Adherence and Concordance Flashcards
name the side effects the oxybutylin can lead to
Anti muscarinic medicine
- dry mouth
- constipation
- blurred vision
- cognitive impairment - older adults more susceptible
Define adherence
- To the extent to which the patients behaviour matches agreed recommendations from the prescriber
define compliance
- The extent to whcih the patients behaviour matches the prescribers recommendations
Why is the definition of compliance criticised
- relegates the role of the patient to one of passive recipient of medical advice
define concordance
- A process of prescribing and medicine taking based on partnership
- idea that medicines should be shared by prescriber and patient so that they can arrive at a harmonious agreement regarding therapeutic decisions that incorporate their respective views
What three things are included in concordance
- knowledge
- partnership
- support
concordance does not..
specifically address medicines taking behaviour
concordance can have an impact on ..
meidcines taking behaviour
What can effect adherence to medicine taking behaviour
- Shared decision making
What is the adherence to long term therapies
- may be as low as 50%
In the UK less than 50% of
patients eligible for treatment receive optimal therapy for their condition
- low levels of adherence to prescribed medication is believed to be a major contributory factor
How many medications are not taken as recommended
- between a third and half of all medicines
What conditions do people not take medicines the most
- astham
- hypertension
- diabetes
- HIV/AIDs
- dyslipidaemia
- epilepsy
what patient group is least likely to believe medicines were necessary
- Patients with asthma were the least likely to believe that their medicines were necessary and the most likely to say that their costs outweighed their benefits
- also the least compliant
in 2018-19 how much did NHS spend of medicines
- 9 billion
- cost of unused or unwanted medicines vary from 100 million to 300 million
why is the economic cost not limited to take medicines
- non adherence has the potential to limit the benefit of prescribed medicines
- a lack of improvement or deterioration in health has a direct impact on the NHS
- leads to increased demand on GP surgeries and hospitals at an additional cost
Patients who adherence to treatment..
have better health outcomes that patients who do not adhere to treatment
Why do people not adhere
- social economic factors - age, gender, an inability to pay for medicines
- health system/health care team factors - poor quality of instructions provided to the patient
- therapy related factors - adverse effects of medicines, complexity of drug regimens
- patient related factors - patient disagreement with the necessity for treatment, low elf esteem
- condition related factors - dysphagia in myasthenia gravis
what age group are less adherent to medication
- Adolescents are less adherent to prescribed medication regimens than younger people
who tends to be more adherent than all other age groups
- 30-65 year olds
what group of people have poor adherence
- older populations where the patients have multiple chronic diseases is a particular problem
- the prevalence of function and cognitive impairments in older patients increases their risk of poor adherence
How do you improve adherence in children under 12
- they should be given the choice of swallowing tablets, or a liquid form or solid dosage form
describe how socioeconomic deprivation can effect adherence to medication
- people who have high socioeconomic deprivation are more likely to have a low level of eduction, be unemployed, have limited social networks, experience poor housing conditions, suffer from family dysfunction
- these can influence their beliefs about health, illness and treatment
How can the health care system reduce your adherence to medication
- insufficient time spent counselling your patient on the importance of adherence to their prescribed treatment regimens
- simple dosing regimen is more likely to promote adherence more than a complex regimen
what are patient related factors that effect adherence
- low motivation
- anxieties about possible adverse effects
- perceptions of a lack of need for the treatment
- fear of dependence
How does the condition effect the adherence rate
- level of disability associated with the condition
- the rate of progression of the condition
- the severity of the illness
- the severity of any symptoms
What drugs are associated with dyspepsia
NSAIDs - need to prescribe a proton pump inhibitor along with dyspepsia
What drugs are associated with myalgia
- Statins
What drugs are associated with gout
- Thiazide diuretics
What drugs are associated with acute dystonia
- anti psychotics - extra-pryamidal side effects
What drugs are associated with mood changes
- prednisolone - systemic corticosteroids may alter mood and behaviour
What drug can cause persistent cough
- ACE inhibitors - due to an increase in bradykinin levels
What are the two types of adherence
- intentional non adherence
- unintentional non adherence
What is intentional non adherence
- The patient makes a conscious decision not to follow the treatment recommendations
What is unintentional non adherence
- The patient wants to follow the treatment instructions but is prevented from doing so by certain factors
What can health care professionals do to improve adherence
- Target specific illness groups
- there is adequate patient demographic/psycho-social profiling
- sympathetic approaches are taken to patient - beliefs, expectations, preferences, lifestyles
- improvements in outcomes have statistical power
- definitions of adherence are clinically appropriate
- measures of adherence and health outcomes are relevant and robust
