Measuring Compliance

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Measuring Compliance

• Self report Problem is patients overestimate
  their compliance level.

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Measuring Compliance

• Therapeutic outcome. We can not be sure that the
  recovery from an illness has been owing to the
  treatment. It could have been spontaneous, or
  perhaps the patient is suffering less stress.
• Health worker estimates Very unreliable.

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Measuring Compliance

• Pill and bottle counts Problem is patients can
  throw the pills away!
• Mechanical methods Device for measuring the
  amount of medicine dispensed from a container.
  Expensive and not fool-proof.

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Measuring Compliance

• Biochemical tests Blood tests or urine tests.
  Accurate, but Expensive, Inconvenient. Urine and
  blood samples are accurate ways of checking on
  compliance but a patient could easily take the
  required dose just before the appointment with
  the doctor. Also one has to take account of a
  patients metabolism or biochemical response to
  the prescribed drugs.

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• If multiple readings are taken by using several
  of the methods that check compliance then a more
  accurate picture of the patients' compliance can
  be made.

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• If a patient is shown to be non-compliant by
  several different measures then we can be almost
  certain that the subject really has not complied.

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TrackCap

• A treatment that is growing in the UK is oral
  asthma medication, and measuring adherence rates
  will help us to measure the effectiveness of the
  medicines.

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TrackCap

• If people follow the prescribed treatment
  programme they should reduce the attacks of
  breathlessness, but many people forget or decline
  to take the medicine regularly.

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TrackCap

• A study in London used an electronic device
  (TrackCap) on the medicine bottle which recorded
  the date and time of each use of the bottle
  (Chung and Naya, 2000).
• The patients were told that adherence rates were
  being measured, but were not told about the
  details of the TrackCap.

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TrackCap

• The medicine was supposed to be taken twice a
  day, so a person was seen as adhering to the
  treatment if the TrackCap was used twice in a
  day, 8 hours apart.
• Over a twelve-week period, compliance was
  relatively high (median 71 per cent), and if the
  measure was a comparison of TrackCap usages with
  the number of tablets then adherence was even
  higher (median 89 per cent).

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Sherman et al., 2000

• Another study on asthma medicines, this time
  inhalers, checked for adherence by telephoning
  the patients pharmacy to assess the refill rate
  (Sherman et al., 2000).
• They calculated adherence as a percentage of the
  number of doses refilled divided by the number of
  doses prescribed.

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Sherman et al., 2000

• This study of over 100 asthmatic children in the
  USA was able to compare pharmacy records with
  doctors records and with the records of the
  medical insurance claims for treatment.
• They concluded that the pharmacy information was
  over 90 per cent accurate and could therefore be
  used as basis for estimating medicine use.

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Sherman et al., 2000

• They also found that adherence rates were
  generally quite low (for example 61 per cent for
  inhaled corticosteroids), and that doctors were
  not able to identify the patients who had poor
  adherence.

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The Role of Medication Compliance in Improving
Outcomes of Pharmaceutical Care
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• Sweeping changes continue to reshape the practice
  of pharmacy. The pharmacy professional needed
  today is a knowledgeable drug expert and skilled,
  persuasive communicator. This pharmacist
  embraces a new practice model - pharmacy care.

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The Pharmacy Care Process

• Collect and utilize patient information (build
  rapport)
• Identify patients drug related problems
• Develop solutions
• Select and recommend therapies
• Follow up to assess outcomes

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Vision

• Compliance as a partnership between patients,
  physicians and even managed care to achieve
  desired health outcomes now called
  concordance.
• Managing medication compliance improved
  outcomes
• complex, but, interesting implications for health
  practitioners

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Possible Challenge

• Improved compliance may also mean more drug
  related problems.
• over users who take less medication may
  experience increased symptoms
• under users who take more doses may experience
  more side effects

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Outcomes

• Economic
• increased cost of medications
• To patients, insurers, government
• lower total health care costs
• Clinical
• better control of disease, symptoms
• Humanistic
• patient satisfaction with therapy
• prescriber satisfaction?

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When patients do not take their medications
correctly what happens?
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When patients do not take their medications
correctly what happens?

