In this Issue:
The Compliance Challenge
Consumer Medicine Information
Failure or just forgotten?
Compliance and Adherence
A global issue
Side Effects How real is the threat?
Non-complianceA global phenomenon
DIY Diagnosis A dangerous pastime
Chronic Illness, Antibiotics
Why compliance is so important
Healthcare Professionals Play a Key Role
ISSUE #42 - COMPLIANCE
Welcome to the Pfizer Health Report.
In this edition we focus on the issue of patient “compliance”. Compliance refers to the level of adherence by the patient to the doctor’s prescribing instructions. This can vary from 100% to not filling the prescription at all!
At first glance it may appear startling that a patient may opt against their doctor’s advice. But as we’ll discover in our report, there can be a variety of reasons for this – from physical or financial constraints through to real concerns or beliefs regarding prescription medicine.
Pfizer’s groundbreaking Australian survey raises some issues for patient health. In this edition of the Health Report we look at the reasons for non-compliance along with the possible consequences and we suggest ways in which healthcare professionals can work with patients to allay concerns and improve patient outcomes.
ContentsThe compliance challenge .............................................................................................3Startling statistics reveal poor compliance is a concern for the well-being of Australians
Consumer Medicine Information – failure or just forgotten? ....5The vast majority of Australians are unaware of what CMI is, or how it works
Compliance and adherence – a global issue ..........................................6Non-compliance with prescription medicines is an international issue
Side effects – how real is the threat? ..............................................................7Is the risk real – or merely perceived?
Non-compliance - a global phenomenon ...................................................8The world’s less developed nations face even greater compliance challenges
DIY diagnosis – a dangerous pastime............................................................9Offshore online pharmacies could provide the ingredients for a deadly cocktail
Chronic illness, antibiotics - why compliance is so important ........................................................................................................................................10From burgeoning health bills to anti-bacterial resistance, compliance could be a contributor
Healthcare professionals play a key role.................................................11
2 | HEALTH REPORT | COMPLIANCE
Pfizer’s research, conducted by independent agency StollzNow, confirms that over half the Australian population (53%)1 take prescription medicine on a long-term basis.
Not surprisingly, the elderly are well-represented within this group, and women are also likely to take long term prescription medicines, perhaps as a result of the contraceptive pill2.
Taking medicines as we see fitThe problem is not an over-reliance on prescribed medicines. It’s our tendency to make a personal decision about the way we take our medicine rather than following the doctor’s recommendations.
Almost two out of five Australians (38%)3 choose not to have their prescription filled at all at some stage, often for a variety of reasons. The cost of medicine is a common factor affecting 24% of us, while 37% wait to see if their health will improve. A further 20% never make it to the pharmacy counter because they fear becoming dependent on their medicine4, and an alarming 10% of people say they simply don’t trust their doctor’s diagnosis5.
When we do have a prescription filled, only 55% of Australians “always” finish the course of medicine. Once again there is a range of reasons for this. The majority (57%) of people say they simply “got better”, while 32% “forgot” to take their prescribed medicine6.
Research commissioned by Pfizer reveals that each year millions of Australians either do not have their prescription filled or take their medicine in a way that may not offer the best outcome.
challenge
thecompliance
COMPLIANCE | HEALTH REPORT | 3
When in doubt…If in doubt about your prescription medicine, consult your GP, pharmacist
or other healthcare professional. Or contact Healthdirect Australia for independent information on medicines.
Call 1300 MEDICINE (1300 633 424) from anywhere in Australia for the cost of a local phone call – Monday to Friday, 9am to 5pm.
Appropriate use is central to a good outcome.The appropriate use of medicine is central to the treatment and management of most health conditions. However Dr Bill Ketelbey, Country Medical Director at Pfizer Australia says, “There are often valid reasons why people question their prescription medicine – and this is every patient’s right. But many fears and concerns can often be overcome simply by airing the issues with a GP or pharmacist. It’s important that anyone being prescribed medicine should feel comfortable having an open and frank discussion with their doctor about what is best for their health. It is also very important that the prescribing doctor knows if the medicine is being taken correctly or not. Future diagnoses and prescribing decisions could be dependent on the doctor knowing this.”
Family and friends can play a vital role.Along with the ability to discuss concerns with health professionals, family and friends can play an active role in health management. Bill Ketelbey explains, “Family
are at the frontline of patient support. Encouraging those around us to take prescription medicine correctly will provide valuable back-up to the advice of a GP or pharmacist.”
