BROUGHT TO YOU BY MEDICINES ADHERENCE The Role of the Pharmacist Developed by Pfizer 15 May, 2017 This learning module is intended for UK healthcare professionals only. Job code; PP-GEP-GBR-0682. Date of preparation; May 2017
Agenda I. Training objectives II. Section 1: The Importance of Good Adherence and the Consequences of Poor Adherence II. Section 2: Medicines Optimisation vs Medicines Adherence III. Section 3: Non-Adherence Patient Case Examples IV. Conclusions This learning module is intended for UK healthcare professionals only. Job code; PP-GEP-GBR-0682. Date of preparation; May 2017
Training Objectives As a pharmacist, you are best placed to support patients with their medicines This educational resource aims to help you: Understand the consequences of poor adherence and the benefits of good adherence Understand the barriers to adherence Support patients to get the desired outcomes from their medicines Understand the principles of Medicines Optimisation and how these can help you adopt a patient-centred approach in your practice
1 The Importance of Good Adherence and the Consequences of Poor Adherence This learning module is intended for UK healthcare professionals only. PP-GEP-GBR-0682. Date of preparation; May 2017
What is Adherence? Adherence is the extent to which the patient s actions matches the agreed recommendations 1 A third of patients are non-adherent 10 days after taking their medication 2 Non-adherence includes: 3 - Failing to get a prescription or subsequent repeats dispensed - Discontinuing a medicine before the course of therapy is complete - Taking more or less medicine than prescribed - Taking a dose at the wrong time Healthcare professionals have a duty to help patients to make informed decisions 1 - About treatment - About using their medicines as directed References: 1. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed March 2017 2. RPS (2013) Medicines Optimisation: Helping patients to make the most of medicines, Available at https://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf Last accessed March 2017 3. Buxton, A. Tackling the challenge of non-adherence, Available at http://archive.psnc.org.uk/data/files/eveents/cpc_10/programme_and_presentations/nonadherence_workshop_alastair_buxton.pdf Last accessed March 2017
Why is Adherence Important? According to the World Health Organisation (WHO): 1 Increasing the effectiveness of adherence interventions might have a far greater impact on the health of the population than any improvement in specific medical treatments Poor adherence to treatment of chronic diseases is a massive problem 2-50% of medicines prescribed for long-term conditions are not taken as intended 2 The impact of adherence increases as the burden of chronic disease grows 1 Non-adherence cannot be seen as the patient s problem it represents a fundamental limitation in the delivery of healthcare 3 References: 1. WHO (2003) Adherence to long-term therapies, Available at http://www.who.int/chp/knowledge/publications/adherence_report/en Last accessed March 2017 2. NICE (2015) Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, Available at https://www.nice.org.uk/guidance/ng5 Last accessed March 2017 3. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed March 2017
Consequences of Non-Adherence Up to half of patients don t take their medication as recommended 1* In hospitals there is a prescribing error rate of almost 9% 1* Patient consequences: 2 Sub-optimal management of their condition Potential harm resulting from sub-optimal management This represents a failure to translate technological benefits of new medicines into health gain for individuals 3 * Based on UK data References: 1. RPS (2013) Medicines Optimisation: Helping patients to make the most of medicines, Available at https://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf Last accessed March 2017 2. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed November 2016 3. Buxton, A. Tackling the challenge of non-adherence, Available at http://archive.psnc.org.uk/data/files/eveents/cpc_10/programme_and_presentations/nonadherence_workshop_alastair_buxton.pdf Last accessed March 2017
Barriers to Adherence Barriers to adherence fall into two categories: Unintentional Poor recall 1 Difficulties understanding the instructions 2 Problems using the treatment 2 Inability to pay for the treatment 1 Simply forgetting 1,2 Associated with the individual s beliefs 2 Intentional The patient decides not to follow the recommended instructions 1,2 Taking lower or higher doses 2 Examples of barriers to adherence: 2 Patient access to a specific healthcare setting Transport availability Cost of the medicine Communication Knowledge of the disease Comorbidities Patient s support system Cultural and health References: 1. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed March 2017 2. PGEU (2008) Targeting Adherence, Available at http://www.pgeu.eu/en/policy/5-adherence.htm Last accessed March 2017
