Prescriber, pharmacist collaboration helps in adherence

medicines under magnifying glass

One in two Australians who have chronic disease are not taking their medication as directed by their doctor, according to an Australian physician

In Australian Prescriber, Professor Tim Usherwood from the University of Sydney writes that half of patients living with a chronic disease do not take their medication as directed by their doctor or pharmacist.

He writes of several ways in which prescribers can help improve compliance in collaboration with pharmacists.

Prof Usherwood explains that some might not be taking their medicines properly because they’re concerned about side effects, or think they don’t need the medication.

Others may be misreading instructions, forgetting to take doses, or could have trouble opening medicine bottles or swallowing pills, he says.

“Patient education, shared decision making, pharmacist support and motivational interviewing reduce intentional non-adherence,” he writes.

“Interventions to reduce unintentional non-adherence address patient factors including misunderstanding, confusion or forgetfulness, and factors beyond the patient’s control such as cost.

“Patients should be asked about adherence at every consultation. A collaborative communication style is effective, using the patient’s own expressions and responding to their cues.

“Normalising non-adherence, and starting with open questions then following up with more specific probes, can also help.”

Prof Usherwood writes that clinicians are poor at detecting non-adherence, citing a study of 1169 patients being treated for hypertension.

In the study, their doctors recognised non-adherence in fewer than half of those whos pharmacy records indicated significant gaps in dispensing.

Prescribers also frequently intensified treatment even when they suspected the patients were not sticking to their medicines regimen.

Input from pharmacists and pharmacy staff can be helpful in addressing intentional non-adherence, Prof Usherwood writes, but over time this benefit can decrease.

“A systematic review explored patient-centred interventions to improve adherence, including patient education, shared decision making and pharmacist support.

“Many educational interventions resulted in better adherence and greater patient knowledge. However, their impact on adherence typically decreased over time.

“Shared decision making (including the use of decision aids) increased patient knowledge, but adherence improved in only two out of four studies.

“Adherence also improved with interventions by pharmacy staff, when they were tailored to patient needs, often involving both face-to-face and telephone encounters.”

Motivational interviewing can also help, and has been shown to improve adherence in a variety of settings, though not all studies show benefit and time pressure is an issue.

As for non-intentional non-adherence, cost is a significant barrier for many patients.

Prof Usherwood cites ABS data which showed 7.6% of patients who had received a script either delayed getting the medicine or did not have it filled at all, for financial reasons. He writes that prescribers can help by prescribing generics or lower-cost medicines if appropriate, and that pharmacists can also help by recommending lower-cost brands.

Confusion over the number and variety of drugs in a regimen is also a problem.

“Prescribers should aim to simplify this as much as possible. Discussion with a pharmacist may assist, particularly with tailoring appropriate preparations, formulations and packaging for the individual (e.g. people with an inability to swallow).

“These consultations may be rebatable in Australia using the Medicare medication management review items. It may be possible to reduce the frequency of administration, introduce combination medicines, or even deprescribe in some instances.”

He recommends lists and apps such as NPS MedicineWise’s MedicineList+, as well as patient reminders such as text messaging.

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