FIP 2008: Importance of working in partnership with patients to improve healthcare
Pamela Mason reports from a session that was part of the board ofpharmaceutical practice programme, at the 2008 World Congress ofPharmacy and Pharmaceutical Sciences
Pamela Mason reports from a session that was part of the board of pharmaceutical practice programme, at the 2008 World Congress of Pharmacy and Pharmaceutical Sciences
Non-adherence is prevalent across medical conditions and is a major inefficiency at the core of healthcare, according to Rob Horne, professor of behavioural medicine, The School of Pharmacy, University of London, UK.
Giving a presentation on patients’ behaviour in relation to their medicines, he said that if the prescription is appropriate but is not taken correctly, this represents a loss for patients, the healthcare provider and the pharmaceutical industry.
Attempts to improve adherence have had disappointing effects across illnesses, partly because they have not been comprehensive enough, he said. The causes of non-adherence also need to be better understood.
Professor Horne went on to describe recent insights from research into the causes of non-adherence from the patient’s perspective and the various models used to help explain non-adherence.
The perceptions and practicalities model of adherence suggests that various practical barriers, such as inability to open packaging or a treatment too complex to fit into the daily routine, could often be addressed, but this would not necessarily lead to adherence because of perceptual barriers, such as the patient deciding from the start to take less medicine than prescribed.
“It is important to assess the patient and identify these practical and perceptual barriers as these are key reasons why we are not getting very far with adherence,” he said.
He said that patients with the same medicine and same illness often differ in their perceptions of need for the medicine, although they often report similar concerns about their medicines (eg, side effects, addiction potential and reduced effectiveness with prolonged use).
Low adherence relates to doubts about personal need for the medicine together with concerns about side effects.
The patient view of illness and medication differs from the medical view, he said. Patients use common sense to match their treatment with their illness. This is often influenced by symptoms relative to expectations. Diseases such as hypertension and diabetes have no symptoms.
Treatment makes the patient feel worse, while missing a dose makes them feel no worse. Such perceptions affect adherence and the need for treatment to manage a symptomless disease needs to be explained.
In research studies, patients express dissatisfaction with the information they receive about their medicines, and they see their doctor and pharmacist as not addressing their needs. “We need to bridge that gap,” he said.
Adherence needs to be addressed at several levels. At the patient level, individualising approaches to target the unique perceptual barriers (eg, beliefs, preferences and concerns) as well as practical barriers (eg, forgetting to take the medicine and the complexity of a regimen) is likely to be more effective than targeting general issues.
Support for patients needs to be personalised and not just delivered at the point of prescribing. Informing needs to be an active process that involves more than simply presenting the evidence, he added.
“Medication use review provides an effective platform for this and behavioural medicine is the new challenge for pharmacy.”
The beliefs about medicines questionnaire measures two types of beliefs:
Scores on the BMQ distinguish between high and low adherence and provide a quick and easy assessment of patients’ perspectives, identifying perceptual barriers to adherence.
The BMQ also identifies patients who need further input and helps to target the type of input required
“It is not only about our questions and their answers,” she said. “It is about what they want to say but do not necessarily say. What they want to say reflects their real concerns and is about their day to day experience of health. This is not elicited in dialogue between patients and professionals and there is a need to get inside the patient’s head.”
To illustrate, Marianne Norelius, of Apoteket AB, Sweden, described an old, housebound woman in Sweden who told her doctor at an annual review that she was fine, but told her home care worker she felt dizzy and was afraid of falling. “We need to move to a situation where patients want to provide information,” she said.
Professor Jönsson said that a common focus needs to be developed between pharmacist and patient. In the context of increasing patient empowerment, measurement of parameters in body fluids (eg, lipids and glucose) can help to create that common focus.
Body fluid parameters can be measured in the pharmacy or at home, and discussed with the patient, and the patient is empowered to take appropriate action. A patient diary can also help to create common focus and effective dialogue between pharmacist and patient, she said.
Continuing with the theme of patient empowerment, John Gans, executive vice-president and chief executive officer, American Pharmacists Association, emphasised the importance of developing a true partnership with patients to get them to assume more responsibility for their care.
“After all, who actually manages their diabetes? It is not the healthcare professional. It is the patient,” he said. “If patients become partners, this avoids treatment costs and productivity losses, he added.
