well-received (acceptance rates by physicians ranging 70-90%) • Community pharmacist recommendations have lower acceptance rates ranging from 42-60% • Community pharmacist is vital for improving and monitoring adherence: – Accessible to patients – Direct insight into prescription histories Michaels NM, Jenkins GF, Pruss, DL, et al. Retrospective analysis of community pharmacists' recommendations in the North Carolina Medicaid medication therapy management program. J Am Pharm Assoc (2003). 2010 May-Jun;50(3):347-53.
- 27. • Identify the patient’s concerns • patient’s preferences • Explain the treatment options • Involve patients in decisions Basic Communication Condition-specific intervention • One size doesn’t fit all. • Adjust drugs timing and dosage • Minimize adverse effects • Provide support, encouragement and follow- up • Epilepsy, DM, HTN,Cancer, Asthma Evaluating Adherence • Ask about problems with drugs • Ask specifically about missed doses • Ask about thoughts of discontinuation Reminding • Written instructions, drawings, and illustrations • Pill boxes • Reminders via email or telephone
- 28. • Self-management includes a psychomotor skill such as administering a shot or using an inhaler • Self-management needs to be supported by healthcare providers • The patient need to be competent to get the benefit . • Demonstrations, written instructions,illustrations. • Praise & positive feedback a pharmacist gives to the patient as new skills are return demonstrated. Self Management Support
- 29. POLYPHARMACY • Use of multiple medications. • Complex dosing schemes. • Changes in drug regimens that occur during hospitalization. • Cognitive and functional impairment associated with aging. • The need to manage potential drug-drug interactions.