Adherence [Compatibility Mode]

8/18/2019 Adherence [Compatibility Mode]

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OptimizingAdherence to

Pharmaceutical Care

Plans

Introduction

• Medication non adherence remains amajor problem.

• National Council on Patient Informationand Education(NCPIE) has aptly termednoncompliance "merica!s other druproblem.#

• $ou ha%e to assess and treatadherence& related problems thatcan ad%ersely a'ect patients! health

outcomes.


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••

Defnition and Scopeo the

Problem

• Medication non adherence is mostsimply dened as the number of dosesnot taen or taen incorrectly that

jeopardi*es the patient!s therapeuticoutcome.

Cont’d• Non adherence can tae a %ariety of

forms includin+,. Not ha%in a prescription lled-

. /ain an incorrect dose-

0. /ain a medication at the 1ron

time-

2. 3orettin to tae doses- or

4. 5toppin therapy too soon


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Cont’d

• Compliance oriinates from apractitioner& centered paradim andis more control oriented.

• It relies on patient obedience and

sometimes stimati*es the patient asenain in de%iant beha%ior if anothercourse of action is chosen.

• patient&centered approach is one in1hich the pharmacist enaespatients to become more acti%e in thecontinuum of decision main abouttheir therapy.

Cont’d

• Poorer health outcomes may also result1hen a patient does not adhere to+

,. 6ecommended lifestyle chanes-such as e7ercise or smoincessation- or

. Prescribed non pharmacoloicinter%entions- such as physical therapy or

dietary plans.


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Cont’d

• Chronic diseases counselin such asasthma- hypertension need to assessand promote adherence to these nonpharmacoloic treatments as 1ell.

• Non adherence is a no1n also as"in%isible epidemic.#

Cont’d

• Non adherence rates are hih amonpatients 1ith chronic diseases.

• /hese patients often must maesinicant beha%ioral chanes toadhere 1ith therapy.

• Chanes can be di8cult tointerate into e%eryday life.


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44

Cont’d

• Non adherence can lead

to+

,. 9ecrease producti%ity-

. Increase disease

morbidity-0. Increase physician

o8ce %isits-

2. :ospital re;or&

admissions- and

4. 9eath.

<

Cont’d

• 3or e7ample- an estimated ,4-===deaths per year ha%e been attributed tonon adherence to treatment forcardio%ascular disease.

• Non adherence places a hue burdenon the patient and o%ernmenteconomy.

• Pharmacies also lose re%enue becausepatients often fail to rell prescriptionmedications- especially for chronic


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Cont’d

• 3or pharmacists the

messae is clear+

,. /o impro%e adherence topharmacotherapy- and

. Impro%e health outcomes-• $ou must assess each patient

indi%idually- then pro%ide taretedinter%entions that are responsi%e tohis or her uni>ue ris factors andneeds.

Cont’dComprehensio

n

Patient

Belies, alues, AttitudesS!ills and "illingness to

perorm

A In the patient-centered adherence paradigm, the pharmacist integrates information About a patient’s medication use from three perspective:the patient’s Knowledge of the medication(comprehension); the patient’s beliefs and

Attitudes toward his or her illness and itstreatment ( beliefs, values, and attitudes); And the

patient’s abilit and motivation to follow theregimen (s!ills and willingness to perform)"


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#on adherence as aBeha$ioral

Disorder

• Non adherence has been

studied 1idely by

beha%ioral scientists in an attempt to e7plain

and predict non adherence.

• Numerous ris factors for nonadherence ha%e been identied.

%&ample Clearly- non adherence is a multi

factorial problem- and a host ofcontributin social- economic-medical- and beha%ioral factors ha%ebeen identied.


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'a(or )is! *actors or#on

Adherenc

e,. symptomatic

conditions

. Chronic conditions

0. Coniti%e impairments-especially foretfulness

2. Comple7 reimens

4. Multiple daily doses

?. Patient fears and concernsrelated to medication e'ects

@. Poor communication

Cont’d• %ariety of direct and indirect

methods are a%ailable to assess thepresence and se%erity of nonadherence.

• E'ecti%e inter%entions are a%ailableto treat non adherence.

• Many cases of non adherence can betreated 1ith carefully selectedinter%entions.

• 5ome cases may not be resol%abledespite the best e'orts of health carepro%iders.


