Supporting patients: pharmacy based interventions to improve medication adherence

Abstract

For many patients it is not easy to adhere to the agreed treatment with medication. Adherence has been defined as “the extent to which a person’s behaviour - taking medication - corresponds with agreed recommendations from a health care provider”. Numerous factors influence this taking behaviour and non-adherence must not be seen as the patients’ problem only. Health care providers, including pharmacists, should support patients to adhere. The overall aim of this thesis was to evaluate interventions in community pharmacies focussing on improving medication adherence both at the start of therapy and in the implementation of the therapy. Moreover, we studied frequency, nature and the quality of counselling in pharmacies and proposed definitions and standardization for assessing adherence using dispensing data. The thesis includes two large randomized studies. The first study focussed on patients initiating treatment: the Telephone Counselling Intervention by Pharmacists (TelCIP)-trial. The intervention consisted of a telephone call 7 to 21 days after the start of therapy and focussed on patients starting with Renin-Angiotensin-System (RAS)-inhibitors, bisphosphonates, lipid-lowering drugs and antidepressants. This telephone call aimed at improving patient’s adherence. Counselling during this phone call focused on patients’ information needs and barriers to take medication such as side effects, low necessity beliefs and forgetfulness. Intervention patients were compared with patients receiving usual care. After receiving telephone counselling patients were more satisfied with counselling in general than patients who received usual care. They were also more satisfied with the information on their medication and fewer patients had concerns about the medication. Interestingly, all effects were more pronounced in men than in women. Main objective of this service was to improve medication adherence and this study demonstrated that counselling by telephone clearly improved adherence with Renin-Angiotensin-System (RAS)-inhibitors and indicated an improvement with bisphosphonates and lipid-lowering drugs. However no effect was found in patients using antidepressants. It is important not to focus exclusively on patients initiating treatment but also on patients already using the medication. Therefore, a second trial focussed on non-adherent patients who were using lipid-lowering drugs (statins) for over a year. Two interventions were compared with usual care: provision of an electronic reminder device (ERD) combined with counselling in the pharmacy or the provision of an ERD only. Results showed that patients were difficult to motivate to visit the pharmacy for counselling. In general, medication adherence did not improve by using the ERD, both with and without counselling, but the provision of an ERD improved adherence in women using a statins for secondary prevention compared to women receiving usual care. This thesis concluded that pharmacists can support patients in medication use but that the effectiveness of interventions is not the same for different groups of patients. Within the multidisciplinary team involved in medication adherence, it is time that pharmacists take up the challenge to expand their role in promoting medication adherence.