Medication Changes and Adherence Adherence to long-term therapy for chronic conditions is particularly poor 1 Polypharmacy in the elderly patient population causes an increased risk of negative health outcomes 2 Changing medicines can result in intentional treatment disruptions and double dosing 3 Changes in medicine appearance can cause confusion 3 References: 1. WHO (2003) Adherence to long-term therapies, Available at http://www.who.int/chp/knowledge/publications/adherence_report/en Last accessed March 2017 2. Mayer R. et al. (2014) Clinical consequences of polypharmacy in the elderly, Available at https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3864987/ Last Accessed March 2017 3. Hakonsen, H., Toverud, E.L. (2012) A review of patient perspectives on generics substitution, Available at http://gabi-journal.net/a-review-of-patient-perspectives-on-generics-substitution-what-are-the-challenges-for-optimal-drug-use.html Last Accessed March 2017
Mortality rate Consequences of Poor Adherence A Cardiovascular Example Blood pressure remains uncontrolled in two thirds of hypertensives 1,2 Non-adherence to anti-hypertensive medication has a major impact on: 2 - Health outcomes - The cost of care A landmark study showed a positive effect on 8 blood pressure control with hypertensives following adherence-promoting interventions 2 6 A similar study showed a substantial decrease in death due 4 to cardiovascular disease 2 2 0 20 18 16 14 12 10 Hypertension-related Mortality 3 19% 8.9% Control group Intervention group References: 1. PGEU (2008) Targeting Adherence, Available at http://www.pgeu.eu/en/policy/5-adherence.htm Last accessed March 2017 2. WHO (2003) Adherence to long-term therapies, Available at http://www.who.int/chp/knowledge/publications/adherence_report/en Last accessed March 2017 3. Morisky et al. (1983) Five-year blood pressure control and mortality following health education for hypertensive patients Am J Public Health, 73(2) pp 153-162 * Graph adapted from Morisky et al. (1983)
Level of adherence Consequences of Poor Adherence A Women s Health Example The effectiveness of hormonal contraceptives is adversely impacted by adherence difficulties 1 Many women disclose poor adherence to oral contraceptives 1 Effective communication about oral contraceptive use is required between healthcare professionals and patients 1 Regular interventions were more likely to improve adherence to oral contraceptives after 3 months * References: 1. Halpern, V. et al (2013) Strategies to improve adherence and acceptability of hormonal methods of contraception, Available at https://www.ncbi.nlm.nih.gov/pubmed/24163097 Last accessed March 2017 * Graph adapted from outcomes data found in Halpern, V. et al (2013) Month 1 Month 2 Month 3
2 Medicines Optimisation Versus Medicines Adherence This learning module is intended for UK healthcare professionals only. PP-GEP-GBR-0682. Date of preparation; May 2017
Medicines Optimisation versus Medicines Adherence 1 Medicines Optimisation is a patient-centred approach to medicines adherence. It is about helping patients with their medicines by: - Helping patients to understand and use their medication - Improving their outcomes Pharmacists can support patients with their medicines using these 4 key principles Ultimately Medicines Optimisation can help encourage patients to take ownership of their treatment References: 1. RPS (2013) Medicines Optimisation: Helping patients to make the most of medicines, Available at https://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf Last accessed March 2017 Image adapted from RPS (2013)
Helping Patients to Understand & Use Their Medications 1 Using the 4 principles of Medicines Optimisation in your practice, you can support your patient with their medicines 1. Aim to understand the patient s experience Elicit patient s feeling his or her ability to follow the treatment regimen 2. Evidence-based choice of medicines Treatments of limited clinical value are not used and medicines no longer required are stopped 3. Ensure medicines use is as well tolerated as possible Patients taking several medicines for long-term conditions are most likely to have errors 4. Make these principles part of your routine practice Make these medicines optimisation principles part of your routine practice References: 1. RPS (2013) Medicines Optimisation: Helping patients to make the most of medicines, Available at https://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf Last accessed March 2017
