Patient medication adherence

PATIENT MEDICATION
ADHERENCE
P.Rana kishore M.Pharm.,
Dept of Pharmacy Practice
Vignan Pharmacy College-Guntur
JNTU-Kakinada
A.P (INDIA)

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. SOCIALAND 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

Con…
7.Lack of health care insurance
8.Inability or difficulty accessing pharmacy
9.Medication cost
10.Cultural and lay beliefs about illness and
treatment
11.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

Cont…
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

Cont…
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

Cont…
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

Cont…
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.

Cont…
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.

Cont…
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.

Cont..
• 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.

4. Reminder calls, texts, or e-mails are helpful
for many patients, especially those with busy
lifestyles. Automatic refills are a useful
strategy

• What ever 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.

Patient medication adherence

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Patient medication adherence