16 Chemist+Druggist 19.03.2016

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Module 011Medicines adherenceFrom this module you will learn:

● The difference between intentional and unintentional non-adherence

● Why patients often do not take their medicines as directed ● The roles of the pharmacist in promoting safe and effective

medicine use ● The strategies and solutions to encourage correct

medicines adherence

By Hayley JohnsonHospital Pharmacist

What does adherence mean?Medicines adherence is defined as the extent to which a patient takes their medicine as prescribed. The term has gained favour over ‘compliance’ and ‘concordance’ in recent years because it evokes a more active patient role. Adherence is extremely difficult to achieve and measure; even the most diligently compliant patients may lapse in taking medication when the irregularities and impracticalities of life get in the way.

Adherence can be divided into two broad categories – intentional and unintentional. Intentional non-adherence stems from a conscious decision not to take medicine. This may be because of a patient’s beliefs about the medicine or their need to take it, or concerns about its safety. Unintentional non-adherence is usually caused by practical issues – the patient intends to take their medicine, but they are hindered in doing so, perhaps by not being able to swallow the tablets, by not being able to procure the medicine, or simply by forgetting.

Not taking a medicine as intended can have clinical and economic consequences. Patients may end up with stockpiles of medicines that are not being used, thus wasting scarce NHS resources. A reduction in efficacy because of missed doses can lead to loss of therapeutic effect, meaning a reduced quality of life for the patient, as well as further costs. Conversely, a patient taking more medicines than prescribed may be at an increased risk of adverse effects or toxicity. This could also reduce quality of life and increase healthcare costs.

Why don’t patients take their medicines as prescribed?The causes of non-adherence are complex and varied, making it a tough problem to tackle effectively. General factors include gender, personality and cultural background. Women tend to be better at taking medicines than men. Some patients have an antagonistic view of medicines, viewing them as dangerous and unnatural; others may have erroneous health

beliefs. Language barriers can make it difficult for patients to understand instructions.

Factors relating to the medicines themselves are also important. Short-term regimes are adhered to better than long-term ones. Once-daily regimens are easier to follow than those requiring multiple doses. Taking medicines at the same time as meals (ie three times a day) leads to improved adherence compared with courses that require medicines be taken four times daily. Longer-term illnesses tend to be associated with lower levels of adherence than acute illnesses. The World Health Organisation (WHO) cites asthma, depression, diabetes and hypertension as particularly problematic. The stigmatisation of certain illnesses, or a lack of

insight into them (mental health problems, for example), may lead people to avoid their medication. Diseases that affect memory or swallowing can severely affect a patient’s ability to take their medicines.

The tone and quality of interactions with healthcare professionals (HCPs) can also have an effect. Studies suggest that patients are less likely to comply if a HCP adopts an authoritarian tone. Those who feel they have been involved in decisions, and who perceive their HCP is friendly, are more likely to be adherent.

What is the scale of the problem?It is estimated that up to 50% of patients do not take their medicines as prescribed. The

An estimated £4bn-worth of medicines are wasted in england alone each year

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Practice: ● Medicines adherence March 19*Online-only for Update Plus subscribers

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prescription of medicines is the most common patient intervention in the NHS, so it is important to ensure it is effective. Just over a billion prescription items were dispensed in England in 2014, at a cost of £8.9 billion. If 50% of patients are non-adherent, more than £4bn-worth of medicine is being wasted annually – before we even consider the resulting increased healthcare costs.

How can adherence be improved?Given the variety of causes, adopting a blanket approach to improving adherence is unlikely to be effective. While there is no shortage of proposed interventions to improve adherence, it is difficult to decide which approach will suit individual patients best. The Nice guidelines on improving medicines adherence sets out the key principles that all HCPs should apply to their practice. The guidance centres on providing individualised care at various stages of the prescribing process (See ‘Adapted Nice guidance’ below).

Nice also acknowledges the important role of pharmacists in identifying and solving medicines-related issues that arise after a prescription is issued. It provides a suite of materials to support implementation of the guidance, including patient information and audit tools, which are available on its website at tinyurl.com/niceadher.