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Cont’d

• Most chronic medical conditionsre>uire periodic ree%aluation andtherapeutic adjustments.

• Patients 1ith adherence problems alsoshould be reassessed on a reular basis.

AssessingAdherence

• Pharmacists need to e%aluate ho11ell a patient is adherin topharmacotherapy and identify risfactors that may predispose theindi%idual to non adherence.

• Aoth direct and indirectmethods are a%ailable to assessadherence.


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Direct'ethods

• It can include blood&le%el monitorinand urine assay for themeasurement of dru metabolites ormarer compounds.

• Collectin blood or urine samples canbe e7pensi%e and incon%enient forpatients- and- moreo%er- only a limitednumber of drus

can be monitored in this 1ay.

Cont’d

• /he bioa%ailability and completenessof absorption of %arious drus- as 1ellas the rate of metabolism ande7cretion- are factors that mae itdi8cult to correlate dru le%els inblood or urine 1ith adherence.

• It depends on the accuracy of the testand the deree to 1hich the patient 1as

non adherent before test 1as taen.


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Indirect'ethods

• Patient inter%ie1s- pill counts- rellrecords- and measurement of healthoutcomes.

• /he inter%ie1 is ine7pensi%e

• It allo1s the pharmacist to sho1concern for the patient and pro%ideimmediate feedbac.

• dra1bac of this method includeo%erestimate adherence- accuracy andinter%ie1 correct interpretation ofresponses.

Cont’d

• Pill counts pro%ide an objecti%emeasure of the >uantity of dru taeno%er a i%en time period.

• It is time&consumin andassumes that medication not inthe container 1as consumed.


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Cont’d

• /he rell record pro%ides anobjecti%e measure of >uantitiesobtained at i%en inter%als

• It assumes that the patient obtained

the medication only from therecorded source.

• Inter%ie1in patients to detect nonadherence is most e'ecti%e 1henindirect probes are used.

Cont’d

• Pharmacists can obtain reliableinformation from patient or a familymember or carei%er.


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22

Probes PharmacistsCan +se to AssessAdherence

• ssessin the patient!s medicationno1lede or medication&tainbeha%ior+

,. Bhat is the reason you are tain this

dru

. :o1 do you tae this medication0. re you tain the medication 1ith

food or Duid

2. Bhere did you recei%e informationabout this medication

4. re you tain nonprescription drus1hile on this medication

Cont’d

?. 9o you use any memory aids tohelp you remember to tae yourmedication

@. 9o you depend on anyone to helpyou remember to tae yourmedication or to assist you intain it


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Cont’d

• ssessin attitudes- %alues- andbeliefs reardin medication&tain beha%iors

,. Bhat results do you e7pect to etfrom this medication

. Bhat are the chief problems that youfeel your illness has caused you 9o youha%e any concerns about your illnessand its treatment

0. re you satised 1ith your currenttreatment plan

2. :o1 1ell do you usually follo1 atreatment plan

Cont’d

4. Bhat is the main concern you ha%eabout your medication

?. 9o you feel comfortable asinyour physician or pharmacist>uestions about your medications

@. Bhat is the main concern you ha%eabout your medication

. 9o you feel comfortable asin

your physician or pharmacist>uestions about your medications


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Cont’d

• ssessin 1hether the patient has theproper sills and is moti%ated or 1illinto follo1 throuh on the therapy plan.

,. :a%e you encountered any problems1ith your medication& or pill&tain

procedure. re you condent that you can follo1

your treatment plan

0. Bhat miht pre%ent you fromfollo1in the recommended treatmentplan

Cont’d

2. :o1 liely is it that you 1ill asyour physician or pharmacistabout your medications

4. Can you e7plain ho1 you remindyourself to tae your medication onschedule

?. 9o you normally 1rite do1n>uestions to as your physician orpharmacist before an appointment


