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Measuring Compliance
Self report Problem is patients overestimate their compliance level.
Measuring Compliance
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.
Health worker estimates Very unreliable.
Measuring Compliance
Pill and bottle counts Problem is patients can throw the pills away!
Mechanical methods Device for measuring the amount of medicine dispensed from a container. Expensive and not fool-proof.
Measuring Compliance
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.
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.
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
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
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
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).
The patients were told that adherence rates were being measured, but were not told about the details of the TrackCap.
TrackCap 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.
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
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).
They calculated adherence as a percentage of the number of doses refilled divided by the number of doses prescribed.
Sherman et al., 2000
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.
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
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
Collect and utilize patient information (build rapport) Identify patients’ drug related problems Develop solutions Select and recommend therapies Follow up to assess outcomes
Vision
Compliance as a partnership between patients, physicians and even managed care to achieve desired health outcomes – now called “concordance”.
Managing medication compliance = improved outcomes
complex, but, interesting implications for health practitioners
Possible Challenge
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
Economic– increased cost of medications
To patients, insurers, government
– lower total health care costs
Clinical – better control of disease, symptoms
Humanistic– patient satisfaction with therapy– prescriber satisfaction?
When patients do not take their medications correctly – what happens?
When patients do not take their medications correctly – what happens?
May not get better Can get sicker / worsen disease Can have a relapse
The costs of noncompliance:
> 100 billion dollars annually 125,000 unnecessary deaths 10% (more than 1,000,000) of all
hospitalizations may be due to noncompliance
50% of all medication use
Health Effects
increased morbidity (sickness) treatment failures exacerbation of disease more frequent physician visits increased hospitalizations death
Economic effects:
increased absenteeism lost productivity at work lost revenues to pharmacies lost revenues to pharmaceutical
manufacturers
Dimensions of Compliance: some things we think we know….
Initial noncompliance or defaulting– 2% - 20%, possibly as high as 50%– average 8.7%
Refill compliance or persistence– Decreases over time
Not all non-compliance is improper medication use – rational noncompliance
Benchmark compliance rates:
Disease– Epilepsy– Arthritis– Hypertension– Diabetes– Oral contraceptives– HRT– Asthma
Rates of noncompliance– 30% to 50%– 50% to 71% – 40% (average)– 40% to 50%– 8%– 57%– 20%
Persistence
0
20
40
60
80
100
1 3 5 7 9 11 13
Months
Percen
t
CozarFosamaxZocor
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:
Over or under use, wrong time Taking the wrong medicine Not finishing medication Administration errors Using another persons medication Using old, possibly expired medication
Patient Considerations
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
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: Asymptomatic conditions
– hypertension
Chronic conditions– hypertension, arthritis, diabetes
Cognitive impairment– dementia, Alzheimers
Complex regimens– poly pharmacy, QOD
Patients at higher risk: Multiple daily dosing
– qd < bid < tid, < qid
Patient perceptions – effectiveness, side effects, cost
Poor communication– patient practitioner rapport
Psychiatric illness– less likely to comply
Issues
Measuring compliance– Several methods
Non-response v. non-compliance– Did the doctor choose the right drug, dose,
etc.?
Compliance is not easy to pinpoint– Compliance problems cuts across drugs,
diseases, prognosis, and symptoms.
Issues
Measuring compliance– patient reports, clinical outcomes, pill counts, refill
records, biological and chemical markers, monitors
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
personal interaction with your pharmacist, through counseling and communication, etc.
multimedia educational campaigns patient education, counseling, written information,
special labels teaching methods for self monitoring new idea….contracts with patients? devices, reminders (mail, telephone), special
packaging follow-up
The “RIM” Technique
Recognize– using objective and subjective evidence, the pharmacist can
determine if the patient may have an existing compliance problem
Identify– determine the causes of noncompliance with supportive probing
questions, empathic responses, and other universal statements
Manage– develop partnerships with patients
Identifying Non Compliance
information from the patient– patient comments, concerns, questions
certain clinical outcomes– non response to treatment
information from refill records
Pharmacy Care Skills Needed:
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
More fully implement the pharmacy care model 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: For:
– Patients - better outcomes and quality of life– Practitioners – healthier, more loyal patients– Managed care - lower total HC expenditures– Pharmaceutical Industry - increased sales