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:
- Social/economic
factors - Provider-patient/health
care system factors - Condition-related
factors - Therapy-related
factors - Patient-related
factors
1. SOCIAL AND ECONOMIC DIMENSION
- Limited
English language proficiency - Low
health literacy - Lack
of family or social support network - Unstable
living conditions; homelessness - Burdensome
schedule - Limited
access to health care facilities
- Lack
of health care insurance - Inability
or difficulty accessing pharmacy
9.Medication cost
- Cultural
and lay beliefs about illness and
treatment - Elder
abuse
2. HEALTH CARE SYSTEM DIMENSION
- 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
health care provider and those of the patient - Lack
of positive reinforcement from the health
care 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
3. CONDITION-RELATED DIMENSION
- Chronic
conditions - Lack
of symptoms - Severity
of symptoms - Depression
- Psychotic
disorders - Mental
retardation/developmental disability
4. THERAPY-RELATED DIMENSION
- 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 medication is needed - Expectations
or attitudes toward treatment - Perceived
benefit of treatment - Confidence
in ability to follow treatment
regimen - Motivation
- Fear
of possible adverse effects - Fear
of dependence - Feeling
stigmatized by the disease - Frustration
with health care providers - Psychosocial
stress, anxiety, anger - 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:-
- erroneous/not
faith/falls., because pt may remove
more than one dose - Very expensive
& different devices are needed
for each medication - 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
- Use
Kitchen Table Consults - Improve
Pharmacy Work Flow - Simplify
Patients’ Medications - Identify
Reasons for Medication Non- adherence - 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 card
containing 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 ******