Assessing Adherence 1 Assessing adherence in practice requires: - Recognition that non-adherence is common - A patient-centred approach - A no-blame approach - Identification of specific perceptual and practical barriers for each patient - A frank and open discussion Ways to make it easier to report non-adherence - Patient records their medicine taking - Patient diary to monitor condition - Simplifying dosage regimen - Using alternative packaging for the medicine - Using multi-compartment medicines system References: 1. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed March 2017
Assessing Adherence 1 If side effects are a problem: - Discuss these and the benefits of treatment - Suggest ways of managing side effects - Consider adjusting the dosage or other strategies Understanding the patient s perspective Patients sometimes make decisions about medicines based on their: - understanding of their condition and possible treatments - view of their need for the medicine and their concerns You can improve your understanding by asking patients: - What they know, believe and understand about their medicines - About their need for a particular treatment - About any general or specific concerns whenever you dispense or review medicines References: 1. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed March 2017
Assessing Adherence 1 Review medicines: At agreed intervals Review patients knowledge, understanding and concerns about medicines Enquire about their need for the medicine Offer repeat information and review, especially when treating long-term conditions with multiple medicines - Ask about adherence when reviewing medicines References: 1. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed March 2017
Increase Patient Involvement 1 Increase patient involvement by: - clearly explaining the condition - the pros and cons of treatment - clarifying what the patient hopes the treatment will achieve - talking and listening to the patient and not making assumptions about patients preferences about treatment Help patients make decisions based on likely benefits and risks rather than misconceptions Accept that patients - may have different views from healthcare professionals - ask about risks, benefits and side effects - have the right to decide not to take a medicine if they have the capacity to have the information to make an informed decision References: 1. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed march 2017
3 Patient Case Example of Non-adherence This learning module is intended for UK healthcare professionals only. PP-GEP-GBR-0682. Date of preparation; May 2017
Patient Case Example Non-adherence Pharmacist: Hello, it s nice to see you. How are you? Patient: I m fine, thank you. I have come to pick up a prescription Pharmacist: Good. I see you have got another prescription for the same cholesterol medication Patient: Yes Pharmacist: I expected you would have been in a couple of weeks ago to get a new prescription filled. How are things going with your cholesterol medication? Patient: Oh fine
Patient Case Example Non-adherence Pharmacist: Do you still have many pills at home? Patient: Yes, a few Pharmacist: How often are you taking them? Patient: Well, to be honest just most days now Pharmacist: You ve recently been switched to another version of cholesterol medication haven t you? Patient: Yes. Last time. And I don t think it suits me very well Pharmacist: I see why do you think that it doesn t suit you? Patient: It leaves a funny taste in my mouth* Pharmacist: Oh, I imagine that could be unpleasant Patient: Yes, it is What would you do next? see next slide
Patient Case Example Non-adherence What would you do next? Pharmacist: I see why do you think that it doesn t suit you? Patient: It leaves a funny taste in my mouth* *This adverse event might qualify as a reportable event. Please refer to your local pharmaceutical regulations regarding your local obligations.
Patient Case Example Non-adherence Pharmacist: It is very important you take your cholesterol medication every day, so let s discuss some options. Patient: OK Pharmacist: Have you tried a drink or a light flavoured snack, like a few nuts, to take the taste away? Patient: Yes. But it really didn t help Pharmacist: Ok what do you think would help? Patient: Can I go back on the old version I was on? Pharmacist: Let me check with your doctor.* Patient: Oh, that s fine. I just want to go back to what I know suited me Pharmacist: calls doctor to discuss What would you do next? *The patient must go back and check with their physician in order to go back to the previous medication.
