Three of four American patients do not take their medications as prescribed, according to the National Council on Patient Information and Education (NCPIE). Non-adherence is serious enough, NCPIE reports, that it leads to $47 billion in drug-related hospitalizations each year.
By providing patient counseling and education, medication adherence monitoring, and medication reviews, pharmacists can increase medication adherence and reduce medication errors. In fact, the New England Healthcare Institute (NEHI) stresses the benefits of pharmacist patient counseling and education in addressing the chronic problem of medication non-adherence in an August 2009 report, Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease, A NEHI Research Brief. Yet, NCPIE stresses in a national action plan that while the challenge of poor medication adherence has been discussed for the last three decades, it has not received enough attention as a serious public health issue, leaving Americans uneducated on the significance of the issue. Both NEHI and NCPIE emphasize that many changes to enable improved pharmacist communication with patients are still needed, and that non-adherence rates and associated costs have been rising. Reports from organizations such as these point to changes that are needed to enable pharmacists to provide effective patient education and intervention.
Pharmacists know that taking medications incorrectly can increase the chances of severe medical complications or even death, but many Americans are not aware of the possible risks, contraindications, and adverse effects associated with the prescription medications they are taking. Information from NCPIE highlights the tremendous need to enable pharmacists to provide effective patient counseling, education, and medication monitoring to avoid medication misuse. For example, according to a 2006 survey cited in the NCPIE report, the types of nonadherence are as follows:
- 49% of patients have forgotten to take a prescribed medication;
- 31% of patients have not filled prescriptions;
- 29% of patients stop taking their medications before the supply runs out; and
- 24% take less medication than recommended.
Seniors and children are more prone than other patients to incorrectly use medications. Seniors are vulnerable because they often use multiple medications, and may have declining vision, hearing, and memory. Children are vulnerable because parents administering medication to children can sometimes be confused by different instructions for use based on a child’s age, weight, and other medical conditions.
Chronically ill patients are another vulnerable population, with medication adherence dropping after the first six months of treatment. The chronically ill are also particularly vulnerable to poor health outcomes if they do not adhere closely to their medication regimen, and non-adherence can lead to more outpatient medical care visits and hospitalizations. Further, patients with chronic disease such as diabetes and heart disease, who do not adhere to medication instructions, have significantly higher mortality rates than those who do adhere.
Barriers to Adherence
NCPIE states that nonadherence is America’s “other drug problem” and cites the many factors contributing to the problem including “lack of awareness among clinicians about basic adherence management principles, poor communications between patients and clinicians, operational aspects of pharmacy and medical practice, and professional barriers.” NEHI also identified several barriers to medication adherence, from the perspective of the patient including side effects, the challenge of managing multiple prescriptions, misunderstanding their disease, forgetfulness, imperfect drug regimens, cognitive impairments, and a reduced sense of urgency due to asymptomatic conditions.
Effective Communication Increases Adherence
Many barriers to adherence can be addressed, at least in part, by communication strategies. For example, NCPIE includes on its “Recommendations to Improve Adherence” Web page, a section for pharmacists and educators listing six steps to help patients adhere to medication regimens. NCPIE’s suggestions include several steps involving effective communication with patients. In fact, the first suggestion listed is that pharmacists gather and provide medicine information and initiate active dialogue with patients, including asking questions and discussing care plans, so that pharmacists can use the information to make better decisions. NCPIE also suggests monitoring individual patients for compliance on a monthly basis and sharing findings with the patient and his or her other health care providers. In “Prescription Medication Compliance: A Review of Baseline Knowledge,” NCPIE also suggests that pharmacists should make patients aware of the various medication adherence aids and devices available, and instruct patients and caregivers on home monitoring activities.
Such patient education and intervention efforts can be effective in improving medication adherence as reported in Thinking Outside the Pillbox. For example, one recent study concluded that patient education visits by a pharmacist to elderly patients using three or more medications improved adherence by nearly 12%. Another study found that elderly patients who were taking three or more medications and received pharmacist counseling before and after hospital discharge showed 43% greater adherence compared to patients who did not receive this type of counsel.