Fear and inertia are powerful forces.There are other reasons for non-compliance. Fear of developing a tolerance means 13% of people don’t have a second prescription filled7; 14% stopped taking their medicine because they believed it wasn’t working8 and 17% “couldn’t be bothered” taking their prescribed medicine9.
One in ten people who fail to finish a course of medicine do so because they stockpile medicine for an emergency10, perhaps self-prescribing at some point in the future.
We may also adopt a haphazard approach to the way we take prescribed medicines. Almost 80% of Australians have, in some way, not taken their medicine properly11. Over one in three (35%) take medicine without food – even when directed otherwise12. A worrying 23% take medicine with alcohol, and 16% of us take medicine that is past its expiry date13.
4 | HEALTH REPORT | COMPLIANCE
CMI refers to information available for all prescription and some over the counter medicines. Each leaflet sets out comprehensive details of the medicine including what the medicine is for, when and how it should be taken, possible side effects and ingredients.
CMI leaflets are available online through a variety of websites however the government has invested considerable sums establishing a process whereby
pharmacists provide the appropriate leaflet to people having a prescription filled.
However only 40% of Australians know what CMI is – typically women and people aged 50-plus14. Regional Australians are more aware of CMI than their city-based counterparts, possibly because of a closer relationship with their local pharmacist15.
The low level of awareness is understandable. Of the 40% of Australians who are aware of CMI, only 8% say they have “always” received a CMI leaflet16. Of these people, only 19% consistently read the information17.
Yet CMI plays a vital role, with each leaflet spelling out in clear terms what the medicine is used for and how it works, any warnings and precautions, such as when the medicine should not be taken, how to use the medicine properly and the possible side effects. However, it doesn’t replace a GP’s and a pharmacist’s advice, but it certainly provides worthwhile reinforcement, and is a concise starting point of consumer-friendly information.
That makes it worth asking a pharmacist for a CMI leaflet every time a prescription is filled. Alternatively CMI can be downloaded from websites such as the TGA’s search facility on www.ebs.tga.gov.au, the NPS website, www.nps.org.au, the Royal Australian College of General Practitioners www.racgp.org.au click on ‘Patients’ followed by ‘Consumer medicine information’ or the manufacturer’s website.
With over 1,000 CMI leaflets accessible, there should be information available for your particular medicine.
Consumer Medicine Information failure or just forgotten?
Know your prescription medicineAsk for a copy of the CMI leaflet applicable to your medicine each time you have a new prescription filled.
Despite a significant investment by both the government and pharmaceutical industry in Consumer Medicine Information (CMI), the vast majority of Australians are unaware of what it is, or how it works. Yet CMI remains a valuable tool.
COMPLIANCE | HEALTH REPORT | 5
&compliance adherencea global issue
Studies across the globe confirm that non-compliance with prescription medicines is an international issue.
If you aren’t comfortable taking a prescription medicine, it’s
important to discuss this with your doctor. They can address your
concerns, and possibly consider altering the dose or suggest another therapy altogether.
It’s YOUR health, and you’re right to question
The compliance challenge is not new. For many years, the medical community has been aware that patients do not always follow their doctor’s instructions regarding prescription medicine. Indeed, most reviews agree that between one third and a half of medicines prescribed for long term medical conditions are not taken as directed18. And it’s an issue that has serious consequences.
Non-compliance means Australians are not reaping the benefits of rapidly advancing technologies or improvements in new medicines to enjoy gains in personal health. Aside from the potential loss of benefits to the patient, there is a broader cost to the community as the initial illness may not improve, or become worse, thus requiring longer and possibly more costly treatment.
Part of the problem of non-compliance is that it’s often hidden: undisclosed by patients and undetected by doctors or pharmacists19. Equally, there can be complex reasons why people do not follow their doctor’s advice. Non-compliance can’t be explained by any single factor like the type or severity of disease. Nor is it explicitly linked to socio-economic factors, age, sex or even personality traits20.
A complicated web of factors
Studies have shown that a wide range of factors can contribute to our non-compliance with prescribed medicines. Physical constraints such as memory or dexterity may have a profound impact among the elderly. Environmental constraints like the time taken to visit a doctor, or difficulties paying for the cost of prescribed medicines can also influence our ability to follow a prescription21.
But ultimately human nature plays a significant role, and research has shown that intentional non-compliance can also be a factor especially when our personal beliefs conflict with a doctor’s advice22. This highlights the need for doctors and patients to engage in open discussion when prescription medicine is recommended.
