Pharmacists in Focus: Point-of-Dispensing Adherence Interventions
Pharmacists are well placed to improve adherence. We spoke to Dr Grace Lomax, Co-Founder of Patient Connect, to find out how.
A challenge faced globally by health professionals lies in encouraging patients prescribed medication to better understand their treatment and disease, as well as to take it in the right dose and at the right time. According to Dr Grace Lomax, Co-Founder of Patient Connect, between 20 to 70% of patients do not adhere to their medications. In addition, the European Federation of Pharmaceutical Industries and Associations (EFPIA) report that non-adherence to medications costs the governments of Europe a staggering €125 billion, and contributes to 200,000 premature deaths, each year.
Patient Connect, which was founded in 2004, enables community pharmacists to address the barriers to medicine adherence and persistence at the point-of-dispensing, assisting pharmacists in optimizing their patients’ care. Through a network of more than 80,000 community pharmacies across Europe and the USA, the company have a reach of more than 400 million patients. They have run over 100 programs, with a 15% average improvement in days on therapy, and an average 13% improvement in medicine possession rates. Lomax says, “Across millions of patients we have improved adherence and persistence in an objectively measurable way.”
So, how exactly has this been achieved? First, Lomax highlights the importance of addressing what the patients are struggling with and supporting them with their unmet clinical needs. The pharmacists are ideally placed for this with frequent communication and an open approach with their patients. Lomax also explains that distinguishing between non-adherence and non-persistence is an important step when implementing adherence solutions.
Non-adherence versus non-persistence
It is important to distinguish between non-adherence and non-persistence because they illustrate very different reasons as to why patients might not take their medication. Non-adherence is when people are willing to take their medications but for various reasons do not take it correctly or fulfill prescriptions on time. Lomax says, “Patients are prone to forgetting the evening doses or forgetting to refill their prescription. A 30-tablet pack, which should theoretically be finished after 30 days, can last anything from 7 to 9 weeks as patients may have forgotten to take their tablet each evening, or at weekends etc.”
In contrast, non-persistence suggests a psychological barrier to medication compliance; once diagnosed, the patient may be unwilling to acknowledge they have a problem and simply hope it goes away – hence they may not fulfill the prescriptions at all. Lomax explains, “Across all clinical areas of disease there is non-persistence.”
When it comes to differentiating between the figures, non-adherence accounts for 40% of medicine possession rates where patients, for example, allow a pack for 28 days to last much longer. In contrast, non-persistence accounts for between 20 to 70% of patients over a 12-month period.
Lomax points out that there is a plethora of reasons a patient might not take medication; Patient Connect researches and addresses the causes of non-adherence and non-persistence.
Impact of medication non-compliance on quality of life and mortality
Lomax uses the case of hypertension to illustrate the impact that non-adherence and non-persistence can have on quality of life. She says, “Some legacy hypertension treatments come with side-effects, such as the beta-blockers, which can make patients lethargic and tired so they end up having naps in the afternoon and fall asleep in front of the TV. This changes their quality of life. In this situation we would either suggest changing the medication or suggest different times to take the medication, tackling the caused non-adherence,” she says.
In the long-term, if a hypertensive patient does not adhere or persist with medication, the risk of heart attack and stroke rise again, so Lomax suggests the need to, “Identify the issues in a positive and constructive way, which will make the patient feel empowered rather than threatened.”
Non-adherence and non-persistence can impact more than quality of life; they can be life-threating. Lomax explains, “Unmanaged blood pressure can lead to a heart attack. Unmanaged asthma can lead to an asthma attack. The reason we manage chronic care is to prevent further issues and complications – if we aren’t managing that care, the risks of those complications become greater.”
Some patients are more prone to not taking their medication than others. This is particularly true of the silent diseases such as raised cholesterol, raised blood pressure, osteoporosis, and remitting or relapsing diseases such as asthma, ulcerative colitis, Crohn’s disease and even depression. “When people are having good days and are feeling fine, some simply don’t take their medications,” explains Lomax.
Patient support programs in pharmacy
“Medication compliance solutions must be tailored to the patient and disease, and should be measurable,” states Lomax. The barriers to medication compliance are multiple, complex and varied. Understanding these barriers forms the foundations of adherence and persistence solutions.
Running secondary research through research clinicians, Lomax and her team first identify the issues that patients face with specific medications at a country level, while looking at the disease area, the types of treatments that patients would take, and viewing the patient as a whole.
