1. Optimizing Patient Adherence to Pharmaceutical Care Plans 1

2. Objectives Background Burden of non-Adherence Definitions Factors affecting patient adherence Interventions to detect and assess adherence/non-adherence Consideration for special populations Strategies to optimize adherence to pharmaceutical care plans (prevention and resolving nonadherence) 2

3. Lecture Resources Medication Adherence : Its Importance in Cardiovascular Outcomes. Circulation. 2009;119:3028-3035 Optimizing Adherence to Pharmaceutical Care Plans. J Am Pharm Assoc. 2000;40(4). Accessed from: http://www.medscape.com/viewarticle/406691_2 http://www.medscape.com/viewarticle/406691_2 Enhancing Prescription Medicine Adherence: A National Action Plan (2007). Accessed from: http://www.talkaboutrx.org/documents/enhancing_prescriptio n_medicine_adherence.pdf http://www.talkaboutrx.org/documents/enhancing_prescriptio n_medicine_adherence.pdf 3

4. Background Nonadherence has serious negative impact on patient’s and health outcomes Considered as an "invisible epidemic” “America’s Other Drug Problem” It affect all age and ethnic groups 4

5. Background About 69% of non-adherence to drug therapy is behavioral in nature resulting from forgetfulness or procrastination Share many characteristics of medical disorders 5

6. Non-adherence rates are high among patients with chronic diseases 6

7. “Poor adherence to treatment of chronic diseases is a worldwide problem of striking magnitude. Adherence to long-term therapy for chronic illnesses in developed countries averages 50%. (WHO 2003) 7

8. “A worldwide problem of striking magnitude” In USA: Three out of every four American consumers report not always taking their prescription medicine as directed*. Forgetfulness: 49% Didn’t refill: 31% Ran out of medicine: 29% Took less dose than recommended: 24% About 33% to 69% of medication related hospital admissions are due to poor adherence 8 * Survey conducted by National Community Pharmacists Association-2006

9. “A worldwide problem of striking magnitude” In UK 20-30% don’t adhere to regimens that are curative or relieve symptoms 30-40% fail to follow regimens designed to prevent health problems 33-50% of newly prescribed medicines are subject to non- adherence 9 Survey by The New Medicines Service (NMS), a service commissioned by the Department of Health-UK

10. Nonadherence in Saudi Population Data from Saudi Arabia Hypertensive patient has a compliance rate of 34.2% Factors: organizational variables (time spent with the doctor, continuity of care by the doctor, communication style of the doctor and interpersonal style of the doctor) 10 Khalil et al. Journal of Hypertension, 1997, 15:561-565. Albaz RS. Journal of Social Sciences, 1997, 25:5-8.

11. Nonadherence in Saudi Population Medication adherence among patients in a chronic disease clinic Cross sectional study, n= 347 Age and asthma were significantly associated with low motivation Single status was the only independent predictor of low adherence intention 11 Tourkmani, Saudi Med J. 2012 Dec;33(12):1278-84.

12. “A worldwide problem of striking magnitude” 1.Adverse Heath outcomes:  Decrease productivity  Increase disease morbidity  Increase physician office visits  Hospital re/or-admissions  Death 2.Pharmacies also lose revenue because patients often fail to refill prescription medications, especially for chronic diseases 12

13. “A worldwide problem of striking magnitude” 3.Economic Burden: Data from USA: Annual deaths caused by non-adherence is estimated to be 125,000 Cost: nearly $300 billion annually in direct and indirect costs – Mostly due to readmissions » 70% of which are attributable to medication non-compliance among the elderly 13

14. What is the definition of nonadherence? “Drugs don't work in patients who don't take them” 14 - C. Everett Koop, M.D.

15. The extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider. The definition best describes Compliance Adherence Persistence 15

16. Definitions Compliance: the extent to which the patient’s behavior matches the prescriber’s recommendations’ 1 Adherence: ‘the extent to which the patient’s behavior matches agreed upon recommendations from the prescriber’ Medication persistence: “the length of time from initiation to discontinuation of therapy” 16 Haynes R, et al 1979. Barofsky I. 1978, Cramer, Value Health 2008;11:44–7.

