Unit 2 Medication Adherence Pharmacy Practice

This summarises briefly about Medication Adherence, tests to monitor the adherence and pharmacist responsibility.

1. PATIENT MEDICATION ADHERENCE

2. MEDICATION ADHERENCE Defined by the World Health Organization as “ the extent to which a persons behaviour taking medication…corresponds with agreed recommendations from a health care provider” Adherence : Patient participation in treatment as a shared decision- making process . The patient is under no compulsion to accept a particular treatment.

3. FACTORS AFFECTING MEDICATION ADHERENCE Age ang Gender of the patient Income Education Patient intelligence Knowledge about the disease Illness being treated. Actual seriousness of disease Actual efficiency of the treatment Marital state Number of people in household. Therapeutic regimen Clinical settings

4. Adherence is a multidimensional phenomenon determined by the interplay of five sets of factors, termed “dimensions” by the world health organization: Social /economics factors. Provider-patient/health care system factors. Condition-related factors. Therapy-related factors. Patient-related factors

5. SOCIAL AND ECONOMICS DIMENSION Limited English language proficiency Low health literacy Lack of family or social support network. Unstable living conditions ; homelessness Burdensome schedule Limited access to health care facilities Medication cost Elder abuse Inability or difficulty accessing pharmacy. Cultural and lay beliefs about illness and treatment.

6. HEALTH CARE SYSTEM DIMENSION Provider-patient relationship. Provider communication skills(contributing to lack of knowledge or understanding of the treatment regimen). Disparity between the health beliefs of the healthcare provider and those of the patient. Lack of positive reinforcement from the healthcare provider. Weak capacity of the system to educate patients and provide follow-up. Lack of knowledge on adherence and of effective interventions for improving it.

7. Patient information materials written at too high literacy level. High drug cost Poor access or missed appointments Long wait times Lack of continuity of care Restricted formularies; changing medications covered on formularies.

8. CONDITION-RELATED DIMENSION Chronic conditions Lack of symptoms Severity of symptoms Depression Psychotic disorders Mental retardation/developmental disability

9. THERAPY-RELATED DIMENSION Complexity of medication regimen( number of daily doses ; number of concurrent medications) Treatment requires mastery of certain techniques(injections , inhalers) Duration of therapy Frequent changes in medication regimen Lack of immediate benefit of therapy Medications with social stigma attached to use Actual or perceived unpleasant side effects. Treatment interferes with lifestyle or requires significant behavioural changes.

10. PATIENT-RELATED DIMENSION PHYSICAL FACTORS : Visual impairment Hearing impairment Cognitive impairment Impaired mobility or dexterity Swallowing problems

11. PSYCHOLOGICAL/BEHAVIORAL FACTORS: Knowledge about disease Perceived risk/susceptibility to disease Understanding reason medication is needed Expectations or attitude toward treatment Motivation Fear of possible adverse effects Fear of dependence Psychological stress, anxiety, anger Alcohol or substance abuse

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

13. 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.

14. 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.

15. 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.

16. 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.

17. 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

18. 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.

19. 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.

20. 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.

21. 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.

22. 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 .

23. 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.

24. 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

25. 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

26. 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

27. 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).

28. 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?

29. 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.

30. ROLE OF PHARMACISTS IN MEDICATION ADHERENCE Be friendly and approachable to the patient Improve communication skills Take into account the spiritual and psychological needs of the patient Improve in patient education Encourage the patient to discuss their main concern without interruption or premature closing. Elicit the patient perception of the illness and the associated feelings and expectations. Learning methods of active listening and empathy.

31. STRATEGIES TO IMPROVE MED. ADHERENCE The SIMPLE approach S – Simplify the regimen I – Impart knowledge M – Modify patient beliefs and behavior P – Provide communication and trust L – Leave the bias E – Evaluate adherence

32. S—SIMPLIFY THE REGIMEN Encourage use of adherence aids. Investigate customized packaging for patients Adjust timing, frequency, amount, and dosage Match regimen to patient’s activities of daily living Consider changing the situation vs. changing the patient Avoid prescribing medications with special requirements Recommend taking all medications at the same time of day

33. I—IMPART KNOWLEDGE Advise on how to cope with medication costs Focus on patient-provider shared decision making Involve patient’s family or caregiver if appropriate Keep the team informed (physicians, nurses, pharmacists) Provide all prescription instructions clearly in writing and verbally Reinforce all discussions often, especially for low-literacy patients Suggest additional information from Internet for interested patients

34. M—MODIFY PATIENT BELIEFS AND BEHAVIOR Address fears and concerns Provide rewards for adherence Empower patients to self-manage their condition Ask patients about the consequences of not taking their medications Have patients restate the positive benefits of taking their medications Ensure that patients understand their risks if they don’t take their medications

35. P—PROVIDE COMMUNICATION AND TRUST Use plain language Practice active listening Provide emotional support Improve interviewing skills Elicit patient’s input in treatment decisions

36. L—LEAVE THE BIAS Develop patient- centered communication style Acknowledge biases in medical decision making Understand health literacy and how it affects outcomes Address dissonance of patient-provider, race-ethnicity, and language Examine self-efficacy regarding care of racial, ethnic, and social minority populations

37. E—EVALUATING ADHERENCE Self-report Ask about adherence behavior at every visit Periodically review patient’s medication containers, noting renewal dates Use biochemical tests—measure serum or urine medication levels as needed Use medication adherence scales— e.g. Morisky-8 (MMAS-8), Medication Possession Ratio (MPR), Proportion of Days Covered (PDC)

38. Give clear explanation(regarding disease and drugs) Check the patient understanding. Simplify the therapeutic regimen. Monitor the side effects Monitor the beneficial effects. Speak the same language of patient. Involvement of the patient treatment discussion.

39. THANK YOU