NONCOMPLIANCE
Memory
Dexterity
Environment
Time
Cost
HumanNature
6 | HEALTH REPORT | COMPLIANCE
For 37% of Australians24, the side effects they have experienced from prescription medicine have been significant enough to prevent them continuing with the course of medicine. One-third of these people (31%) have consulted their doctor about the issue25.
The reality is that all medicines have the potential to cause unwanted side effects. This risk can rise among people who take more than one medicine. That makes it important to inform your doctor if you are already
taking another prescription medicine as well as any ‘complementary’ therapies like herbal remedies or supplements, or over the counter medicines.
Another common contributor of side effects is alcohol. As we saw earlier in the compliance challenge, almost one in four Australians consume alcohol in conjunction with prescribed medicines. This not only increases the chance of unwanted side effects, it can alter the effectiveness of the medicine.
Side Effects
Reduce the odds of unwanted side effects
Keep a list of all the medicines you are taking, including non-prescription and prescription
medicines and show your doctor and/or
pharmacist.
Take all medicines as prescribed by your
medical practitioner.
Never take anyone else’s medicine or give yours to
anybody.
Read the Consumer Medicine
Information (CMI) sheet to understand
more about the medicines you are
taking.
Talk to your doctor or pharmacist if you
are experiencing any side effects.
More than one in two Australians (55%) claim to have experienced side effects from prescription medicine23. But is the risk as real as we think?
how real is the threat?
COMPLIANCE | HEALTH REPORT | 7
Non-compliancea global phenomenon
“Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments26”Failing to take prescription medicine appropriately is not an issue that is unique to Australia. An extensive body of international research on patient non-compliance is testimony to the scale of the problem, and it’s a challenge faced by doctors and health professionals across the developed and undeveloped world.
According to the World Health Organisation (WHO) only around 55% of patients suffering chronic conditions comply with the requirements of their long term therapy. In less developed countries the rates of compliance are even lower27.
In developed countries like Australia, poor levels of
patient compliance don’t just affect personal health, they
reduce the overall effectiveness of health systems.
However non-compliance can be a more dire issue in
developing countries. WHO notes, “when taken together
with poor access to health care, lack of appropriate
diagnosis and limited access to medicines, poor
adherence is threatening to render futile any effort to
tackle chronic conditions, such as diabetes, depression
and HIV/AIDS”28.
Low levels of compliance tax already strained resourcesAs a guide, WHO estimates that in China, Gambia and the Seychelles, only 43%, 27% and 26%, respectively, of patients being treated for high blood pressure remain on their prescribed medicine.
Such low levels of compliance occur for a variety of reasons but whatever the cause, WHO concludes that “it compounds the challenges of improving health in poor populations, and results in waste and underutilisation of already limited treatment resources”29.
8 | HEALTH REPORT | COMPLIANCE
A small though noteworthy minority of Australians have taken their health into their own hands and purchased prescription medicine without a prescription - something made possible through the availability of online pharmacies based outside Australia. Around 10% of Australians have self-prescribed at some stage, typically men aged between 18 and 2930.
More worrying perhaps, is the 10% of Australians who purchase prescription medicines from an overseas website. Again, men are five times more likely to do this than women31.
On a positive note, the vast majority of Australians (76%) recognise the dangers associated with buying prescription medicines from an offshore website32. The chief deterrent for most people is the safety of medicines purchased this way, and whether the ingredients would be identical to medicines purchased locally.
Highlighting the very real risks associated with purchasing prescription medicines from an overseas website, 8% of Australians say they know someone who has required
medical treatment as a result of taking medicines purchased from an offshore website33.
There is no doubt that in the relatively unpoliced world of the internet, offshore online pharmacies can pose a threat to personal health and well-being. To be fair, many internet pharmacies are reputable, only selling prescription medicines if a prescription is supplied. However the status of medicines as ‘prescribed’ varies between countries, making it possible to readily purchase medicines online that would only be available with a prescription here in Australia34.
Australia’s National Prescribing Service has warned consumers that not all offshore online pharmacies are legitimate. Plenty sell out of date, poor quality, contaminated or even fake medicines35.
It is essential that consumers protect themselves by avoiding overseas websites. Even if the brand name is similar, medicines purchased overseas may have different ingredients from the brand sold in Australia36. As tempting as it may be to side step a visit to the doctor, taking the DIY approach could jeopardise your health.
The ready availability of online pharmacies based outside Australia has created potentially dangerous opportunities for self-treatment.
DIYdiagnosisa dangerous pastime!
