Transcript measuring adherence

Measuring Compliance
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Self report Problem is patients overestimate
their compliance level.
Measuring Compliance
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Therapeutic outcome. We can not be sure
that the recovery from an illness has been
owing to the treatment. It could have been
spontaneous, or perhaps the patient is
suffering less stress.
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Health worker estimates Very unreliable.
Measuring Compliance
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Pill and bottle counts Problem is patients
can throw the pills away!
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Mechanical methods Device for measuring
the amount of medicine dispensed from a
container. Expensive and not fool-proof.
Measuring Compliance
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Biochemical tests Blood tests or urine tests.
Accurate, but Expensive, Inconvenient.
Urine and blood samples are accurate ways
of checking on compliance but a patient
could easily take the required dose just
before the appointment with the doctor.
Also one has to take account of a patients
metabolism or biochemical response to the
prescribed drugs.
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If multiple readings are taken by using
several of the methods that check
compliance then a more accurate picture of
the patients' compliance can be made.
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If a patient is shown to be non-compliant
by several different measures then we can
be almost certain that the subject really has
not complied.
TrackCap
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A treatment that is growing in the UK is
oral asthma medication, and measuring
adherence rates will help us to measure the
effectiveness of the medicines.
TrackCap
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If people follow the prescribed treatment
programme they should reduce the attacks
of breathlessness, but many people forget or
decline to take the medicine regularly.
TrackCap
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A study in London used an electronic device
(TrackCap) on the medicine bottle which
recorded the date and time of each use of
the bottle (Chung and Naya, 2000).
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The patients were told that adherence rates
were being measured, but were not told
about the details of the TrackCap.
TrackCap
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The medicine was supposed to be taken
twice a day, so a person was seen as
adhering to the treatment if the TrackCap
was used twice in a day, 8 hours apart.
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Over a twelve-week period, compliance
was relatively high (median 71 per cent),
and if the measure was a comparison of
TrackCap usages with the number of tablets
then adherence was even higher (median 89
per cent).
Sherman et al., 2000
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Another study on asthma medicines, this
time inhalers, checked for adherence by
telephoning the patient’s pharmacy to assess
the refill rate (Sherman et al., 2000).
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They calculated adherence as a percentage
of the number of doses refilled divided by
the number of doses prescribed.
Sherman et al., 2000
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This study of over 100 asthmatic children in
the USA was able to compare pharmacy
records with doctor’s records and with the
records of the medical insurance claims for
treatment.
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They concluded that the pharmacy
information was over 90 per cent accurate
and could therefore be used as basis for
estimating medicine use.
Sherman et al., 2000
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They also found that adherence rates were
generally quite low (for example 61 per cent
for inhaled corticosteroids), and that doctors
were not able to identify the patients who
had poor adherence.
The Role of Medication Compliance
in Improving Outcomes of
Pharmaceutical Care
Sweeping changes continue to
reshape the practice of pharmacy.
The pharmacy professional needed
today is a knowledgeable drug expert
and skilled, persuasive
communicator. This pharmacist
embraces a new practice model pharmacy care.
The Pharmacy Care Process
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Collect and utilize patient information (build rapport)
Identify patients’ drug related problems
Develop solutions
Select and recommend therapies
Follow up to assess outcomes
Vision
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Compliance as a partnership between patients,
physicians and even managed care to achieve
desired health outcomes – now called
“concordance”.
Managing medication compliance = improved
outcomes
complex, but, interesting implications for
health practitioners
Possible Challenge
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Improved compliance may also mean
more drug related problems.
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over users who take less medication may
experience increased symptoms
under users who take more doses may
experience more side effects
Outcomes
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Economic
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increased cost of medications
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lower total health care costs
Clinical
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To patients, insurers, government
better control of disease, symptoms
Humanistic
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patient satisfaction with therapy
prescriber satisfaction?
When patients do not take their
medications correctly – what
happens?
When patients do not take their
medications correctly – what
happens?