- resources for the intervention are appropriate and relevant
What should you do to improve communication with the patient
- adapt your consultation style to their needs
- consider any factors which may affect communication
- ask open ended questions which allow them to express any concerns
- encourage them to ask questions
- consider the use of communication aids
What communication aids can you use
- Pictures
- large print
- braille
- information in different languages
- an interpreter
Where can you find a patient information leaflet in braille or audio
X-PIL ensures that patient information leaflets supplied with medicines are accessible to all
How can you increase patient involvement
- explain the condition
- explain the advantages and disadvantages of treatment
- avoid assumptions about patient preferences
- avoid any non-verbal cues - signs of apprehension, disagreement
- assist your patient in making decisions based on likely benefits and risks rather than misconceptions
What information should you provide a patient with
- What the medicine is and how to use it
- likely benefits of treatment
- any adverse effects and the likelihood of these occuring
- what to do should any adverse effects occur
- what to do if they miss a dose
- expected duration of treatment
What are the two ways to assess adherence
- Objective
- subjective
How do you subjectively assess adherence
- strategies for measuring medication adherence focuses largely on the patient self-reporting
- interpreting reports is often problematic
- patients who admit to not following recommendations tend to describe their behaviour accurately whereas patients who deny a failure to follow treatment advice have a tendency to report their behaviour inaccurately
describe how you objectively assess adherence
- involve the measurement of a chemical in a bodily fluid
- electronic monitoring devices that record the date and time when a medication container is opened has also been used to estimate adherence but the expense of these measures precludes their widespread use
what can prescribing data bases be used to check
- can be sed to check when prescriptions are initially filled or refilled over the duration of treatment or are prematurely discontinued
- do not reveal if the patient actually consumed the prescribed medicine
In what case would it be useful to use objective measures for adherence
- mental health patients may not adhere to treatment if there is a lack of insight
- possible to measure the plasma drug concentration of some drugs such as olanzapine, amisulpride and clozapine
- can also measure thyroid function tests as a measure of levothyroxine
How do you approach a patient who has poor adherence
- ask in a way that does not apportion blame
- clearly explain why you are asking
- mention a specific time
- ask about habits
- use prescription records, pharmacy patient medication records and the return of any unused medicines to identify non-adherence
Encouraging patients to monitor ..
there own condition can improve adherence
- increases there engagement with their condition
What should you ask if a patient is being intentionally non adherence
- is the patient experiencing any adverse effects
- is the patient finding the treatment ineffective
- has their opinion of the treatment changed
What are the interventions to increase adherence
- simplification of the medication regimen
- counsellinig
- reminders
- close follow up
- supervised self-monitoring
- rewards for success
- family therapy
- couple focused therapy
- psychological therapy
- crisis intervention
- manual telephone follow up
How do you overcome practical problems
- encourage your patient to monitor their condition
- simplify the dosing regimen
- change the formulation
- change the device
- suggest using a monitored dosage system
Describe how you tell a patient about side effects
- outline the benefits of pharmacological therapy
- explain the likely/potential side effects
- discuss how the patient would like to deal with adverse effects should they occur
what can you report adverse side effects to
- report them to the yellow card scheme
what can patients get if they are not entitled to free prescriptions
- if they have to pay for more than 11 prescribed medicines each year then it may be cheaper to purchase a PPC which spreads the cost of prescriptions across 12 months
if patients are on a low income what are they entitled to for prescirptions
- may be able to receive help through the NHS low income scheme
- HC1 form will need to be completed and the decision as to whether or not a patient is eligible for financial help is based on a comparison between the patients weekly income and assessed requirements at the time the claim is made
- they may be eligible for a HC2 which allows free prescriptions
- or a HC3 which provides some help toward prescription charges
What is the NMS
- new medicine service - this is a pharmacy based intervention which provides support for people with long term conditions who are newly prescribed a medicine
Who is eligible for the NMS
- asthma and COPD
- type 2 diabetes
- anti-platelet and anti coagulant therapy
- hypertension
What happens in the NMS
- two interventions with the patient using a semi-structured interview schedule -
schedule is designed to assess adherence, identify any problems the patient may be having in taking the medicine as prescribed and identify any further information or support that the patient may need - first intervention takes place 7-14 days after the new medicine is dispensed
- second intervention takes place 14-21 days post dispensing of the prescription
- successful at reducing rates of non adherenace at 10 weeks post enrolment but not a 6 weeks or 26 weeks post enrolement
Patients over ..
the age of 60 are entitled to free prescriptions