17. More than just medications…. Nonadherence encompass any of the following: Medications Recommended lifestyle changes: exercise or smoking cessation Prescribed non-pharmacologic interventions: physical therapy or dietary plans 17

18. Medication Nonadherence Can take many forms: Not having a prescription filled Taking an incorrect dose Taking medications at incorrect times Forgetting to take doses Stopping therapy before the recommended time Drug Holiday 18

19. What does the patient Really Say... “If I don’t put my pills on my plate 3 times a day, my wife will put them for me, there is no question about that!” “I believe the doctor will know. He is trained regularly, he knows the newest things. What do we know about it? I suppose that it is necessary to take the medication.” 19

20. What does the patient Really Say.. “That is why I always ask for samples.. I take a lot of medicines and it is very expensive.” “I never forget my medication, except for the one pill that I have to take twice.” “I couldn’t make neither head or tail because in hospital they have another name for the same tablet.” “I didn’t take my diuretics (metoprolol) because of my visit to HF clinic.” 20

21. What does the patient Really Say.. “It is just a routine… I put the tablets on the breakfast table and hope I take them.” “I suppose it is a built-in fear; if you don’t comply you will end up back in the hospital again-and you don’t want that, do you? “When you so far gone as I am now, you will take them, you have no choice.” 21

22. Major Risk Factors for Non-Adherence 1.Asymptomatic conditions 2.Chronic conditions 3.Cognitive impairments, especially forgetfulness 4.Complex regimens 5.Multiple daily doses and polypharmacy 6.Patient fears and concerns related to medication effects 7.Poor communication 22

23. Causes for Nonadherence Reasons for patient non-adherence are complex and multidimensional Many internal and external factors The WHO define 5 dimensions for nonadherence: Social/economic factors Provider-patient/health care system factors Condition-related factors Therapy-related factors Patient-related factors 23

24. Factors affecting Patient Adherence 24

25. I. Social and economic factors Poor socioeconomic status and poverty Illiteracy, low level of education Unemployment Lack of effective social support networks Unstable living conditions (Wars) Long distance from treatment center High cost of transport; high cost of medication 25

26. I. Social and economic factors Changing environmental situations Culture and lay beliefs about illness and treatment Family dysfunction Race: cultural beliefs, social inequalities Age: Children, Adolescent, Elderly 26

27. II. Health care team and system-related factors Poorly developed health services Poor medication distribution systems Lack of knowledge and training for health care providers on managing chronic diseases, overworked health care providers Lack of incentives and feedback on performance Short consultations times 27

28. II. Health care team and system-related factors Weak capacity of the system to educate patients and provide follow-up Inability to establish community support and self-management capacity Lack of knowledge on adherence and of effective interventions for improving it 28

29. III. Condition-related factors Severity of symptoms Level of disability (physical, psychological, social and vocational) Rate of progression and severity of the disease The availability of effective treatments Comorbidities: depression Substance of abuse 29

30. IV. Therapy-related factors Complexity of the medical regimen Duration of treatment Previous treatment failures Frequent changes in treatment The immediacy of beneficial effects Side-effects and the availability of medical support to deal with them 30

31. V. Patient-related factors Knowledge and beliefs about illness, motivation to manage it Expectations regarding the outcome of treatment and the consequences of poor adherence Inadequate knowledge and skill in managing the disease symptoms and treatment Misunderstanding of treatment instructions 31

32. V. Patient-related factors Negative beliefs regarding the efficacy of the treatment Lack of perception of the health risk related to the disease Lack of self-perceived need for treatment Lack of perceived effect of treatment 32

33. V. Patient-related factors Anxieties about possible adverse effects Low motivation Low attendance at follow up, or at counseling, motivational, behavioral, or psychotherapy classes Hopelessness and negative feelings Frustration with health care providers 33

34. V. Patient-related factors Forgetfulness Psychosocial stress Misunderstanding and non-acceptance of the disease Lack of acceptance of monitoring Disbelief in the diagnosis Low treatment expectations 34

35. Patient-related factors Fear of dependence Anxiety over the complexity of the drug regimen Perceived effect of treatment Feeling stigmatized by the disease 35

36. Next Lecture Assessing Adherence Resolving adherence problem Preventing adherence 36