How can pharmacists help improve medication adherence

For healthcare professionals, lack of time and remuneration might leads to poor communication with patients. Non-adherence is more likely to occur during transition of care [9] or situations involving change, such as weekends and holidays or during acute illness, and results in waste of medication [10] , illness aggravation, hospitalisation [11] and decreased quality of life [12]. Subsequently, the annual costs of non-adherence are high [13].

In this respect, the pharmacist must tailor interventions to the individual patient in addition to their standardised, structured consultation [14]. According to the World Health Organization, there are five sets of factors that affect adherence, of which patient-related factors are only one element [2] :. The Theoretical Domains Framework identified 14 domains of theoretical constructs that can be used to simplify the behavioural problems associated with adherence [15].

Within these domains, Allemann et al. According to their results, adherence interventions should address the modifiable patient determinants and be tailored to the unmodifiable ones. For example, patients who are failing to adhere to their medicine because of social influences e. Many interventions conducted by pharmacists have been developed [16] , [17] and new services have been implemented, such as medication reviews, medication management and enhanced patient counselling [18].

Although pharmacist interventions have been structured to fit into daily practice [19] , medication adherence remains an unsolved issue, even within clinical trials [20]. Community pharmacists are the last healthcare professionals that patients will see before using their medicine and, therefore, this may have an impact on their perception of the therapy. Pharmacists can influence patient expectations depending on whether they are confident that the treatment is effective and are able to communicate enthusiasm [21] see Box 1.

Box 1: Example of how pharmacists can either reinforce A or not reinforce B the choice of treatment. Can I ask you some questions? I could double check for you, if you like? Trust in the healthcare professional and the healthcare system is important for adherence to medicine and for optimum health outcomes [22]. Meetings between healthcare professionals and patients can increase trust, if conducted properly. Trust involves the following [23] :. Even though pharmacy consultations might be of short duration, building trust is a prerequisite of every successful discussion with a patient.

In general, pharmacists only have a few minutes per consultation; however, this can be enough for a targeted intervention since merely having more time does not guarantee a good consultation [24].

To be efficient, healthcare professionals must use every minute of the encounter in a motivating, patient-centred way. Each consultation must be well prepared and motivational aspects need to be taken into account. Saying the right things is not sufficient — they must be said in the right manner, so the patient feels motivated. In its report on the role of pharmacists in promoting adherence, the International Pharmaceutical Federation identified three overlapping elements of all successful settings and interventions [25] :.

Once the patient is actively involved in taking responsibility for their own treatment, the healthcare professional may find that the patient needs social support.

When treatment resistance has been observed, but no obvious cause has been identified, it is important to assess medicine adherence before the therapy is changed to avoid therapy escalation [28]. Pharmacists and healthcare professionals can use a variety of different methods to assess adherence. For example, direct adherence measures, such as laboratory tests or swallowing a medication that is attached to an ingestible chip, can prove whether the medicine was taken.

These are reliable but not the most practical options. Indirect measures, such as questionnaires, are cheap and easy to use [29] , while electronic monitoring is the most objective measure [30] and should be used in preference to questionnaires.

Adherence measures should not be used to control patients, but rather to unveil errors; therefore, the pharmacist should develop a participative behaviour rather than an authoritarian one. A short, three-step intervention — with modifications for those starting a new treatment — is outlined in Box 2 [34].

It starts with trust-building measures where the pharmacist introduces themselves, followed by an assessment of the medication history. Practical difficulties, misunderstandings or problems can be solved at all stages. For new medicine users, knowledge-based aspects dominate the consultation, while motivation is the main issue for persisting on the regimen. Each consultation ends with agreement on a joint goal until the next visit see Box 3. These can help identify non-adherence and enable pharmacists to intervene and educate patients on the importance of taking their medicines as instructed.

To avoid difficulties and errors, compliance aids should be delivered with any complex therapy e. In case of intentional non-adherence, motivational interviewing becomes more relevant.

