Are pharmacies taking the right approach in their medication management services?
Provision of dose administration aids is now very much an accepted, standard part of pharmacy practice, but is the service currently offered by pharmacies all that it should be?
In most Australian pharmacies stocking and distributing a regular number of dose administration aids is a regular part of practice. Most pharmacies see it as a regular source of income and a welcome service to offer to their customers.
However, new research shows that the service is not often well explained to patients, not well marketed and is missing out on improving the medication adherence of potentially thousands of patients – with the resultant loss of income to pharmacies.
The raw numbers
The raw numbers are compelling: it is estimated that adherence to medicines for chronic conditions stands on average at only about 50%.
In Australia 12% of all medical admissions and up to 30% of all admissions in the population aged over 65 years are estimated to be medication-related.
One in four Australians aged over 50 take ongoing medications for more than one chronic therapy condition.
Given current Budgetary pressure, the importance of reducing patient non-adherence and errors when taking multiple and often complex combinations of medications has become acute, and recent increased funding for DAA provision (an additional $60mil in the 6CPA) indicates this is a service seen by the government as vital in this regard.
Given this focus, former Pharmacy Guild of Australia national president Kos Sclavos said pharmacies should be preparing for a “tsunami of DAA patients”.
However, new research prepared by the Guild has highlighted shortfalls in the profession’s current approach and the public’s knowledge and awareness of DAAs.
Sclavos, who is currently a health strategist at Sinapse, said each pharmacy should be preparing a specific DAA strategy, and the profession as a whole should be ready to handle the 4.2 million Australians to be aged over 65 years in 2020.
In January 2016, the Pharmacy Guild commissioned McCrindle to undertake research into Australian attitudes, behaviours and expectations regarding their future health and medicine management.
The research was supported by Amneal Pharmaceuticals.
A range of topics were explored amongst 1,027 Australians across all ages of the general public above the age of 18. Of these, 523 people aged over 50 years who take ongoing medications for at least one chronic condition, were asked to provide their views on chronic therapy management, medication management, and the use of dose administration aids.
The first, and most dramatic finding, was that only 16% said they current used a dose administration aid to take their medicines.
Two out of three respondents (67%) said they use the original bottle or packaging to take their ongoing medication for chronic therapy conditions indicated that they use the original bottle or packaging that the medicine comes in.
Another 26% said they used plastic pill boxes to manage their medication(s), and only one in six (16%) use dose administration aids.
Of those who currently don’t use a DAA, 40% said that they are open to using dose administration aids prepacked by their pharmacist.
“The most useful component of dose administration aids identified by these respondents was the visible and clear packaging which would allow them to see what to take and when, aiding the identification of their medicines with a clear plan for administration,” the researchers said.
The primary deterrent to using DAAs was the respondents “strong” belief that they were capable and able to manage their medication autonomously. This was the view of 74% of this age cohort.
Other deterrent were cost (with 40% saying the usual cost of $6 per week was a deterrent), time taken to collect medications every two weeks (19%) and being limited to one pharmacy to pick up their medications (14%).
In the spotlight
Increasing your pharmacy’s focus on DAAs is timely given the demographics, and the additional support for the service in the Sixth Community Pharmacy Agreement, Kos Sclavos believes.
As part of the 6CPA, an incentive payment will be paid four times per year to an eligible pharmacy participating is this ‘priority’ area of the PPI Programme.
The incentive payment specifically relates to service delivery to community-based patients, and specifically excludes those in government-funded residential aged care facilities.
In total, $178.3 million has been dedicated to the program during the life of the 6CPA.
This funding is “another reason pharmacists should be stepping up to reduce medicine-related misadventure through the use of DAA services”, Sclavos said.
“The average pharmacy is doing DAAs for around 55 patients at the moment,’ he said. “But given the demographics I’ve calculated it should be around 300 patients per pharmacy”.
“This means some patients are or being offered the service when they should be, or it’s not being properly marketed or resources by the pharmacy”.
“Pharmacists need to be more analytical with this cohort,” he said. “Most want to remain independent, and DAAs are for many a critical component of that.”
Giving the best service
However, the data produced some findings which should make all providers reassess the way they approach the marketing and provision of this service.
Among the findings that most stood out for Sclavos were those relating to product knowledge and description.
The researchers indicated that a substantial number of the cohort did not know what dose administration aids actually are, many struggled to understand the benefits they provided.
“The research shows you have to explain what’s happening and why you’re suggesting they use DAAs,” Sclavos said. “Pharmacists take it for granted that people will understand, but we’ve got to better explain the benefit of packing”.
More than 80% of the patients said they relied on habit as their prompt to take their medicines
“Also, the evidence shows we shouldn’t refer to them as dose administration aids or DAAs, the research shows this means nothing to patients”.
He suggested using titles such as packed unit or medicine pack.
Another strong trend was the desire to include not only prescription medicines in their DAA packs.
“Many patients said want their complementary medicines packed too,” he said. “For many they are such a part of their life and regimen that they want them as part of the schedule too”.
“Also consider adding S3 medicines to their DAA list. For example if a patients is being told to take aspirin daily by their GP, then why not add this to their DAA regimen as well?”
Who is it suitable for?
However, are DAAs necessarily suitable for all older patients?
A 2014 Australian review, conducted by pharmacy lecturer Rohan Elliott, from Austin Health and Monash University, found DAAs can improve medicines management for some people, but that they have a number of limitations and are not suitable for all patients.
“Dose administration aids are not a panacea for all medicines management problems,” he said. “They only benefit appropriately selected patients when a specific medicines management problem has been identified and less complex adherence strategies have been tried”.
“In such patients a dosing aid, as part of a coordinated multidisciplinary approach to medicines management, may support the person to remain independent with medicine-taking and reduce the risk of medication administration errors,” Elliott said.
“Healthcare providers need to be aware of the benefits and limitations of dosing aids, and carefully assess patients to determine whether potential benefits outweigh risks and costs”.
Patient assessment is required to identify factors contributing to non-adherence or medication errors. Strategies like simplifying the drug regimen, education and counselling, and a medicines reminder chart or alarm, should be considered before using a dose administration aid, Elliott said.
The patient’s preferences and attitude to medicine-taking, and their suitability for a dose administration aid, should also be explored.
“There have been few well-designed controlled trials evaluating the impact of dosing aids on medication adherence and clinical outcomes. Most studies have had methodological flaws… and most have focused on a single health problem, for example hypertension, limiting their generalisability to typical users of dose administration aids (older people with multiple comorbidities)”.
A 2013 Cochrane review of 15 studies found DAAs modestly increased the percentage of pills taken (mean difference of 11%), he said.
Meta-analyses of studies that focused on patients with hypertension or diabetes suggested some improvements in diastolic blood pressure and HbA1c in users of dose administration aids, but with low certainty.