Transcript Caglar MACIT

International Summit on
Clinical Pharmacy & Dispensing
The Impact of pharmacist-led patient
education on adherence to
antibiotic therapy in primary care
MSc. Pharm. Caglar MACIT
Yeditepe University, School of Pharmacy
Istanbul, Turkey
November 18-20, 2013 San Antonio, Texas, USA
Introduction
What is adherence?
 The term compliance or adherence can be described as
the extent of correlation between the patients’
obedience to the therapy and the advice of health
providers.
 Thus, it is related to the patient’s drug-taking attitude.
*Barber N WA. Churchill’s Clinical Pharmacy Survival Guide. Edinburgh: Churchill Livingstone; 1999.
*Segador J, et al. Int J Antimicrob Agents 2005;26, 56-61.
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Adherence can be affected by certain factors;
Dose & frequency of drug
Duration of treatment
Pharmacological factors (eg; adverse effects)
Psychosocial factors (eg; patient dissatisfaction)
Medical errors (eg; lack of patient information)
*Pechere JC, et al. Int J Antimicrob Agents 2007; 29: 245-53.
*Claxton AJ, et al. Clin Ther 2001; 23:1296-310.
*Jackson C, et al.Patient Educ Couns 2006; 61:212-8.
*Niederman MS. Int J Antimicrob Agents 2005; 26 Suppl 3:170-5.
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Antibiotics & Adherence
Antibiotics are efficient, potent, safe and life-saving
agents used to facilitate the healing of bacterial
infections.ɫ
Unnecessary and/or inappropriate use of these drugs
is a common cause of development and spread of
antibiotic resistance.ɫɫ
ɫ Hawkings NJ, Butler CC, Wood F. Patient Educ Couns 2008; 73:146-52.
ɫɫ http://www.acponline.org/patients_families/diseases_conditions/antibiotic_ resistance/.
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Antibiotics & Adherence cont...
Clinical Pharmacy is a health science discipline in
which pharmacists provide patient care that
optimizes medication therapy and promotes health,
wellness, and disease prevention.ɫ
Clinical pharmacists are active supporters of rational
drug use; it has been shown that they provide
patient care, and facilitate successful and effective
medication use, including antibiotic treatment.ɫɫ
ɫ
The definition of clinical pharmacy. http://www.accp.com/docs/about/ClinicalPharmacyDefined.pdf
(Accessed on 2013) (American Collage of Clinical Pharmacists)
ɫɫ Hand K.. J Antimicrob Chemother 2007; 60 Suppl 1:73-6.
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Aim of study
The aim of these studies were;
to investigate whether pharmacist-led patient education about prescribed
antibiotics has a positive impact on adherence.
Istanbul
Kars
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Materials & Methods
ISTANBUL (n: 60)
KARS (n:199)
Inclusion criteria
*Out-patients
* ≥ 18 years old
*Oral antibiotic use
Exclusion criteria
*Possible drug interactions between the prescribed drugs
*Possible allergic reactions to prescribed antibiotics
* ≤ 18 years old
n:31
Study group
*Received both verbal and written education regarding dose and frequency, use &
possible side effects. (Warning stickers were also used)
*How does resistance develop?
*Reccurence of disease and effectiveness of same antibiotic.
*Why is it important to finish all antibiotic medications?
n: 29
Control group
n: 99
n: 100
Educated about their medications verbally and in written instructions on dose and
frequency (prescribed by physician) NO EXTRA INFORMATION
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Material & Methods cont...
ISTANBUL (n: 60)
Data collection
KARS (n:199)
First questionnaire was applied when patients come to pharmacy
(socio-demographic, diagnosis, details of antibiotics, take info from physician or not, need
more info from pharmacist, having any allergy, and etc.)
Second survey was performed on telephone one day after the end of the treatment
(amount of pills remaining in blisters or container, omitting the treatment or missing a
dose, at what time patient takes drugs, feeling better or not , whether read medicine
insert)
Data analysis
*Self-administration Adherence pill count =
*Timing Adherence
*ATA (Administration and Timing Adherence)
*Statistical Analysis (SPSS v.17, Chicago,IL)
pills taken by patient
pills prescribed by physician
x 100
Limitations
* Because these studies were performed in two pharmacies, study population remained
limited.
*One of the method used in studies was based on a self-reported surveys due to the
phone call interviews. The reliability, especially objectivity, of the method depended on
the truthfulness of the patients.