Source: www.immi.gov.au/living-in-australia/help-with-english/help_with_translating/free-services.htm#c
Communication between health professionals and patients is essential in helping people understand how their medicine should be taken and how it will benefit their health.
If language difficulties pose a problem, a number of resources are available that can help:
Free interpreting services The Australian Government provides free interpreting services to non-English speaking Australian citizens or permanent residents communicating with private medical practitioners providing Medicare-rebateable services and their reception staff to arrange appointments and provide
results of medical tests. Telephone: 131 450
Doctors Priority Line The Doctors Priority Line is a free telephone interpreting service which helps doctors communicate with non-English speaking patients. It’s available 24 hours a day, seven days a week.
Telephone interpreting service for pharmacies Provides pharmacies with access to telephone interpreting services to communicate with people about the appropriate use of medicines.
To check if your pharmacy is registered for the service, log onto www.immi.gov.au, click on “Living in Australia’ followed by ‘Help with English’.
Language barriers? Help is available
COMPLIANCE | HEALTH REPORT | 9
ChroNIC IllNESS, aNtIbIotICS why compliance is so important
Medicines don’t work when people don’t take them. But sometimes the damage doesn’t stop there.
There are often good reasons why people choose not to take their prescription medicine. In the instance of chronic illnesses such as heart disease, which may be asymptomatic, there are no obvious symptoms, and it’s easy to see why a patient may feel that they experience no obvious benefits in taking prescribed medicine for the condition. This lack of symptoms and benefits can encourage people to discontinue their medicine or not take the prescribed dose at the required intervals.
As we’ve seen, people often worry about long term effects that prescription medicines may have on their body. These
fears are understandable as all medicines have some risks as well as benefits. But before they can be released for public use, new medicines are studied extensively through clinical trials, additional testing, research and evaluation to ensure the benefits outweigh the risks. So even if you feel no different as a result of taking your prescription medicine, it is important to do so. And of course, discuss any concerns you may have with your doctor.
Speak with your GP or pharmacist. Air your concerns. Follow their advice.Doctors and pharmacists understand how medicines work and are aware of any considerations related to their use, including how they interact with other medicines their patients may be taking. This underlines the importance of airing any concerns about your treatment with your doctor or pharmacist and following your doctor’s advice. Always speak with your health care professional if you feel unwell while taking medicine.
Antibiotics! Non-compliance encourages resistance
Compliance can also be extremely important when a person is being treated for a relatively short term condition requiring antibiotics. Indeed non-compliance can undermine the effectiveness of antibiotics, which are under threat from antibiotic-resistant bacteria37.
Non-compliance contributes to resistance in several ways. Often we discontinue a course of prescribed antibiotics once we start to feel better. This leads to the proliferation of the surviving bacteria, which may develop a resistance to the original antibiotics. As we fail to fully recover, we return to our GP, who prescribes greater strength antibiotics, and the cycle of non-compliance and increasing resistance begins again38.
10 | HEALTH REPORT | COMPLIANCE
hEalthCarEProFESSIoNalS
A person may be actively opposed to taking prescription medicine for a variety of reasons that are quite sensible including fears of dependence or side effects. In this case, it’s essential that doctors and pharmacists establish lines of communication that allow patients to discuss personal views about their medicines.
It’s also vital to be able to see the situation from the patient’s perspective. There may be cultural or deep-seated personal beliefs and fears about a particular condition and/or its treatment. Unless these are addressed and resolved at an early stage, there can be little gain in writing a prescription that may never be filled.
Practical problems can make life difficult. Non-compliance with prescription medicines may also be unintentional. Physical and cognitive factors for example, can impact the likelihood that a person will gain maximum benefit from their medicine. The effect may be compounded where a person uses multiple medicines or multiple prescribers.
In these circumstances a Home Medicines Review (HMR) can help patients better manage their medicines39.
A HMR involves an interview between a pharmacist and patient, typically in the patient’s home, with feedback flowing from the pharmacist to the patient’s doctor. It can help to identify non-compliance and provide a forum for ways to help patients resolve their problems or concerns.
It may be every patient’s right to refuse a medicine. But it is the responsibility of health care providers to help patients make an informed choice. Taking the time to know patients and understand their concerns and views can play a key role in improving compliance with prescription medicines – and ultimately a person’s health.
Human beings are complex creatures, and our ability to question and reason extends to a doctor’s prescription. For healthcare professionals around the globe, the issue of non-compliance poses an ongoing challenge. There is a range of possible steps that healthcare professionals can adopt to improve a patient’s understanding of their medicine – what it will achieve, how it should be taken and why. Most of these steps centre on better communication and an improved understanding of a patient’s personal viewpoint.
