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

  1. Lack
    of health care insurance

  2. Inability
    or difficulty accessing pharmacy 
    9.Medication cost

  1. Cultural
    and lay beliefs about illness and 
    treatment

  2. 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 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 ******

 

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