Yet another study, which focused on patients with heart failure, found that pharmaceutical counseling combined with dose simplification increased adherence by 46%. Further, NEHI points out that the medication therapy management (MTM) services promoted as part of the 2003 Medicare Modernization Act have helped to increase medication adherence among Medicare beneficiaries.
Patient Literature Important
While patient counseling and the other strategies have shown positive results, some patient factors can make matters more challenging. For example, pharmacists have noted that often the person picking up the prescription is not the patient. In such cases, easy-to-understand medication literature may be the primary means of encouraging adherence. Pharmacists recognize this need as illustrated in the Boehringer Ingelheim Pharmaceuticals, Inc 2006 “10 Steps to Customer Satisfaction.” According to the Wilson Health Information survey used in this report, more than 95% of pharmacists say that receiving productspecific, patient-counseling literature from manufacturers helps in providing effective patient counseling.
Yet, the Institute for Safe Medication Practices also stresses that low literacy skills prevent many patients from proper medication adherence because they are not able to understand medication labels or instructions. ISMP points out that 90 million Americans read below the fifth grade level, but the majority of consumer medication instruction sheets are written at a ninth grade level or above. A study published in the American Journal of Health-System Pharmacy concludes that low literacy leads to a high level of misunderstanding of prescription drug warning labels and to patients misusing their medications. Including images that effectively illustrate medication instructions may assist patients with low literacy skills.
Future Changes Warranted
Re-educating patients, further study of the effects of pharmacist communication, and updating pharmacy education curriculum are changes that can facilitate effective pharmacist-patient communication in the future. Several organizations emphasize the need to educate the public about the expanding role of pharmacists. Pharmacists surveyed for the Boehringer Ingelheim study noted the need to re-educate the public about the services pharmacies are providing, and to change their view of pharmacy from a pill dispensary to a source of medication information. And a 2006 policy brief from the Center for Health Improvement, based on surveys and studies of California pharmacists, stresses the need to educate patients about the changing practice of pharmacy so that patients will learn to rely on pharmacists for medication and health information.
More data and documentation, as well as updating pharmacy curriculum, can also provide pharmacists with information that will help them move communication and education efforts forward. Many organizations and researchers call for more studies to document evidence that pharmacist intervention does decrease rate of errors, and increase medication adherence. NCPIE calls on the federal government to begin collecting information on medication management and adherence intervention best practices. NCPIE also suggests that colleges of pharmacy and continuing education programs adopt curriculum on patient adherence management, train faculty appropriately, and include patient adherence management as a graduation competency.
Pharmacy Compliance Needed
According to “Medication Non-adherence: A Call to Action,” published in the Fall 2009 North Carolina Pharmacist, “pharmacists are uniquely qualified to discuss the importance of medications and adherence with their patients.” In fact, a portion of the North American Pharmacist Licensure Examination ® (NAPLEX®) addresses candidates’ knowledge and judgment related to providing recommendations and health care information to patients. Specifically, as detailed in the NAPLEX blueprint, area 3, 11% of the NAPLEX questions require the examinee to demonstrate that they can assess, recommend, and provide health care information that promotes public health, including identifying sources of drug and health information for consumers, and recommending appropriate resources to address questions or needs.
Yet, according to the North Carolina Pharmacist article, while medication non-adherence is a widespread problem, “few pharmacies have protocols in place to address the need for patient education regarding medication adherence and few pharmacists in the US routinely discuss the importance of medication adherence with their patients.”
NABP’s forthcoming community pharmacy accreditation program can help address this need by specifying requirements for pharmacy policies and procedures that guide and monitor patient care, medication therapy management programs, and other patient safety initiatives. The community pharmacy accreditation program aims to assist boards of pharmacy in ensuring that community pharmacies implement and maintain continuous quality improvement standards, and implement and maintain effective systems, including pharmacist counseling, for measuring and improving patient care and medication therapy adherence. By ensuring compliance in these areas, the community pharmacy accreditation program is expected to result in reduced rates of quality related events.
Updating pharmacy policies will empower pharmacists to offer and allow time for patient counseling and education services. Further, pharmacist communication efforts can be assisted by re-educating patients about the pharmacy as the source for medication information, providing resources such as patient literature, promoting continued study and documentation of pharmacist intervention results, and creating continuing education training and college curriculum that include communication skills and strategies as a component.