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Cont’d

• 3actors that promote

adherence+

,. 9isease&related

factors

. Percei%ed or actualse%erity of illness

0. Percei%ed susceptibility to thedisease or de%elopincomplications

2. /reatment&related factors

*actors that

Promote

Adherence

• 9isease&related factors+

,. Percei%ed or actual se%erity

of illness

. Percei%ed susceptibility to thedisease or de%elopincomplications

0. /reatment&related factors

2. Percei%ed benets of therapy

4. Britten and %erbal instructions


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,,

22

,,

Cont’d

• Patient&related factors

,. Food communication andsatisfactory relationship 1ithphysician

. Participation in de%isin the

treatment plan

0. Condence in the physician- thedianosis- and the treatment

2. 5upport of family members and friends

4. Gno1lede about the illness

*actors that)educe

Adherence• 9isease&related factors

,. Chronic disease

. Hac of symptoms


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,,

,,

Cont’d

• /reatment&related

factors

,. /reatment re>uires sinicantbeha%ioral chanes

. ctual or percei%ed unpleasant side

e'ects

0. 6eimen comple7ity and duration

2. Medication taes time to tae e'ect

Cont’d

• Patient&related factors,. 5ensory or coniti%e

impairments

. Physical disability or lac

of mobility

0. Hac of social support

2. Educational deciencies

(literacy problem)

or poor Enlish Duency


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••

••

Cont’d

• 3ailure to reconi*e

the need for medication

• :ealth is a lo1 priority

• ConDictin health

beliefs

• Economic problems

• Neati%e e7pectations or attitudesto1ard treatment

Designing Patient*ocused

Inter$entions or #on

adherence

• /o impro%e adherence you shouldidentify factors and causes of nonadherence.

• It should be tailored to the indi%idualpatient.


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%&ample

• foretful patient may benet from aspecial pacae or container thatpro%ides a %isual reminder that amedication 1as taen (for e7ample-blister pacain or a computer& aidedcompliance pacae).

• 3oretful patients also can be ad%isedto tae dosaes in conjunction 1ithother routine daily acti%ities- such as atmealtimes or before tooth brushin.

Cont’d

• 6ell reminders or automatic deli%eryto the home also can be %aluable forthe foretful patient- as cansimplication of the dosae schedule-such as chanin to a once&dailyprescription.


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Cont’d

• 3ollo1&up is important to no1 ho1 1ellthe plan is 1orin and 1hetherchanes are needed.

• Plan should also be ree%aluated from

time to time to assess its e'ecti%enessand determine ho1 1ell it meetspatient e7pectations.

Cont’d

• Identifyin and measurin theoutcomes of a pharmaceutical careadherence plan is also important.

• bjecti%e measures of impro%ed healthstatus and;or reduced health caree7penditures document success in a1ell&desined pharmaceutical care plan.


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Strategies or%nhancing

Adherenc

e

• Promote self&e8cacy+

,. Encourae patients to assume anacti%e role in their o1n treatmentplans.

. Mae patient condent.

0. In%ol%in patients in decisions abouttheir care.

• Empo1er patients to becomeinformed medication consumers+

focus on educatin for patient-family members and carei%ers.

Cont’d

Pro%ide both 1ritten and oralinformation to such as+

,. Bhat is the disease

. Bhich treatments ha%e beenprescribed or recommended and1hy

0. Bhat is the patient!s role inmanain the disease

2. Bhich treatments ha%e beenprescribed or recommended and1hy


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Cont’d

4. Bhat is the patient!s role inmanain the disease

?. Bhich ad%erse e'ects may occur

@. Perhaps surprisinly- the amount of

factual information that a patient hasabout his or her medication is nothihly correlated 1ith adherentbeha%ior.

Cont’d

• %oid fear tactics.

5carin patients or i%in them dire1arnins about the conse>uences ofless&than&perfect adherence canbacre and may actually 1orsenadherence.

more constructi%e approach is tohelp the patient focus on 1ays tointerate medication tain into his or

her daily routine.


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Cont’d

• :elp the patient to de%elop a list ofshort& term and lon&term oals.

6ealistic- achie%able- and

indi%iduali*ed.

Encourae constructi%e beha%iors-such as ettin more e7ercise orbeinnin a smoin cessationproram.

Cont’d

• Plan for reular follo1&up.

Interact 1ith the patient

at reular.


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Cont’d

• /he plan should be adapted to thepatient!s lifestyle and be ree%aluatedfrom time to time.

• /ime for counselin on adherence

should be separated from thedispensin and pic&up functions.

Cont’d

• Implement a re1ard

system.

Fi%in prescription coupons or specicproduct discounts for successfullyreachin a oal in the treatment plancan help to increase adherence-particularly in patients 1ith lo1moti%ation.


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Adherence [Compatibility Mode]

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