He then went on to describe the Asheville diabetes project in North Carolina, US, in which pharmacists are used as “patient coaches”. Given that most people with diabetes are taking seven to 12 medicines, many have problems understanding how to use them and research shows that medication adherence is the biggest barrier to improvement in diabetes control. Pharmacists seemed to be the most appropriate professionals to get alongside patients to improve adherence, he said.
The Asheville project aimed to improve the diabetic care of employees. Poor therapeutic outcomes are of concern to employers because of the costs of productivity losses and the costs of health insurance, which many US employers pay on behalf of their employees.
Dr Gans explained that patients were given incentives to join the programme in the form of free glucometers and co-payment waivers. Pharmacists were remunerated for supporting patients in collaboration with other health professionals.
The project demonstrated several benefits. First, diabetes-related emergency room visits fell from 3 per cent to 1 per cent. Sick days were reduced by 50 per cent for all diseases as well as diabetes. HbA1c fell from 8 to below the American Diabetes Association guideline of 7.
Over five years, overall healthcare costs fell by over US$2,000 per year per patient. The use of medicines increased. At the start of the programme, medicines amounted to 30 per cent of medical care cost, increasing at the end to 65 per cent of medical care cost.
Turning to the Asheville cardiovascular disease project, Dr Gans said that too had shown beneficial outcomes. The proportion of patients reaching their blood pressure target increased from 40 to 67 per cent and patients reaching their low density lipoprotein (LDL) cholesterol target increased from 50 per cent to 75 per cent.
The cardiovascular event rate decreased to almost half during the study period. Cardiovascular medication use increased nearly threefold and cardiovascular related medical costs decreased by almost half. Similar benefits have also been demonstrated in an asthma project, he said.
Missed or non-productive workdays fell from 10.8 to 2.6 days per year and all measures of asthma control improved and were sustained for as long as five years.
The Asheville project has now been rolled out further and 90 employers are currently participating. The diabetes programme is being run across 10 cities and interim results show that self management goals are being met in increasing numbers of patients.
Satisfaction with overall diabetes care has more than doubled and 97 per cent of patients say they are “satisfied” or “very satisfied” with the services of the coaching pharmacist.
Importance of structured assessment
He said that community pharmacists have traditionally spent only a few minutes of unstructured time with patients to assess their overall health. This situation is similar whether the patient asks for a non-prescription medicine, wants help with a minor ailment or requires information on a dispensed medicine.
Important health and medicines issues can be missed in this unstructured scenario. Conducting patient assessment at the point of sale results in poor performance, Dr Hersberger added.
Specific guidelines and protocols are helpful in reducing poor pharmacist performance, of which the WWHAM approach (What are the symptoms? Who is the treatment for? How long has the patient had the symptoms? Action already taken? Medicines being taken for other problems?) is among the best known.
However, research has shown that performance with the WWHAM questions is not perfect. “This points to the need for more elaborate protocols and tools,” he said. “These need to be tailor-made to distinct patient groups and disease states.”
Describing his own research in pharmacist supply of emergency hormonal contraception, he said that a structured 19-item assessment produced effective pharmacist performance.
Turning to care issues in relation to prescribed medicines, he said that not all patients expressed the same needs for pharmacy services. Preliminary results from the Pharmaceutical Care Network Europe study showed that a quarter to a third of patients value counselling.
Pharmaceutical care can take place at various levels, he said, and a useful model is “Room for review”.
According to this model, level 1 pharmaceutical care might involve unstructured counselling at the point of care (eg, information on drug taking), level 2 might be structured telephone interview (eg, checks on drug related problems and adherence), level 3 could be a medication review and level 4 a home visit.
Home visits can reveal a high prevalence of medicines-related risk factors, including poor storage of medicines, hoarding of medicines, medicines beyond their expiry dates, and no routine for taking or administering medicines, he said.
Concluding, Dr Hersberger said that, regardless of the care situation, the patient plays an important role. “We must use them as important partners to boost our impact. Only if we succeed in efficient assessment of their needs can we provide tailored and rational care. If we develop our effectiveness in pharmaceutical care, we get positive feedback.
“We should recognise that we can learn a lot from our patients. Effective patient partnership is a win-win situation, resulting in improved care for the patient and empowerment for the pharmacist.”
Reports from the 68th World Congress of Pharmacy and Pharmaceutical Sciences
Citation: The Pharmaceutical Journal URI: 10038108
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