One of the challenges of non-compliance is detection. The box below outlines possible early warnings signs. These signs may be readily detected - like missed appointments or the doctor may pick up an unexpected non-response to the prescribed treatment, while others, like lack of belief in the treatment, may be less obvious.
play a key role.
Possible predictors of non-compliance
Source: Osterbeg L, Blaschke T. Adherence to medication. N Engl J Med 2005., p 353: 487-97
u Psychological problems including depression
u Cognitive impairmentu Treatment of asymptomatic
diseaseu Inadequate follow upu Side effects of medicine
u Lack of belief in treatmentu Lack of insight into the illnessu Poor relationship between
patient and health care provideru Missed appointmentsu Complexity of treatmentu Cost of medicine
COMPLIANCE | HEALTH REPORT | 11
1 Medication Compliance StollzNow Research Page 7 2 Medication Compliance StollzNow Research Exec Summary 3 Medication Compliance StollzNow Research Page 9 4 Medication Compliance StollzNow Research Page 11 5 Medication Compliance StollzNow Research Page 11 6 Medication Compliance StollzNow Research Page 13 7 Medication Compliance StollzNow Research Page 14 8 Medication Compliance StollzNow Research Page 13 9 Medication Compliance StollzNow Research Page 13 10 Medication Compliance StollzNow Research Page 13 11 Medication Compliance StollzNow Research Exec Summary 12 Medication Compliance StollzNow Research Page 14 13 Medication Compliance StollzNow Research Page 14 14 Medication Compliance StollzNow Research Page 16 15 Medication Compliance StollzNow Research Page 16 16 Medication Compliance StollzNow Research Page 17 17 Medication Compliance StollzNow Research Page 18 18 World Health Organisation, 2003 19 Concordance, adherence and compliance in medicine taking Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) December 2005 20 Concordance, adherence and compliance in medicine taking Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) December 2005 Page 13 21 Concordance, adherence and compliance in medicine taking Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) December 2005 Page 14 22 Horne, R and Weinman, J. 2004. The theoretical basis of concordance and issues for research. In: Bond, C (ed) Concordance, A Partnership in Medicine Taking. London: The Pharmaceutical Press 23 Medication Compliance StollzNow Research Page 20 24 Medication Compliance StollzNow Research Page 21 25 Medication Compliance StollzNow Research Page 22 26 Haynes RB. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2001, Issue 1, 2001. 27 Adherence to long-term therapies - Evidence for Action. WHO, 2003 28 Adherence to long-term therapies - Evidence for Action. WHO, 2003 29 Adherence to long-term therapies - Evidence for Action. WHO, 2003 Section 1 page 22 30 Medication Compliance StollzNow Research Page 20 31 Medication Compliance StollzNow Research Page 27 32 Medication Compliance StollzNow Research Page 28 33 Medication Compliance StollzNow Research Page 30 34 http://www.nps.org.au/consumers/publications/medicines_talk/mt22/buying_medicines_over_the_internet 35 http://www.nps.org.au/consumers/publications/medicines_talk/mt22/buying_medicines_over_the_internet 36 http://www.nps.org.au/consumers/publications/medicines_talk/mt22/buying_medicines_over_the_internet 37 THE ISSUE OF PATIENT NON-COMPLIANCE: Response to a Costly Health Problem Presented at the 2002 International Pharmaceutical Congress New York, April 2002 Prepared by: Allan Wilson, MD, Ph.D. Michael Petersen 38 THE ISSUE OF PATIENT NON-COMPLIANCE: Response to a Costly Health Problem Presented at the 2002 International Pharmaceutical Congress New York, April 2002 Prepared by: Allan Wilson, MD, Ph.D. Michael Petersen 39 Pharmacy Guild of Australia, Home Medicines Review Information athttp://www.guild.org.au/mmr/content.asp?id=421
© 2010 Pfizer Australia Pty Ltd ABN 50 008 422 348.
This Report is copyright. Except as permitted under the Copyright Act, no part of this publication may be reproduced by any process, without the specific written permission of the copyright owner, except that one copy of this Report may be downloaded for free for personal use from the websit www.healthreport.com.au. Inquiries should be directed to [email protected]
The information contained in this Report is not designed to replace the advice of your doctor or health care professional. For advice on any symptoms or conditions referred to in the Report, please contact your health care professional. Contact us for additional copies at [email protected] or on 1800 675 229.
12 | HEALTH REPORT | COMPLIANCE