Patient Case Example Non-adherence Pharmacist: I can understand that. Your doctor agrees that I can fill this prescription with the old version of your cholesterol medication Patient: Great Pharmacist: Can I also check when you take your pill usually? Patient: In the morning Pharmacist: And do you normally remember to take them? Patient: Usually Pharmacist: Some people find it useful to keep their pills by the coffee or water glasses to jog their memory in the morning Patient: What a great idea thank you! Pharmacist: You are welcome I will check with you next time to see how you are getting on, as taking your cholesterol medication is important. Just call or come in if you have questions in the meantime
Summary Adherence is a vitally important component of medication effectiveness and health outcome optimisation 1 However, adherence to long-term therapy for chronic illnesses may be as low as 50% 2 There are many barriers to adherence 3 - One of the most common is confusion over pill changes with the increased use of generic medicines 4 By adopting a patient-centred approach, pharmacists can help patients to improve adherence to their medicines 3 References: 1. RPS (2013) Medicines Optimisation: Helping patients to make the most of medicines, Available at https://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf Last accessed March 2017 2. NICE (2015) Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, Available at https://www.nice.org.uk/guidance/ng5 Last accessed March 2017 3. PGEU (2008) Targeting Adherence, Available at http://www.pgeu.eu/en/policy/5-adherence.htm Last accessed March 2017 4. Hakonsen, H., Toverud, E.L. (2012) A review of patient perspectives on generics substitution, Available at http://gabi-journal.net/a-review-of-patient-perspectives-on-generics-substitution-what-are-the-challenges-for-optimal-drug-use.html Last Accessed March 2017
Summary 1 Healthcare professionals need to consider perceptual and practical factors that influence the patient s motivation and ability to adhere to agreed treatment Applying this in practice requires: - Recognition that non-adherence is common - A patient-centred approach - A no-blame approach - Identification of specific perceptual and practical barriers for each patient - A frank and open discussion References: 1. NICE (2009) Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, Available at https://www.nice.org.uk/guidance/cg76/chapter/introduction Last accessed March 2017
MEDICINES ADHERENCE Self-assessment quiz
Q1) Which of the following is not a barrier to adherence? A) Inability to access a pharmacy B) Confusion over continual changes in drug appearance C) Good knowledge of drug costs D) Complex treatment regimen
Q1) Answer C) Good knowledge of drug costs
Q2) What should the pharmacist assume about a patient s switch from a branded drug to a generic drug? A) Should not assume anything, but should make sure the patient is fully informed about their options B) Should assume that the patient would like to pay to stay on the originator drug C) Should assume that the patient would like to switch to the generic drug D) Should assume that the patient knows what the costs of their medications are Job code and date of prep
Question 2) Answer A) Should not assume anything, but should make sure the patient is fully informed about their options
Q3) Non-adherence includes which of the following? A) Failing to get a prescription or subsequent repeats dispensed B) Discontinuing a medicine before the course of therapy is complete C) Taking more or less medicine than prescribed D) Taking a dose at the wrong time E) All of the above
Question 3- Answer E) All of the above
Q4) What of the below factors DOES NOT lead to non-adherence? A) Taking lower or higher doses B) Evidence- based choice of medicines C) Polypharmacy and changes of medicines D) Difficulties with understanding the instructions of a pharmacist
Question 4- Answer B) Evidence- based choice of medicines
Question 5- What are the consequences of non-adherence? A) Sub-optimal management of a patient s condition B) Adverse effects as a result of excess dosage C) Increase in costs of care D) All above answers are correct
Question 5- Answer. D) All above answers are correct
Contact Us For general inquiries or information about Pfizer medicines, you can contact Pfizer on 01304 616161. PP-GEP-GBR-0682. Date of preparation; May 2017