• May not get better
• Can get sicker / worsen disease
• Can have a relapse

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The costs of noncompliance

• gt 100 billion dollars annually
• 125,000 unnecessary deaths
• 10 (more than 1,000,000) of all hospitalizations
  may be due to noncompliance
• 50 of all medication use

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Health Effects

• increased morbidity (sickness)
• treatment failures
• exacerbation of disease
• more frequent physician visits
• increased hospitalizations
• death

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Economic effects

• increased absenteeism
• lost productivity at work
• lost revenues to pharmacies
• lost revenues to pharmaceutical manufacturers

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Dimensions of Compliance some things we think we
know.

• Initial noncompliance or defaulting
• 2 - 20, possibly as high as 50
• average 8.7
• Refill compliance or persistence
• Decreases over time
• Not all non-compliance is improper medication use
  
• rational noncompliance

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Benchmark compliance rates

• Disease
• Epilepsy
• Arthritis
• Hypertension
• Diabetes
• Oral contraceptives
• HRT
• Asthma

• Rates of noncompliance
• 30 to 50
• 50 to 71
• 40 (average)
• 40 to 50
• 8
• 57
• 20

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Persistence

• Product persistency curves
• after 1 year as much as a 50 percent decline
• after 5 years, compliance as low as 29 to 33
• greatest declines in first six months

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Improper medication use

• Over or under use, wrong time
• Taking the wrong medicine
• Not finishing medication
• Administration errors
• Using another persons medication
• Using old, possibly expired medication

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Patient Considerations

• Factors believed to affect compliance
• patient knowledge
• prior compliance behavior
• ability to integrate into daily life / complexity
  of the particular drug regimen
• health beliefs and perceptions of possible
  benefits of treatment (self efficacy)
• social support (including practitioner
  relationships)

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Patient Considerations

• Factors which are NOT believed to be associated
  with compliance
• age, race, gender, income or education
• patient intelligence
• actual seriousness of the disease or the efficacy
  of the treatment

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Patients at higher risk

• Asymptomatic conditions
• hypertension
• Chronic conditions
• hypertension, arthritis, diabetes
• Cognitive impairment
• dementia, Alzheimers
• Complex regimens
• poly pharmacy, QOD

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Patients at higher risk

• Multiple daily dosing
• qd lt bid lt tid, lt qid
• Patient perceptions
• effectiveness, side effects, cost
• Poor communication
• patient practitioner rapport
• Psychiatric illness
• less likely to comply

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Issues

• Measuring compliance
• Several methods
• Non-response v. non-compliance
• Did the doctor choose the right drug, dose, etc.?
• Compliance is not easy to pinpoint
• Compliance problems cuts across drugs, diseases,
  prognosis, and symptoms.

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Issues

• Measuring compliance
• patient reports, clinical outcomes, pill counts,
  refill records, biological and chemical markers,
  monitors
• MAS, MOS, BMQ
• Medication Adherence Scale, Medical Outcomes
  Study, Brief Medical Questionnaire
• Range from complicated to simple, such as
• How often have you taken your prescribed
  medication in the past four weeks?

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High Tech Tools To Improve Compliance
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Strategies to improve compliance

• personal interaction with your pharmacist,
  through counseling and communication, etc.
• multimedia educational campaigns
• patient education, counseling, written
  information, special labels
• teaching methods for self monitoring
• new idea.contracts with patients?
• devices, reminders (mail, telephone), special
  packaging
• follow-up

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The RIM Technique

• Recognize
• using objective and subjective evidence, the
  pharmacist can determine if the patient may have
  an existing compliance problem
• Identify
• determine the causes of noncompliance with
  supportive probing questions, empathic responses,
  and other universal statements
• Manage
• develop partnerships with patients

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Identifying Non Compliance

• information from the patient
• patient comments, concerns, questions
• certain clinical outcomes
• non response to treatment
• information from refill records

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Pharmacy Care Skills Needed

• Patient skills needed for behavior modification
• problem solving
• self monitoring
• develop systems for reminders
• enlisting social support get family involved
• identify positive and negative compliance
  behaviors

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Actions Needed

• More fully implement the pharmacy care model
• Challenges
• pharmacist commitment to pharmacy care
• enhance the key skills necessary for patient care
• develop partnerships with physicians, MCOs and
  patients
• integrate, coordinate and manage drug use

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Benefits of improved compliance

• For
• Patients - better outcomes and quality of life
• Practitioners healthier, more loyal patients
• Managed care - lower total HC expenditures
• Pharmaceutical Industry - increased sales