Measuring Compliance n Self report Problem is patients overestimate their compliance level.

Measuring Compliance n 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. n Health worker estimates Very unreliable.

Measuring Compliance n Pill and bottle counts Problem is patients can throw the pills away! n Mechanical methods Device for measuring the amount of medicine dispensed from a container. Expensive and not fool-proof.

Measuring Compliance n 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.

n 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.

n 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 n 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 n 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 n 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). n The patients were told that adherence rates were being measured, but were not told about the details of the TrackCap.

TrackCap n 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. n 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 n 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). n They calculated adherence as a percentage of the number of doses refilled divided by the number of doses prescribed.

Sherman et al., 2000 n 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. n 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 n 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 n Collect and utilize patient information (build rapport) n Identify patients’ drug related problems n Develop solutions n Select and recommend therapies n Follow up to assess outcomes

Vision n Compliance as a partnership between patients, physicians and even managed care to achieve desired health outcomes – now called “concordance”. n Managing medication compliance = improved outcomes n complex, but, interesting implications for health practitioners

Possible Challenge n Improved compliance may also mean more drug related problems. – over users who take less medication may experience increased symptoms – under users who take more doses may experience more side effects

Outcomes n Economic – increased cost of medications n To patients, insurers, government – lower total health care costs n Clinical – better control of disease, symptoms n Humanistic – patient satisfaction with therapy – prescriber satisfaction?

When patients do not take their medications correctly – what happens?

n May not get better n Can get sicker / worsen disease n Can have a relapse

The costs of noncompliance: n > 100 billion dollars annually n 125,000 unnecessary deaths n 10% (more than 1,000,000) of all hospitalizations may be due to noncompliance n 50% of all medication use

Health Effects n increased morbidity (sickness) n treatment failures n exacerbation of disease n more frequent physician visits n increased hospitalizations n death

Economic effects: n increased absenteeism n lost productivity at work n lost revenues to pharmacies n lost revenues to pharmaceutical manufacturers

Dimensions of Compliance: some things we think we know…. n Initial noncompliance or defaulting – 2% - 20%, possibly as high as 50% – average 8.7% n Refill compliance or persistence – Decreases over time n Not all non-compliance is improper medication use – rational noncompliance

Benchmark compliance rates: n Disease – Epilepsy – Arthritis – Hypertension – Diabetes – Oral contraceptives – HRT – Asthma n Rates of noncompliance – 30% to 50% – 50% to 71% – 40% (average) – 40% to 50% – 8% – 57% – 20%

Persistence n Product persistency curves – 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

Improper medication use: n Over or under use, wrong time n Taking the wrong medicine n Not finishing medication n Administration errors n Using another persons medication n Using old, possibly expired medication

Patient Considerations n Factors believed to affect compliance – 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 n Factors which are NOT believed to be associated with compliance – age, race, gender, income or education – patient intelligence – actual seriousness of the disease or the efficacy of the treatment

Patients at higher risk: n Asymptomatic conditions – hypertension n Chronic conditions – hypertension, arthritis, diabetes n Cognitive impairment – dementia, Alzheimers n Complex regimens – poly pharmacy, QOD

Patients at higher risk: n Multiple daily dosing – qd < bid < tid, < qid n Patient perceptions – effectiveness, side effects, cost n Poor communication – patient practitioner rapport n Psychiatric illness – less likely to comply

Issues n Measuring compliance – Several methods n Non-response v. non-compliance – Did the doctor choose the right drug, dose, etc.? n Compliance is not easy to pinpoint – Compliance problems cuts across drugs, diseases, prognosis, and symptoms.

Issues n Measuring compliance – patient reports, clinical outcomes, pill counts, refill records, biological and chemical markers, monitors n MAS, MOS, BMQ – 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 n personal interaction with your pharmacist, through counseling and communication, etc. n multimedia educational campaigns n patient education, counseling, written information, special labels n teaching methods for self monitoring n new idea….contracts with patients? n devices, reminders (mail, telephone), special packaging n follow-up

The “RIM” Technique n Recognize – using objective and subjective evidence, the pharmacist can determine if the patient may have an existing compliance problem n Identify – determine the causes of noncompliance with supportive probing questions, empathic responses, and other universal statements n Manage – develop partnerships with patients

Identifying Non Compliance n information from the patient – patient comments, concerns, questions n certain clinical outcomes – non response to treatment n information from refill records

Pharmacy Care Skills Needed: n Patient skills needed for behavior modification – problem solving – self monitoring – develop systems for reminders – enlisting social support – get family involved – identify positive and negative compliance behaviors

Actions Needed n More fully implement the pharmacy care model n Challenges: – 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: n For: – Patients - better outcomes and quality of life – Practitioners – healthier, more loyal patients – Managed care - lower total HC expenditures – Pharmaceutical Industry - increased sales