May not get better
 Can get sicker / worsen disease
 Can have a relapse
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The costs of noncompliance:
> 100 billion dollars annually
 125,000 unnecessary deaths
 10% (more than 1,000,000) of all
hospitalizations may be due to
noncompliance
 50% of all medication use
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Health Effects
increased morbidity (sickness)
 treatment failures
 exacerbation of disease
 more frequent physician visits
 increased hospitalizations
 death
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Economic effects:
increased absenteeism
 lost productivity at work
 lost revenues to pharmacies
 lost revenues to pharmaceutical
manufacturers
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Dimensions of Compliance: some
things we think we know….
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Initial noncompliance or defaulting
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Refill compliance or persistence
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2% - 20%, possibly as high as 50%
average 8.7%
Decreases over time
Not all non-compliance is improper
medication use
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rational noncompliance
Benchmark compliance rates:
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Disease
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Epilepsy
Arthritis
Hypertension
Diabetes
Oral contraceptives
Rates of
noncompliance
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HRT
Asthma
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30% to 50%
50% to 71%
40% (average)
40% to 50%
8%
57%
20%
Persistence
100
Product persistency
curves
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after 1 year as much
as a 50 percent
decline
after 5 years,
compliance as low
as 29% to 33%
greatest declines in
first six months
80
Percent
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Cozar
Fosamax
Zocor
60
40
20
0
1
3
5
7
9 11 13
Months
Improper medication use:
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Over or under use, wrong time
Taking the wrong medicine
Not finishing medication
Administration errors
Using another persons medication
Using old, possibly expired medication
Patient Considerations
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Factors believed to affect compliance
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patient knowledge
prior compliance behavior
ability to integrate into daily life / complexity of
the particular drug regimen
health beliefs and perceptions of possible benefits
of treatment (self efficacy)
social support (including practitioner
relationships)
Patient Considerations
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Factors which are NOT believed to be
associated with compliance
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age, race, gender, income or education
patient intelligence
actual seriousness of the disease or the
efficacy of the treatment
Patients at higher risk:
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Asymptomatic conditions
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Chronic conditions
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hypertension, arthritis, diabetes
Cognitive impairment
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hypertension
dementia, Alzheimers
Complex regimens
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poly pharmacy, QOD
Patients at higher risk:
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Multiple daily dosing
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Patient perceptions
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effectiveness, side effects, cost
Poor communication
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qd < bid < tid, < qid
patient practitioner rapport
Psychiatric illness
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less likely to comply
Issues
 Measuring
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compliance
Several methods
 Non-response
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Did the doctor choose the right drug, dose,
etc.?
 Compliance
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v. non-compliance
is not easy to pinpoint
Compliance problems cuts across drugs,
diseases, prognosis, and symptoms.
Issues
 Measuring
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compliance
patient reports, clinical outcomes, pill counts, refill
records, biological and chemical markers, monitors
MAS, MOS, BMQ
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Medication Adherence Scale, Medical Outcomes
Study, Brief Medical Questionnaire
Range from complicated to simple, such as:
• How often have you taken your prescribed
medication in the past four weeks?
High Tech Tools To Improve
Compliance
Strategies to improve compliance
 personal
interaction with your pharmacist, through
counseling and communication, etc.
 multimedia educational campaigns
 patient education, counseling, written information,
special labels
 teaching methods for self monitoring
 new idea….contracts with patients?
 devices, reminders (mail, telephone), special
packaging
 follow-up
The “RIM” Technique
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Recognize
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Identify
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using objective and subjective evidence, the
pharmacist can determine if the patient may have
an existing compliance problem
determine the causes of noncompliance with
supportive probing questions, empathic responses,
and other universal statements
Manage
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develop partnerships with patients
Identifying Non Compliance
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information from the patient
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certain clinical outcomes
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patient comments, concerns, questions
non response to treatment
information from refill records
Pharmacy Care Skills Needed:
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Patient skills needed for behavior
modification
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problem solving
self monitoring
develop systems for reminders
enlisting social support – get family involved
identify positive and negative compliance
behaviors
Actions Needed
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More fully implement the pharmacy care model
Challenges:
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pharmacist commitment to pharmacy care
enhance the key skills necessary for patient care
develop partnerships with physicians, MCO’s and
patients
integrate, coordinate and manage drug use
Benefits of improved
compliance:
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For:
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Patients - better outcomes and quality of life
Practitioners – healthier, more loyal patients
Managed care - lower total HC expenditures
Pharmaceutical Industry - increased sales