Measurement of medication adherence

This slides contains definition, epidemiology, assessment, ways to encourage and role of pharmacist in medication adherence.

1. MEASUREMENT OF MEDICATION ADHERENCE BY : Dr. Vishwas A T L Assistant Professor Dept. of Pharmacy Practice Bharathi College of Pharmacy Bharathinagara - 571422

2. CONTENTS Definitions Epidemiology Ways to encourage adherence Methods for assessment Role of pharmacist Conclusion References

3. DEFINITIONS 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. Compliance is the extent to which a patient’s behavior matches the prescriber’s advice. Compliance implies patient obedience to the physician’s authority.

4. EPIDEMIOLOGY   Nonadherence can account for up to 50% of treatment failures, around 125,000 deaths and up to 25% of hospitalizations each year in the United States according to a report in the Annals of Internal Medicine. Typically, adherence rates of 80% or more are needed for optimal therapeutic efficacy. The report estimates that non-adherence costs the U.S. healthcare system between $100 billion and $289 billion annually. According to the Annals of Internal Medicine, 20 to 30 percent of prescription medications are never filled, and approximately 50 percent of medications for chronic disease are not taken as prescribed.

5. Formula for calculation of medication adherence Percentage adherence = Total number of actual dose of patient has consumed last appointment _________________________________ 100 Total number of calculated dose to be consumed

6. Ways to Encourage Medication Adherence Addressing prescription cost concerns. The patients, doctors, and pharmacists need to have frank discussions about any challenges a patient may have affording a specific course of treatment. Improving patient education Patients need to understand why they are taking a particular medication, how they are supposed to take it, and what will happen if they will stop treatment. Exploring creative solutions One study in South Africa used text reminders and “treatment partners” to help encourage medical adherence in the treatment of serious mental conditions.

7. METHODS TO MEASURE ADHERENCE Methods for measuring medication adherence can be categorized into two basic types: Direct measurement. Indirect measurement.

8. DIRECT METHODS Direct observed therapy Measurement of the level of a drug or its metabolite in blood or urine Detection or measurement of a biological marker added to the drug formulation in the blood.

9. Directly O bserved T herapy It is most accurate method. Patients can hide pills in the mouth and then discard them. This method takes place in the presence of interviewer.

10. Measurement of the level of a drug or its Metabolite in Blood or Urine Biological assays measure the concentration of a drug, its metabolites, or tracer compounds in the blood or urine of a patient. These measures are intrusive and often costly to administer. Patients who know that they will be tested may consciously take medication that they had been skipping so, the tests will not detect individuals who have been nonadherent . Drug or food interactions, physiological differences, dosing schedules, and the half-life of the drugs may influence the results.

11. Measurement of a Biological Marker This method was not suitable for all the medications. For instance riboflavin, a biological marker in which simply nonquantitative for detection. Additionally, drug-drug interactions and drug-food interactions can hinder the assay’s accuracy. It is difficult to collect the samples.

12. INDIRECT METHODS Patient Interviews Patient self reports Pill counts, prescription refills Assessment of patient’s clinical response, electronic medication monitors Measurement of physiologic markers Patient diaries

13. Patient Interviews Interviewing patients by clinicians is generally an easy-to-use, low-cost subjective method to assess patient’s adherence. Patients can be asked to estimate their own medication-taking behavior, namely, which percentage of dose that they may miss within a designated period or the frequency that they are unable to follow the medication regimen. Alternatively, questions can also be based on patient’s knowledge on the personal prescribed regimen, including drugs’ name, schedule, and indications.

14. Patient Self Reports Self-reported measures, such as diaries and questionnaires, are fairly simple to administer. However, because some patients may be resistant to periodically answering a series of questions or entering their medication administration information in a diary on a regular basis, this may present an obstacle to the enrollment process. Although diaries are less influenced by recall bias, they have been used as an intervention to improve adherence.

15. Pill Counts Counting the number of pills remaining in a patient's supply and calculating the number of pills that the patient has taken since filling the prescription is the easiest method for calculating patient medication adherence. This method is simple, it has many disadvantages that the patients can switch medicines between bottles and may even discard pills before hospital visits in order to appear to be following the regimen. Hence, this is not an ideal measure of adherence.