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Results
Demographic results
(Kars study)
Female
80
60
40
20
0
(Istanbul study)
Male
67
44
32
30
56
Female
24
18
20
11
10
Study
Control
Male
7
0
Study
Control
Figure 1a & 1b:Gender distribution of patients in Kars and Istanbul
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(Kars study)
(Istanbul study)
Figure 2a & 2b: Educational status of participants in Kars and Istanbul
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120
108
100
80
60
40
91
18-30 y old
31 ≤ y old
32
28
20
0
Istanbul
Kars
Figure 3: Age distribution of participants
Table 1: Mean age of participants according to groups (Mean ± SD)
Mean age ± SD
Study group
Control group
Istanbul
37.77 ± 16.52
34.96 ± 16.10
Kars
32.28 ± 11.74
36.39 ± 13.73
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In which diseases are antibiotics prescribed mostly?
(Kars study)
(Istanbul study)
Upper respiratory
tract infections
Lower respiratory
tract infections
Skin infections
Genitourinary
infections
Gastrointestinal
infections
Dental infections
Eye infections
Upper respiratory tract infections
Lower respiratory tract infections
Genitourinary infections
Skin infections
Dental infections
Gastrointestinal infections
Figure 4a & 4b: Antibiotic prescriptions according to infection types
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Adherence Results
Table 2: Adherence rates of patients in Istanbul study
Adherence
Study group
(n=29)
Control group
(n=31)
p values
Did you quit antibiotic treatment deliberately after
feeling better? (AA)
Yes
No
3 (10,4%)
26 (89,6%)
9 (29,1%)
22 (70,9%)
0,438
At what time and how many pills did you take per
day? (TA)
Correct (time and dose)
Wrong (time and dose)
25 (86,2%)
4 (13,8%)
19 (61,2%)
12 (38,8%)
0,185
Did you get better following antibiotic therapy?
(ATA)
Yes
No
20 (68,9%)
9 (31,1%)
16 (51,6%)
15 (48,4%)
0,460
Chi Square Test
We can see that study group is more adherent than control group. Pharmacistled-education provides some benefits. However, the difference in adherence is 13
not significant.
Table 3: Adherence ratio of patients in Kars study
Adherence
Study group
(n=99)
Control group
(n=100)
p values
Did you quit antibiotic treatment deliberately after
feeling better? (AA)
Yes
No
15 (33,3%)
84 (54,5%)
30 (66,7%)
70 (45,5%)
0,012*
At what time and how many pills did you take per
day? (TA)
Correct (time and dose)
Wrong (time and dose)
69 (51,5%)
30 (46,2%)
65 (48,5%)
35 (53,8%)
0,480
Did you get better following antibiotic therapy?
(ATA)
Yes
No
92 (52,6%)
7 (29,2%)
83 (47,4%)
17 (70,8%)
0,032*
AA: Administration Adherence; TA: Timing Adherence; ATA: Administration&Timing Adherence
More patients in the study group used antibiotic until the last day of therapy (p < 0.05).
Patients in the study group are more AT Adherent than the control group. As a result,
subjective recovery rate is significantly higher.
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Table 4: Correlation between Administration Adherence (AA) and examination
period, number of pills in container and duration of therapy
Correlation with Administration Adherence
R
p values
Examination period- Administration adherence %
0,182
0,164
Number of pills in container- Administration adherence %
-0,257
0,048*
Duration of therapy- Administration adherence %
-0,260
0,045*
*Spearman’s rho correlation test
Table 5: Effect of examination period, number of pills in container and duration of
therapy to Administration & Timing Adherence (ATA)
ATA
Not ATA
p values
Examination period
(Mean ± SD)
14,30 ± 9,63 13,70 ± 8,14
0,798
No of pills in container
(Mean ± SD)
8,87 ± 4,32
12,33 ± 4,35
0,003*
Duration of therapy
(Mean ± SD)
5,69 ± 2,20
7,07 ± 2,23
0,007*
*Student T test ; Mann-Whitney U test ; SD: Standart Deviation
According to these results:
- number of pills
- duration of therapy
Adherence
(Compliance)
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Table 6: Effect of age on adherence in Istanbul study
Age
18 – 30
Fully adherent
(n: 32)
15 (41,7%)
Not fully adherent
p value
17 (70,8%)
0,027*
31 ≤
(n: 28)
21 (58,3%)
7 (29,2%)
*Chi Square test
 In the study performed in Istanbul, patients older than 30 y old
were observed to be more adherent than younger (18 - 30 y old)
participants, especially in the study group. This differece in
adherence between age groups is significant (p: 0,027).
