Medication adherence is defined as:
“The extent to which the patient’s behaviour matches agreed recommendations from the prescriber” (Horne et al, 2005).
It is estimated that between 30 and 50% of patients on long-term treatment are not taking their medication as recommended (Horne et al, 2005). The impact of this on the treatment of long-term conditions as well as the cost implications have a huge impact on patient care and the economy.
In their review of “Interventions for enhancing medication adherence”, Haynes et al (2008) concluded that improving medication adherence may have a far greater impact on clinical outcomes than any improvement in treatments. They concluded that high priority should be given to interventions that assist patients to follow medication prescriptions for long-term medical disorders.
Pharmacists have a pivotal role to play in helping patients improve their adherence with medication regimens. Pharmacists in both community and hospital settings are well placed when reviewing or dispensing medication to engage patients in discussion about adhering to treatment protocols. One of the first questions to determine when discussing adherence is: “How do you know if a patient does or does not comply with his or her medication regimen?” As it is not practical to ascertain medication levels, practitioners mostly rely on patients telling them, or more importantly feeling they can tell them, about any adherence issues. Sometimes practitioners can suspect that patients may not be adhering to their medication regimen by noticing long gaps between prescription collection or, when reviewing patients’ medication, noticing they are using boxes or blister packs dispensed months previously.
As well as asking patients on new medication regimens about adherence, which is supported by the New Medicines Service, pharmacists need to also check adherence with patients on long-term medications. Additionally, pharmacists should be aware that just because a patient collects a regular prescription it does not mean that he or she is taking the medication correctly.
It is important to address any issues to help patients optimise their medication. A good example of this was recently experienced by the author, who could not determine why a woman with diabetes had poor glycaemic control despite being on insulin for a number of months and being seen by the diabetes team. After consultation it became apparent that she was taking her twice-daily insulin 2 hours after her meals as a result of miscommunication; it is therefore sometimes necessary to ask what may seem obvious questions, as the patient may have misunderstood the medication protocol given.
Reasons for patients not taking their medications can be unintentional or intentional:
- Unintentional non-adherence is when patients want to take their medication but are prevented from doing this because of barriers beyond their control, such as the tablet being too large to swallow or too small to handle, or having difficulties with opening the packaging.
- Intentional non-adherence is when patients do not take their medication because of beliefs or preferences that prevent them from taking it; for example, a teenage girl with type 1 diabetes may not take her insulin dose or full dose because of concerns that she will gain weight, without understanding the long-term implications of this action.
The way practitioners ask patients about adherence is most important, and open, “non-blame” questioning alongside motivational interview techniques are crucial. Closed questions such as “You do take your tablets, don’t you?” should be avoided, instead using open questions such as “How do you manage taking your tablets?” It is important patients understand information so they can make informed decisions; further information sources or leaflets can be given to reinforce advice, as people only retain a fraction of verbal information given. Internet sites are a good resource to highlight, such as www.diabetes.org.uk for people with diabetes.