Patient Medication Adherence and the Health Outcome

 

Juveriya Fatima¹*, Safa Mohammed Sadiq¹, Saniya Ahmed¹, Rana Khan¹,

Mohammed Nayeem Uddin²

¹II Year Pharm. D, Nizam Institute of Pharmacy, Deshmukhi (V), Pochampally (M), Behind Mount Opera, Yadadri (Dist)-508284, Telangana, India.

²Asst. Professor, Department of Pharmacology and Pharmacy Practice, Nizam Institute of Pharmacy, Deshmukhi (V), Pochampally (M), Behind Mount Opera, Yadadri (Dist)-508284, Telangana, India.

 

ABSTRACT:

Adherence to therapies is a primary determinant of treatment. Quality health care outcomes depend upon patient’s adherence to recommended treatment regimens. Failure to adherence is a serious problem which not only affects the patient but also the health care system. Medication non-adherence in patient leads to substantial worsening of disease, increased health care costs and death. More than 40% of patient’s significant risks by misunderstanding, forgetting or ignoring health care advice. A variety of factors are likely to affect adherence. Barriers to adherence could be patient, provider and health system factors. Adherence is a multidimensional phenomenon determined by interaction of five sets of factors i.e Socio-economic, Health care/ system related, Disease/condition related, Therapy related, Patient related. Health care professionals such as physicians, pharmacists and nurses have significant role in their daily practice to improve patient medication adherence.

 

 

 

INTRODUCTION:

The word ‘compliance’ comes from the Latin word complire, meaning to fill up and hence to complete an action, to fulfill a promise. In the oxford English dictionary the relevant definition is the acting in accordance with desire, request, condition etc., in this context it means acting in accordance with advice given by prescriber, but the modern attitude to the world is that it betrays a paternalistic attitude towards the patient⁵.
For this reason, the idea of concordance was introduced, implying that the prescriber and patient should come to an agreement about the regimen that the patient will take.

 

Concordance also carries the Illichian implication that patients should take greater responsibility for their management, even though not all are willing to do that. The relevant meaning of concordance in the OED is ‘The fact of agreeing or being concordant; agreement, harmony’. But another meaning of compliance in the OED is Accord, concord, agreement; amicable relations which mean exactly the same as concordance².

 

Now the term ‘adherence’ is generally preferred and increasingly used. It comes from the latin word adhaerere, which means to cling to, keep close, or remain constant. In the OED it is defined as ‘Persistence in practice or tenet; steady observance or maintenance’, a definition that appropriately conjures up the tenacity that patient needs to achieve in sticking to a therapeutic regimen¹.

 

Medication adherence is defined by the World Health Organization as the degree to which “the person’s behavior corresponds with the agreed recommendations from a health care provider”.¹ though the terms adherence and compliance are synonymously used adherence differs from compliance. Compliance is the extent to which a patient’s behavior matches the prescribers advice.² compliance implies patients obedience to the physician’s authority,^3-5  whereas adherence signifies that the patient and physician collaborate to improve the patient’s health by integrating the physician’s medical opinion and the patient’s life style, value and preferences for care.^6-8

 

In 2003 report on medication adherence,⁹ the World Health Organization [WHO] quoted the statement by Haynes et al that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”. Among patients with chronic illness approximately 50% do not take medications as prescribed.^9,10 this poor adherence to medication leaders to increased morbidity and death and is estimated to incur costs of approximately $100 billion per year.¹¹ Adherence has gained popularity as an alternative descriptor because it implies a more reciprocal dynamic in the doctor patient relationship and recognizes salient influences on medication- taking behavior.^12,13,14 Patient adherence has substantial implications in preventative medicine and treatment of chronic disease. It is a key component of successful medical management; an understanding of patient adherence and its modulating factors is crucial to interpreting treatment efficacy and barriers to therapeutic success. Adherence is the fundamental link between intent outcomes of medical care.¹⁵ Studies have shown that in the united states alone, non adherence to medication causes 125,000 deaths annually and accounts for about 10% to 25% of hospital and nursing admissions.¹⁶ there are several types of non adherence but most often the categorization is indisputable, and there is a degree of overlap¹⁵.

