Lecture 7: Medication Adherence

Question 0

What is compliance?

Answer 0

The extent to which the patients behaviour matches the health care professionals instructions.

Attitudes around this term are like providers just expect patients to do as we say

I.e. A more paternalistic approach which implies passivity, lack of involvement or autonomy of the patient.

The blame for failing thus rests solely with the patient

Question 1

Does adherence = compliance?

Answer 1

Historically the two terms were used interchangeably, but now we prefer adherence due to shifts in the attitudes of the delivery of health care services

Question 2

What is adherence?

Answer 2

This is the extent to which a patients behaviour matches the agreed recommendations from the healthcare professional.

In this sense, patient and provider have come to an agreement, and adherence is the extent that the patient keeps to that agreement
adherence is a more patient centred approach which emphasises the collaboration

Implies a more complex healthcare delivery with the patient an active, voluntary participant.
There is a shared responsibility between the patient and the health care professional

Question 3

What 3 main behavioural components does medication adherence comprise of?

Answer 3

Collecting prescription
Taking medication correctly
Taking medication for the full course

Question 4

When is medication adherence realised?

Answer 4

When all three components of medication adherence are satisfied,

This is particularly applicable for preventative medications as there is often no visible change so patients presume the medication has no effect

Question 5

Is medication non adherence common?

Answer 5

Yes. Nearly 20% of patients fail to collect their prescribed medications - this is primary nonadherence

WHO estimates between 33% - 50% of medications prescribed for chronic conditions are not taken as prescribed

Question 6

What does taking medications correctly mean?

Answer 6

Taking the right medication at the right dose at the right time and under the right conditions

Question 7

What is the secondary non adherence of medicines?

Answer 7

Failure, including under use, over use and misuse

Question 8

What is medication discontinuation?

Answer 8

Patient stops taking their medication prematurely.
This is particularly relevant in the management of chronic conditions where the patient is typically required to take their medication for the rest of their life

In a large study across 6 chronic conditions, only 28-66% of patients still took their medication at 6 months

Question 9

Why is medication non adherence a significant cost for the patient, healthcare system and society?

Answer 9

Patient has poor treatment outcomes, loses health gain, can lead to progression of disease, development of complications and reduced quality of life.

Research has shown that if the patient is adherent a good outcome is almost 3x higher than if the patient is nonadherent

The odds of dying are also halved if patients take their medication as prescribed.

Question 10

What are costs associated with non adherence?

Answer 10

These include costs associated with medication wastage and disposal,
Increased healthcare utilisation e.g. Unscheduled GP visits and hospital admissions.

For society, non adherence causes a loss of productivity
Increase in use of disability and social services

There is an estimated cost of $522-700million NZD per year for premature death, hospital expenditure and lost productivity

Question 11

What is WHO’s statement of the effect of medication nonadherence and its impact on health?

Answer 11

Increasing effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatment

Question 12

What are three main components for medication non adherence?

Answer 12

Patient, treatment, system

Question 13

What are reasons for medication nonadherence to do with the patient?

Answer 13

Practical barriers:
Capability (cognitive and physical limitations)
Medication cost
Access to a pharmacy

Perceptual barriers:
Motivation to take medication
Beliefs about their condition and their medication
Their balance of perceived need vs. Perceived cost

Question 14

What are barriers to medication nonadherence to do with treatment?

Answer 14

Treatment complexity and duration- the prescribed amount of doses per day is inversely proportional to the extent of adherence,

The longer the treatment duration, the less likelihood of adherence.

for treatment of chronic conditions, it is important to give adherence support at the beginning of treatment and throughout the treatment duration

Question 15

What are barriers to medication nonadherence to do with the healthcare system?

Answer 15

At the systems level: social support and healthcare professional patient communication are important in encouraging adherence,

Lack of communication or insufficient communication training in healthcare professionals causes a decrease in adherence

Question 16

Why are pharmacists ideally placed to improve medication adherence?

Answer 16

Pharmacists are perceived to have expertise in managing medication
They are most accessible and most frequently consulted of all healthcare professionals
They can contribute to the process rather than assume full responsibility

Question 17

How can effective adherence interventions be offered?

Answer 17

Tailor intervention to individual patient
Assess patient barriers (both practical and perceived)
Ask patient directly about possible barriers to adherence,
Dont assume or judge

Question 18

How is adherence assessment carried out?

Answer 18

Starts with patient questioning
Then turn to practical barriers and how patients can be supported through these.
Then address perceptual barriers,

Question 19

What does initial patient questioning consist of?

Answer 19

Inviting the patient to explain their medication regime so any misunderstandings can be corrected

When you know patient accurately understands the dosing and administration instructions, you can start to address the practical barriers

Question 20

How do you address practical barriers?

Answer 20

Consider factors that may impact on patient’s cognitive ability (age, learning disabilitiyes, disease conditions etc.)

Consider any factors that may impact on patients physical ability (manual dexterity, mobility, vision, swallowing problems)

Patient can be supported to manage these barriers through many interventions. Common interventions include 
Simplifying medication regime
Use of reminder aids, SMS messaging
Medico packs
Starting home delivery services

Question 21

How can perceptual barriers be addressed?

Answer 21

Invite patient to talk about their condition and medication using open ended questions.

E.g. Everyones experience of this condition is different, can you tell me a little about how it is like for you?
Or it is natural to have concerns about medicatiom, what are your concerns?

Question 22

What can the information retrieved from an adherence assessment do?

Answer 22

It can help to provide a framework for intervention by helping to identify any unhelpful beliefs which patient may have about their condition and medication.

Once identified, these beliefs can be further explored and eventually changed.

Question 23

What else can be a helpful aid to remove barriers of nonadherence?

Answer 23

Motivational interviewing