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Discussion
 In our study, two subjective methods (self-questionnaire and
telephone interviews) and one objective method (pill count)
were combined in order to measure adherence to antibiotic
therapy.
 The pill count method was performed by patients themselves
so it was considered as partially objective. However, it should
preferably be carried out by a health professional.
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 Among demographical characteristics, only age (participants
> 30 are more adherent) affected the adherence of patients,
and only in the Istanbul study (p: 0,027).
 The length of time taken for the physician to examine the
patient did not significantly affect adherence (p: 0,164 for AA and
p: 0,798 for ATA).
 It was observed that there was a negative correlation
between number of doses prescribed, the duration of therapy
and adherence in terms of ATA.
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 In Istanbul,
 No statistically significant differences between study and control
groups were observed in terms of adherence.
 However, administration, timing and ATA rates were found higher in
the study group.
 Lack of significance may be due to the small numbers of patients in
this study (n: 60). So, the study should be expanded to include more
participants.
 Finally, as in the studies (Claxton AJ et al. in 2001; Kardas P. in
2002 and 2003) gender, education, and working status did not
affect adherence of patients; however, the age of patients in
Istanbul did seem to affect adherence.
*Claxton AJ.et al. Clin Ther 2001; 23:1296-310.
** Kardas P. J Antimicrob Chemother 2002;49:897-903.
*** Kardas P. The Journal of Applıed Research in Clinical and Experimental Therapeutics 2003. (Accessed at 2013:
http://www.jarcet.com/articles/Vol3Iss2/Kardas.htm.)
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 Many studies that support our studies, demonstrate that
structured education provided to patients by physicians and
pharmacists can improve adherence to prescribed therapy.
 Al-Eidan et al performed a study in 2002 on adherence of patients to
Helicobacter pylori eradication therapy; adherence were measured in
study and control groups, 92.1% and 23.7% respectively (p= 0,02).
 In a study carried out by Kardas P. in 2002, effect of pharmacist-led
education on adherence to antibiotic treatment in respiratory tract
infections was shown.
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 Segador J et al. performed a study in 2005 on effect of patient
education on adherence to antibiotic treatment in acute sore throat
therapy and study group were observed more adherent.
 Morgado MP et al. carried out a study on hypertension in 2011 and
this study showed that improved adherence and blood pressure
control were provided by pharmacist-led patient education.
 In a study performed in midwest USA by Taitel M et al. in 2012, the
positive impact of face-to-face patient education provided by the
pharmacist on adherence to statins was demonstrated.
 On the other hand, one study suggested that patients did not
adhere to penicillin treatment even although they were
informed and educated about their disease and aim of the
treatment*.
*Kardas P. The Journal of Applıed Research in Clinical and Experimental Therapeutics 2003. (Accessed
at 2013: http://www.jarcet.com/articles/Vol3Iss2/Kardas.htm.)
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Recommendations arising from this research…
In order to increase adherence,
 Antibiotics should be prescribed following
culture and sensitivity testing. Thus, both
adherence to antibiotic treatment and
healing ratio of patients will increase. Also,
development of resistance against antibiotics
can be prevented.
 Patients should be instructed to take their
drugs with/without, before or after meals
according to the pharmacokinetic properties of drug.
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 Patients should be educated not only about
their usage, but also about possible side effects,
the importance of adherence to therapy,
the aim of therapy, and the duration of treatment.
 Patients should be advised to set the alarm
on their mobile phones or clocks to remind
them to take their medications.
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Conclusion
 Pharmacists may be able to play an important role in providing
pharmaceutical care to patients receiving antibiotic treatment via
patient education.
 They can also provide a counseling service to their patients and
help to ensure patients use their medications appropriately thus
enhancing rational drug use.
 Further researches should be performed in order to compare
adherence of patients to the antibiotic therapy and demonstrate
the potential benefit and importance of the clinical pharmacist-led
patient education in the provision of antibacterial therapy.
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for their contribution
Assist. Prof. Dr. Philip M. CLARK
Assist. Prof. Dr. Latif OZBAY
Res. & Teach. Assist. S. Beril KADIOGLU
MSc. Pharm. Nefise Bilge ESEN
MSc. Pharm. Serdar Sinan GUNES
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