With a patient-centred attitude and targeted communication, the pharmacist can help patients to appropriately manage their condition. Therefore, each encounter with patients should be used as a short intervention and to review adherence problems. Box 2: Example dialogue of a knowledge-based short intervention with a new drug user Scenario 1 and a motivation-based short intervention for the same patient already on a treatment Scenario 2.

In both scenarios the patient has a problematic attitude towards their anticoagulant medicine. Listen to the conversation here. The pharmacist reads through the discharge letter and looks at the prescription. Factors facilitating adherence included perceived seriousness of the disease; acceptance of having a chronic disease requiring lifelong treatment; time of dose many preferred morning dosing and often associated their medication with breakfast ; and good patient—physician relationship with reinforcement for positive efforts and results.

Reasons for nonadherence were negative attitude toward drugs in general; adverse drug reactions; drug effects e. One patient reported that he stopped his medicine when his BP was within acceptable limits.

In research, there are several ways to measure adherence. Medication event monitoring systems MEMS are the most accurate method of measuring adherence because they record the date and time the medication bottle was opened through microprocessor technology embedded in the cap.

This is an impractical way to determine adherence in clinical practice. Patient self-report, pill counts, pharmacy databases or refill rates, and blood levels, which also are employed in research, are more feasible options for clinical practice. Patient self-report is probably the easiest way to determine adherence, but there are obvious problems with this method. To please his or her HCP, the patient is likely to report taking medication more often than is actually the case.

When adherence is being assessed, open-ended questions should be asked. Each question measures a specific medication-taking behavior rather than adherence or compliance behavior. More than 1, hypertensive patients participated in the study. A baseline interview was conducted to assess demographic characteristics, medical history, health behaviors, appointment-keeping, and medication adherence, and BP was measured at all outpatient visits over the next 6 months.

The correlation between BP control and high scores on the adherence scale was statistically significant. Variables associated with medication adherence were knowledge, patient satisfaction, coping skills, stress level, and regimen complexity. Once the reasons for nonadherence have been determined, the pharmacist can intervene to help the patient achieve a better therapeutic outcome.

Improved patient-centeredness involving the patient in decision-making can lead to improved adherence. A behavioral model of medication adherence that is based on the theory of planned behavior has been proposed. This information should be individually tailored to the patient and must be presented by the HCP in easily understandable language. The pharmacist can positively influence attitude by explaining the benefits of adherence e.

In attempting to modify perceived behavioral control, it is most beneficial to make small, simple changes e. These modifications must occur in a setting where the patient feels confident of successfully performing the behavior every day.

Another adherence tool was shown to be effective in a study involving low-health-literacy patients with coronary heart disease. The card was designed to give the least amount of necessary information. The medication coaches also investigate co-pay assistance programs to help patients overcome financial obstacles that can affect adherence.

Pharmacists balancing prescriptions, insurance issues, physician callbacks, and patient care services can find themselves in a chaotic workplace, but there are ways to create a more balanced and dynamic workflow.

One way to improve efficiency is using color-coded prescription baskets based on priority, including separate baskets for special cases that may need insurance resolution, for example. Pharmacy owners should try to allow pharmacists to schedule their work hours around 3-day weekends or take off every other Friday to tackle non-work responsibilities, Grove advised.

This will allow for increased employee satisfaction and less turnover. Our teams went to work with the express goal of removing those obstacles. Within two months of the change, his A1c number, which indicates blood sugar levels, was lowered from 9.

In many cases, clinical care teams spend a lot of time simply educating patients about their medications. A pharmacist explained to Anna the difference between maintenance and mealtime insulins and how they work together to regulate blood sugar levels.

He also simplified her regimen by putting her on premixed insulin and an oral medication that meant she only had to inject herself twice a day. Many of the solutions that emerged were quite creative. Consequently, when delivery services left her insulin on the front porch, it would spoil in the degree heat.

That pharmacy schedules deliveries with the patient and makes sure she puts her insulin inside the refrigerator before the deliverer leaves.

As the pharmacists learned more about the specific obstacles older patients face, they adjusted their practices accordingly.