Potential interventions to improve adherence are varied and wide-ranging. Some methods can include sweeping changes, while others seem imperceptibly small, but may add up to make a difference. Compliance aids, while useful for some patients, are often overused,

and may lead to reduced patient knowledge and autonomy when it comes to medicines. Practical measures

● finding alternative administration methods for those with swallowing difficulties

● introducing compliance aids ● procuring pleasant-tasting medicines ● simplifying multiple-dose regimens ● using reminder charts ● counselling patients ● employing logical questioning ● using clear dispensing labels.

Management of adverse drug reactions (ADRs) ● counselling on ways to reduce ADRs (such

as taking with food or just before bed) ● identifying ADRs ● encouraging reporting via the Yellow

Card Scheme.Community pharmacy services

● Medicines Use Reviews (England, Wales and NI)

● New Medicines Service (England) ● Chronic Medication Service (Scotland) ● Discharge Medicines Review (Wales) ● facilitating repeat dispensing and

managed repeats.

Improving adherence: what works?As mentioned, adherence can be difficult to measure. Most patients, consciously or not, want to please their healthcare provider, who they may perceive as an authority figure. Therefore, they are prone to downplaying any difficulties they are having with their medicines. They may find it difficult to express contradictory beliefs or opinions, believing they may be dismissed or told off. It is also easy for patients to forget instances when they have not taken their medicines, and they may not realise they have misunderstood directions.

In order to measure adherence properly, healthcare providers would need to record

each dose as it is being taken by the patient. Not only would this be impractical, costly and invasive, but it would also likely severely skew results. Various alternative methods have been proposed, ranging from patient diaries, pill-counting and monitoring prescriptions to computerised pill caps and biochemical tests. There is no consensus on which measures should be used for which type of intervention.

All of this means that gathering evidence on interventions to improve adherence is difficult – and the resulting trials can be confounding or methodologically flawed. The most definitive evidence available comes in the form of a Cochrane Review. It included a total of 182 randomised, controlled trials and concluded that there remains a good deal of uncertainty regarding which methods are most effective.

Adapted Nice guidanceHere are the key principles for improving medicines adherence:

● Adapt your consultation style to suit the individual patient’s needs

● Establish and use the most effective method of communication

● Allow patients to be involved in decision-making

● Remember that patients have a right to make an informed choice. This may include deciding not to take a medicine

● Where a patient declines a medicine, record their reasons for doing so

● Be aware of concerns or beliefs that may affect adherence

● Offer relevant information that is easy to understand

● Routinely assess adherence in a non-judgmental manner

● Do not apply blanket policies to all patients – tailor interventions to individual needs

● Review the patient’s knowledge, understanding and concerns regularly

Case studyMr Gaston is a 72-year-old who regularly visits your pharmacy to collect his prescription. He suffered a heart attack two years ago and was placed on a secondary prevention regime consisting of an ACE inhibitor, a beta-blocker, a statin and an antiplatelet.

During a medicines use review, he confesses that he has decided to stop taking the statin because of concerns about side effects.

Mr Gaston says a neighbour told him that the side effects can kill. Mr Gaston did not experience any side effects while taking his statin, but he decided to stop taking it just in case.

You explore Mr Gaston’s concerns further, in a non-judgmental way. You explain that all medicines have side effects, but that they are not suffered by everyone and that the benefits usually outweigh the risks. This is true in Mr Gaston’s case because he did not experience

any side effects when taking the statin.You explain to Mr Gaston that it is his right

to decide whether or not to take a medicine. You discuss the potential side effects of statins and how much they can reduce risk. You use a visual decision aid, such as the one produced by Nice, to demonstrate the value of taking a statin. You also give Mr Gaston some printed leaflets and direct him to reliable websites, such as NHS Choices and patient.info.

Next month, Mr Gaston returns again for his prescription. He tells you that, after your discussion, he had a good think about whether or not to take his statins again.

After looking at the information you gave him, he felt reassured and decided that he should. After speaking to his GP he continued taking the original dose; he says he does not need to have it dispensed this time, though, because he has a stack of them at home.