16. Prescription Refills This method also allows for an evaluation of a large number of patients over an extended period of time. However, the adherence value obtained from refill data does not produce any information on medication consumption; rather, it solely provides assessment of acquisition and possession of medication. It is assumed that patients administer the medication between the day of dispensation and the day of the refill. Since this method is based on prescription refills of prescriptions, it is better suited to study chronic rather than short-term treatment.

17. Assessment of Patient’s Clinical Response The patients’ clinical response can be used as a surrogate marker of adherence. Measurement of the clinical response can be performed during regular visits to the health care provider and may already constitute the standard of care for monitoring of the disease being treated. While this method may allow the investigator to capture severe nonadherence .

18. Electronic Medication Monitors Electronic drug monitors, including the medication event monitoring system ( MEMS ), consist of specialized microchips incorporated into medication bottles that catalogue every opening of the bottle. MEMS offers a precise record of patients’ medication-taking behavior provided that each bottle-opening truly represents a single administration and that patients avoid transferring medications into other containers. These systems are also expensive and usually require regular downloading of information directly from the microchip to the compatible software program.

19. The Medication Event Monitoring System (MEMS ) manufactured by  Aardex Corporation allows the assessment of the number of pills missed during a period as well as adherence to a dosing schedule. MEMS Cream Tube MEMS Pills Bottle

20. Measurement of Physiologic Markers Biomarkers are quantitative measures that allow us to diagnose and assess the disease process and monitor response to treatment.  Blood pressure is used to determine the risk of stroke. It is also widely known that cholesterol values are a biomarker and risk indicator for coronary and vascular disease

21. Patient-Kept Diaries This is the only self-report tool that is consistently documented with how the patient follows their prescribed regimen. However, overestimation is very common and an average of 30% surplus of diary entries has been shown to occur when comparing with different results from MEMS data. Authors also mentioned other factors that can contribute to its unreliability, including the inability to carry out the assessment if the patient does not return the diary or the reported “false” increase in patient’s adherence rate from monitoring phase to self-assessment phase

22. Scaled Questionnaires Morisky et al. (1986) developed a 4-item scaled questionnaire to assess adherence with antihypertensive treatment. Thier scale demonstrated acceptable psychometric properties.  Li et al. (2005) developed four instruments to measure antihypertensive medication adherence in a population of Chinese immigrants in the US. Their measures are culturally sensitive and demonstrate good reliability. The Hill-Bone Compliance to High Blood Pressure Therapy Scale includes 14 items, 8 of which are directed at assessing medication taking behavior in hypertensive patients (Hill et al. 2000).

23. Morisky scale It’s used for many different diseases such as hypertension, hyperlipidemia, asthma, and HIV. (Please tick Yes\ No) 1. Do you ever forget to take your (name of health condition) medicine? 2. Do you ever have problems remembering to take your (name of health condition) medication? 3. When you feel better, do you sometimes stop taking your (name of health condition) medicine? 4. Sometimes if you feel worse when you take your (name of health condition) medicine, do you stop taking it?

24. Scoring the Morisky Scale Yes=0 and No=1 • Zero is the lowest level of medication adherence • 4 is the highest level of medication adherence Patients scoring 0 or 1 would benefit most from pharmacist intervention Goal: Screen for those in which the pharmacist time should be spent on enhancing adherence.

25. ROLE OF PHARMACIST Be friendly and approachable to patient. Improve patient education. Give clear explanation regarding drugs and disease. Check the patient understanding. Simplify the therapeutic regimen. Moniter the side effect.

26. CONCLUSION Medication adherence is a complex public health issue that demands continued progress to overcome a multitude of patient, provider, and health system barriers. Pharmacists can take a lead role in delivering effective patient care services to improve medication adherence and optimize patient outcomes.

27. REFERENCES P. Michael Ho, Chris L. Bryson and John S. Rumsfeld. Medication Adherence. AHA journal. 2009; 119(23): 3028-3035. Marie T. Brown and Jennifer K. Bussell . Medication Adherence: WHO Cares?. Mayo Clin Proc . 2011 Apr ; 86(4): 304–314. Beena Jimmy and Jimmy Jose. Patient Medication Adherence: Measures in Daily Practice. Oman Med J. 2011 May; 26(3): 155–159. Charlotte A. Kenreigh and Linda Timm Wagner. Medication Adherence: A Literature Review. Medscape. Oct 12, 2015.

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