 

TYPES OF NON ADHERENCE:

Primary non adherence / non fulfillment adherence: Medication is never filled or initiated.

 

Secondary non adherence / persistence:

Patient stops taking medication after starting it, without being advised by a health professional to do so. It is rarely intentional. Unintentional non adherence arises from capacity and resource limitation¹⁸.

 

Non-conforming:

it includes variety of ways in which medication are not taken as prescribed, such as skipping doses, incorrect dose or frequency, or even taking more dose than prescribed. The consequence of non-adherence is waste of medication, disease progression, reduced functional abilities, A lower quality of life, increased use of medical resources such as nursing homes, hospital visits and hospital admissions. Economic studies reveal that poor regimens to prescribed regimens can result in serious health consequence which is supported by various studies. For instance in a study conducted by Anon, it was shown that the risk of hospitalization was more than double in patients with diabetes mellitus, hypercholesterolemia, hypertension or congestive heart failure who were non adherent to prescribed therapies compared with a general population.¹⁷ Studies conducted among Chronic Obstructive Pulmonary Disease patients have shown that poor adherence to drug therapy and disease management leads to emergency hospitalization.¹⁸ Rate of adherence is usually reported as the percentage of the prescribed dosage of medication actually taken by the patient over a specified period.¹⁹the extent of non-adherence varies widely, and in different studies it has been recorded as low as 10% and as high as 92%.¹⁹ extensive review of literature reveal that in developed countries adherence to therapies averages 50%.²⁰

 

METHODS:

The MEDLINE database literature search limited to English - non – English language articles published between January 1, 1990 and March 31, 2010, using the following search terms: cardiovascular disease, health literacy, medication adherence and pharmacotherapy was conducted. We identified original studies by searching MEDLINE 1990-2002 through Ovid with the MeSH heading “patient compliance” or “treatment refusal” and at least one of the following keywords: “inversion studies,” “prospective studies”, “outcome assessment,” “patient’s education”, “health promotion” and “patient’s dropout.” Bibliographies of relevant articles were searched to identify studies that might have been missed in the review⁷.

 

Methods to measure adherence:

Various methods have been reported and are in use. The methods available can be broken down into direct and direct methods of measurement.

 

DIRECT METHOD:

It includes direct observed therapy, measurement of the level of a drug or its metabolite in blood or urine and detection or measurement of a biological marker added to a drug formulation, in the blood. Direct approaches are one of the most accurate methods of measuring adherence but are expensive. Moreover, variations in metabolism and “white coat adherence” can give a false impression of adherence.²¹

INDIRECT METHOD:

It includes patient questionnaires, patient self reports, pill counts, rates of prescription refills, assessment of patient’s clinical response, electronic medication monitors.

 

Each method has its own advantages and disadvantages and no method is considered as the gold standards.^{22, 23} the simplest way of measuring adherence is from the patient’s self-report.^{19, 20}

 

Rates of refilling prescriptions are an accurate measure of overall adherence in a closed pharmacy system (health maintenance organization countries with universal drug coverage) since refills are measured at several points in that time.^{21, 23}

 

GENERAL ASPECTS OF MEDICATION ADHERENCE:

Medication taking behavior is extremely complex and individual, requiring numerous multifactorial strategies to improve adherence. An enormous amount of research has resulted in the development of medication with proven efficacy and positive benefit-to- risk profiles.

 

Treatment →Adherence→ Outcomes

 

Measurement of medication adherence is challenging because adherence is an individual patient behavior¹⁵. The following are some of the approaches that have been used (1) subjective measurement obtained by asking patients, family members, care givers and physician about patient’s medication use; (2) objective measurement obtained by counting pills, examining refill records: or using electronic medication event monitoring system (3) biochemical measurements obtained by adding a non toxic marker to the medication and detecting its presence in blood or urine or measurement of serum drug levels¹⁸.