With a disciplined approach to identifying what the patient is struggling with, we can best tailor communication, support, education, and information that the pharmacists help deliver to the patient.
Lomax says, “Some patients worry about long-term treatments and may be afraid they will become addicted or tolerant; they often fear the dose will have to be increased. Some feel the medication won’t work when they need it to work, and patients on polytherapy may worry that medicines will interact with each other and cause problems.”
“Many patients don’t really understand which medicine does what; when they are meant to take it, or at which intervals and dose,” Lomax continues, “Half to 60% don’t understand the dosage rules of their medicines. Taking medicines regularly reminds a patient they have a chronic disease, and people often don’t want to be classified as a patient.”
“With a disciplined approach to identifying what the patient is struggling with, we can best tailor communication, support, education, and information that the pharmacists help deliver to the patient,” explains Lomax. “We need to support patients in their unmet clinical needs. We need to find out what they are struggling with about the medicine – are they getting confused about which medicine to take, when to take it, and do they know whether they take it three or four times a day, for example?”
According to Lomax, there are good capabilities for tailoring pharmacy services to patients in 10 European countries. “In addition, in France or the US, we can provide specific drug-level information for women as compared to men, and for various age profiles; for example, for under 12’s or over 65’s,” she says. “We even tailor specific information to be given to an Atrial Fibrillation (AF) patient who has experienced a heart attack or stroke, as opposed to the information given to an AF patient who hasn’t experienced a heart attack or stroke.”
Connecting with patients through the pharmacist
Pharmacists are well placed to assist with the provision of optimal care. “Pharmacists see patients at the point-of-dispensing, and Patient Connect enables pharmacists to support the patient clinically. Pharmacists are provided with a call to action to supply literature, recruit people to a patient support programme, or verbally reinforce messages to the patients regarding their prescriptions and how to get the most from their medication. Whatever is best for the patient – we enable pharmacists to optimize the patient’s care,” says Lomax.
She further explains, “Pharmacists should be involved in optimizing patient care at a community level because a pharmacist is a trusted health professional. Patients see a pharmacist more often than a doctor or nurse. They often talk to a pharmacist freely, especially if they have a worry around treatment protocols, which is another contributor to non-adherence and non-persistence.”
Asked if pharmacists reported back to doctors on patient concerns, Lomax was quite clear on this issue: “In the main, this isn’t currently being done – it could be done, but would then require the consent of the patient for their concerns to be passed on to the doctor. We can recommend a patient goes back to their doctor with concerns, but we aren’t there to police patients. Our role is to support and help patients with their unmet clinical needs.”
One of the key ways in which the Patient Connect team have achieved improvements in adherence and persistence is through their patient support programs, which involve mobilizing community pharmacists to verbally reinforce clinical messages to patients regarding their prescriptions across a certain disease area.
For example, in Italy Patient Connect addressed medicine adherence to antihypertensive medication in men and women (Figure 1). Before Patient Connect’s mobilization of 10,000 community pharmacies across Italy, 70% of patients taking the target program antihypertension medication didn’t take their medication regularly, 15% didn’t collect their prescriptions on time, and only 30% had control of their blood pressure. Once alerted to the challenge, pharmacists at the point-of-dispensing verbally reinforced the clinical message about the importance of taking the medicine properly, resulting in an overall 13% increase in medication adherence by three months compared to a control group.
In the UK, Patient Connect is tackling the barriers to adherence and persistence of treatments for chronic constipation (Figure 2). Since commencement of the patient support program, there has been a sustained increase in medication possession ratio of up to 24%.
Patient Connect programs have also improved medicine compliance in chronic obstructive pulmonary disease (COPD), asthma, women’s health, diabetes, cardiovascular disease, mental health, pain management, oncology, men’s health, nutrition, and dermatology.
The key message here is that the less than 60 seconds on average spent by doctors telling patients when and how to take their medication needs reinforcement at the point-of-dispensing - each time a repeat prescription is fulfilled. Indeed, pharmacists are at the frontline when it comes to assisting with problems of non-adherence and non-persistence.
A win-win situation
So, how have pharmaceutical companies responded to the Patient Connect programs? Lomax describes a “win-win situation” – various pharmaceutical companies have, and continue to, sponsor programs so that adherence and persistence can be improved. This means that both patients and pharma companies benefit. Lomax is keen to ensure that these benefits continue to be reaped by running programs in pharmacy that remain patient-centric, objective and measurable.