1. Adherence Ensuring Better Patient Outcomes Lecture # 2 Ghadah Asaad Assiri,MSc May 2014

2. Example: RCT  Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan* *Jarab AS, Alqudah SG, Mukattash TL, Shattat G, Al-Qirim T: Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan. J Manag Care Pharm 2012; 18: 516–26.

3. Example.. Cont. Study design : randomized controlled trial Randomization :Patients with type 2 DM attending an outpatient diabetes clinic of a large teaching hospital were recruited,randomly assigned to either usual care or a pharmacist-led pharmaceutical care intervention program, using Minim software technique. Setting : outpatient diabetes clinic clinic at the Royal Medical Services (RMS) Hospital in Jordan. Duration of the study :over a 4-month period from January through April 2011 then 6 month assessment (until October 2011 ) Sample size: A total of 77 of 85 patients (90.6%) randomly assigned to the intervention group and 79 of 86 patients (91.9%) assigned to usual care had baseline and 6-month follow-up values.

4. Example.. Cont. OBJECTIVE: T o evaluate the impact of clinical pharmacist- led pharmaceutical care program on : 1- Primary clinical outcome of glycemic control (A1c) 2- Secondary outcomes, including BP, lipid values, self- reported medication adherence, and self-care activities for patients with type 2 diabetes

5. Example.. Cont

6. Example.. Cont.  Statistical test : SPSS software for statistical analysis P value of <0.05 was considered statistically significant  Follow up & monitoring : 6 months after the initial visit for each patient (e.g., a patient recruited in April 2011 was followed up in October 2011)

7. Example…Cont. Usual care Vs pharm-led pharmaceutical care intervention program Type of intervention : If required, initial adjustment of diabetes medication & antihypertensive medication as suggested by pharmacist. Structured diabetes education, including the importance of adherence and lifestyle that negatively affect blood pressure; providing patient with information leaflets. 20 minutes telephone consultation wit pharmacist every 8 weeks ( topics: currant medications, importance of adherence & treatment plan, possible concerns on the part of the patient ) Matthes J, Albus C.Improving adherance with medication- a selective letreture review based on the example of hypertention treatment. Medicine, Dtsch Arztebl Int 2014; 111(4): 41-7

8. Example…Cont. Adherence tool : Self-Reported Medication Adherence (Morisky Scale) Simple, validated 4-question survey assessed the likelihood that patients take their medications as prescribed http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=15581 Jarab AS, Alqudah SG, Mukattash TL, Shattat G, Al-Qirim T: Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan. J Manag Care Pharm 2012; 18: 516–26.

9. Example…Cont. QuestionsScore Do you forget to take your medications?To score the questionnaire, each “yes” response is given a score of 1, each “no” response is given a score of 0 (range 0 to 4) According to the Morisky classification, adherence is divided into 3 groups: high for those scoring 0, medium for those scoring (1 -2), low for those scoring (3-4) For the purpose of the present analysis, the patients were divided into 2 groups: those scoring 0 were considered adherent, and those scoring 1-4 were nonadherent. Are you careless about time of taking your medications? Do you stop taking your medications when you feel better? Do you stop taking your medications when you feel worse?

10. Example…Cont. Result : 1- Effect on clinical end point :Reduction in A1c. patients in the intervention group had a mean reduction of 0.8% in A1c Vs a mean increase of 0.1% from baseline in the usual care group (P = 0.019). 2- Effect on adherence :  significantly lower proportion of non adherent patients in the intervention group (28.6%) compared with the usual care group (64.6%) at the 6-month assessment

11. Example…Cont.  Compared with the usual care group, intervention patients who received the clinical pharmacy service showed significant improvement in self-reported medication adherence and lifestyle changes that represent the cornerstone in the management of type 2 diabetes.

12. Special population  For pediatric patients  give rewards and ensure medications are palatable5  For psychiatric patients  provide frequent follow-up. Choose well-tolerated medications. Provide positive reinforcement  For asymptomatic conditions such as Hypertension  Choose well-tolerated medications,  Consider cultural or language barriers that may affect adherence

13. Conclusion  Best possible decision about therapy should be reached according to clinical demand and patient preference  The key to improve adherence is to identify the unique causes of non-adherence for each patient and to select the correct solutions  One of the most effective measure to improve adherence are based on simplified therapeutic regimen

14. Questions ?