 

Patient are generally considered adherent to their medication, if their medication adherence percentage, defined as the number of pills absent in a given time period (“X”) divided by the number of pills prescribed by the physician in that same time period, is greater than 80%.¹²

 

No. of pills absent in time X/ No of pills prescribed for time X × 100  ≥ 80%.

 

FACTORS AFFECTING ADHERENCE:

The ability of patients to follow treatment plans in an optimal manner is frequently compromised by more than one barrier. these can be classified into six broad dimensions that need to be addressed by health stakeholders ; namely patient – related factors , health- care system and provider- related factors , therapy – related factors , condition – related factors , cost – related factors , and socio – economic related factors. Solving the problems related to each factors is necessary to improve patient adherence to therapies¹².

 

1       Patient – related factors:

·        Inadequate knowledge of disease and treatment

·        Perceptions of diagnosis and health risk associated with disease and treatment¹⁹

·        Misunderstanding of treatment instructions and follow- up routine

·        Forgetfulness and patient attitude.

2     Health care system and providers related factors:

·        Inadequate reimbursements – like type of health insurance; pharmacy benefit design

·        Poor medication distribution systems

·        Barrier to care by provider – lack of knowledge / training of providers , weaker capacity , inability to establish community support

·        Poor patient – provider relationship – time spent communication style, follow ups and monitoring.

3     Therapy – related factors²⁰:

·        drug effectiveness and tolerability

·        route of administration 

·        complexity of medical regimen

·        previous treatment failures

·        Frequent changes in treatment.

4     Condition / disease – related factors:

·        severity of symptoms

·        level of disability ( physical , psychological, social  and vocational)

·        rate of progression and severity of the disease

·        Availability of effective treatment.

5       Cost – related factors :

·        co – payment

·        Out – of – pocket payment.

6       Socio – economic factors :

·        demographics like age , race and sex of patient

·        income status

·        lack of effective social support network

·        Culture and beliefs about illness or treatment.

 

STRATEGES FOR IMPROVING PATIENT ADHERENCE²²:

Following are the strategies for improving the patient’s medication adherence.

·        Seeking continuing education of health care professionals on principles and implementation of evidence – based guidelines

·        Implement a team approach to preventive care

·        ask about patient adherence at every visit

·        Beware  of pharmacy refill dates

·        Simplify the regimen if possible ( fewest number of pills and simplest dosing schedule , tailored to the patient’s lifestyle )

·        Involve patient as active partner in treatment goals and regimen

·        Use proven behavioral modification tools ( reminder systems , prompts for health care professionals ; in-office and home educational tools for  patients ; clear verbal and written instructions)¹⁸

·        Compliance aids : use of devices that can be use to remind patient to take medication , dispensing medication in blister pack according to dosage regimen , preparing medicine reminder charts , administration devices ( e.g. eye – drop applicators ) Although improving medication adherence is challenging, clinicians can take several steps to assist patient’s medication – taking behavior, and subsequently, outcomes. the ensuring discussion will focus on strategies to improve medication adherence related  to the areas of patient , physician and health system  / team building – related  factor^s14 .

 

Patient – related factors:

Medication adherence  is primarily in the domain of the patient because patients recall as little as 50 % of what is discussed during the typical medical encounter effective patient education must be multifactorial , individualized and delivered in a variety  of methods and settings outside¹⁰. A key component of any adherence improving plan is patient education .formal heath education programs, such as diabetes self – management education, have been shown to be effective, however, access to similar non – disease – specific programs is limited⁹.

·        use a patient – centered approach

·        build trust

·        Employ good communication skills

·        Demonstrate empathy

·        Use active listening skills

·        Have patient keep dairy of food intake and physical activity

·        Help patient feel confident that he /she can make necessary lifestyle changes.