Dexterity issues may cause non-adherence

18 Chemist+Druggist 19.03.2016

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Tips for your CPD entry on Medicines Adherence Reflect What factors affect medicines adherence? How many patients do not take their medicines as prescribed? What are the key principles for improving medicines adherence?

Plan This article describes medicines adherence and including about why patients do not take their medicines as prescribed, the extent of the problem and how adherence can be improved. An example of how adherence to statins can be improved and a case study are also discussed.

Act Think about how you can target patient groups that are associated with lower levels of adherence. For example, a different group each week could be provided with simple reminders or information when they collect their prescriptions.

Identify any patients who might benefit from an Medicines Use Review (MUR) to help improve their adherence.

Find out about aids that can help improve medicines adherence, such as large-print labels for those with low vision, reminder apps or language leaflets.

Complete a Centre for Postgraduate Pharmacy Education (CPPE) course, for example those on consultation skills, medicines optimisation or reducing medicines wastage, which encompasses the principles of improving adherence.

Evaluate Are you now confident in your knowledge of medicines adherence? Could you use the principles in this article to help improve adherence in your patients?

Where to find out moreThe Centre for Postgraduate Pharmacy Education (CPPE) provides a series of courses on consultation skills, medicines optimisation, reducing medicines wastage, as well as a comprehensive range of individual therapeutic area training, all of which encompass the principles of improving adherence. You can find your nearest medicines information centre at ukmi.nhs.uk, which can assist with a wide variety of enquiries that can help with adherence, including compliance aid stability and how to manage swallowing difficulties.

The results of the trials were inconsistent and often conflicting, and many were of poor quality. However, over a longer time period, more intensive interventions appeared to be the most effective overall.

Improving adherence to statinsIn 2014, more than 37 million prescription items for statins were dispensed in English community pharmacies, making them the most commonly prescribed drugs. In clinical trials, their effectiveness at preventing primary and secondary cardiovascular disease is clear, but estimates suggest that only one in four patients take their statins regularly, and only 50% of those on statin therapy reach their target cholesterol level.

Patients may be more likely to forget about or stop taking a medicine that does not provide a rapid benefit. Preventative medicines such as statins fall into this category. There is also the risk that patients may be influenced by negative press about adverse effects. Given the NHS spends more than £50 million on statins, not to mention the severe consequences of cardiovascular disease, improving adherence in this area is clearly important. But how best to do so remains unclear. The most successful intervention appears to be the most simple: reminding patients of the importance of taking their medicines regularly. A Cochrane Review showed that this led to increase in adherence of up to 24% in randomised, controlled trials.

A significant increase in adherence was also seen when written, pharmacist-mediated information was sent to patients who had been newly prescribed a statin medication, although this effect seemed to wane as time passed. Regular medicines reviews by a community pharmacist also appeared to increase adherence, by around 6.5%. These options are not particularly time-intensive and may be combined and tailored to individual patients to provide the biggest impact. Most pharmacists counsel their patients regarding antibiotics; it is worth considering whether they should do the same for those who have been prescribed statins.

5-minute quiz1. The human papillomavirus vaccine protects against six different types of HPV.true/False

2.The human papillomavirus vaccine is more than 99% effective at preventing pre-cancerous lesions. true/False

3. Two doses of the HPV vaccine, six months apart, are routinely given to girls at the age of 16 years. true/False

4. The MenACWY vaccine is currently given to children aged 14 to 18 years and those aged under 25 years attending university for the first time.true/False

5. Common side effects of the MenACWY vaccine include headache, nausea, rash, drowsiness, irritability and appetite loss. true/False

6. The quadrivalent 2015-16 flu vaccine protects against two types of influenza A and two types of influenza B.true/False

7. Patients with an egg allergy should be given a flu vaccine containing less than 0.12µg/ml ovalbumin. true/False

8. People living in long stay residential or other care facilities including prisons and university halls of residence should be given the seasonal flu vaccine. true/False

9. The pneumococcal vaccine is given to all people aged 55 years and over. true/False

10. The VZV vaccine is currently being offered to people aged 70 and 78 years.true/False

11. The VZV vaccine is currently being offered to people aged 70 and 78 years. TVZV vaccine is given.true/False