 

Physician – related factor:

The substantially improved adherence of patients who report good relationship with their physician highlights  the important role of physicians in the medication adherence equation .one key to a good physician  - patient relationship is effective communication .the foremost strategy  physicians can use to increase medication adherence is to follow a patient- centered approach to care that promotes active patient involving  in the medical decision .as part of such a patient – centered approach , the physician should consider patients cultural beliefs and attitudes. For instance, a common cultural attitude held by many patents is a preference for herbal remedies .an essential component of effective physician- patient relationships is the creation of an encouraging, blame – free environment, in which patients are praised for achieving treatment goals¹¹.

 

·        Make the program simple

·        Make the program convenient

·        Make the program enjoyable

·        Set realistic and attainable goals

·        Provide  a variety of foods and activities

·        Design the program so that the patient can manage it independently

·        Remain in frequent  contact with the patient

·        Ensure that the patient has social support at home and at work.

 

Health – system / team building – related factors:

The health system in which a physician practices is integral to achieving the ultimate goals of improved patient health because medication adherence is an important contributor to improved patient health , health care systems must evolve in a way that emphasizes its importance .health system changes are necessary to ensure that sufficient time is allotted to discussing aspects of medication adherence .increased implementation of electronic medical records and electronic prescribing has the potential to increase adherence by identifying patients at risk of non-adherence and targeting them for intervention¹³. Some pharmacies already use automated reminders to alert patients that their prescription should be refilled and remind physicians to contact the patient who do not refill their prescription.

 

CONSEQUENCES OF NON ADHERENCE:

·        Wastage of medication

·        Serious health issues

·        Poorer health outcomes

·        High healthcare expenditures

·        Reduce functional abilities¹⁸

·        Lower quality of life

·        Treatment failure /reoccurrence of diseases

·        Non adherence also leads to severe relapses antibiotic resistance, preventable hospitalization, even death.

 

 

ROLE OF PHARMACIST IN IMPROVING   PATIENT MEDICATION ADHERENCE:

While medication dispensing is the best – known function of the pharmacist, pharmacists through counseling, medication therapy management, disease- state management, and the means can play a pivotal role in patient care. There are opportunities in every type of pharmacy practice to improve patient’s adherence and therapeutic outcomes and pharmacists must embrace and act on them²².

 

·        With the new health care reform laws – the patient protection and affordable care act , in particular there may be reimbursement for such activities

·        The patient –centered medical home model of health care delivery will allow the pharmacists to be part of a physician or nurse practitioner –led health care team.

·        Many factors indicate a patients medication adherence and each patient is unique , the pharmacists must approach each patients individually to determine the level of adherence and what barriers may exist that are preventing the patient from taking his or her medication appropriately⁷ .

·        Dosing simplification and minimization of adverse effects are extremely successful strategies for improving adherence, when filling a prescription; the pharmacist should do quick review to see whether the dosing schedule is as simple as possible.

·        The pharmacist should inquire frequently about any adverse effects the patient is experiencing and then consult the physician regarding suggested alternatives.

·        Reminder calls, texts, or e-mails are helpful for many patients, especially those with busy lifestyles. Small detail, like splitting patient’s pills when necessary and providing easy tips, can be beneficial⁶.

·        Preparing a dosing card containing only the most essential elements of the patient medication s can be highly beneficial, including the name of the pills, an images, the condition it is for and time of day taken can be extremely helpful for patients who take many medication or who have cognitive barriers².

 

CONCLUSION:

Patient medication non adherence is a major medical problem globally. There are many inter related reasons for the same. Though patient education is the key to improving compliance aids, proper motivation and support is also shown to increase medication adherence. Health care professionals should identify practically possible strategies to improve medication adherence within the limits of their practice eventually enhancing therapeutic outcome. It should be a multidisciplinary approach that needs to be carried out with the supports of all those who are involved in medication use. Addressing medication no adherence is critical for patient health and safety and for your practice to deliver the most effective care possible this module provides an overview of reasons for medication non adherence and suggestion for how to broach this subject with your patient s. use the strategies and tactics in this module to promote medication adherence by your patients.

 

 

 

 

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Received on 19.01.2018       Accepted on 20.04.2018

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