How pharmacists can help improve patient compliance

Peter Mansell reports on the changing role of pharmacists in promoting adherence.



Peter Mansell reports on the changing role of pharmacists in promoting adherence.



With the growing emphasis in healthcare systems on securing value from medicines, it is all the more imperative to make sure these medicines are taken as directed. 


The flipside of the value coin islimited or no access to medicines that do not meet selected value criteria. And the driving force for that process is ultimately cost. The misuse, including under-use, of prescribed drugs is a waste of money.


Not only that, but the adverse reactions and sub-optimal treatment outcomes associated with non-adherence create extra costs for healthcare systems, such as (re)-hospitalization. Ultimately, this rebounds on the supplier.


Any wasted or additive costs arising from non-adherence reduce the available drug budget and the window of opportunity for new medicines that may save healthcare systems money in the long term, including through better adherence.


The role of pharmacists


The PGEU, the European association for community pharmacists, sees pharmacists as ideally placed to tackle non-adherence. They are not only experts on medicines but among the most accessible and most consulted health professionals, according to the PGEU. A number of countries have launched medication review or adherence programs as part of a wider trend towards expanding the pharmacists role in pharmaceutical care.


A number of factors contribute to poor patient adherence, including the challenges of managing a long-term condition, intolerable side-effects, the impact of adverse media coverage, the costs of treatment, asymptomatic conditions, and cutting short treatment as soon as the patient feels better (e.g., with antibiotics).


According to the National Institute for Health and Clinical Excellence, between 33% and 50% of patients in England do not use medicines prescribed for long-term conditions as recommended, while the estimated cost of unused or unwanted drugs to the NHS is more than 100 million a year.


This is also an international phenomenon. According to the PGEU, an estimated 194,500 deaths per year in the EU are down to mis-dosing of, or non-adherence to, prescribed medicines, running up annual costs of around 1.25 billion. In the US, the non-adherence tally is about $177 billion per year in direct and indirect healthcare costs.


Clinical medication reviews


According to the PGEU, clinical medication review is proven effective at optimizing therapy, improving health outcomes, cutting waste and reducing the likelihood of drug-related problems. In one Swedish study, medication reviews brought the average number of medicines taken by elderly patients down from 12.4 to 10.7, while the average drug cost per patient fell by around 160 per patient per year.


In the UK, the Medicines Use Review (MUR) scheme was introduced in April 2005 as the first advanced service offered under a new contractual framework between community pharmacies and the NHS.


Patients are selected for a consultation to ensure they understand why they are taking a particular medicine and how they should be taking it. Any problems identified in the review can be relayed to the prescriber via an NHS MUR form.


Medicines Use Reviews


MURs are not without their difficulties, though, particularly as the extra workload comes against a backdrop of rising prescription volumes. The scheme was slow to take off, although more recent figures indicate uptake has improved significantly.


Some pharmacists see MURs as a natural and welcome extension of moves to raise their profile in front-line patient management. But others are cynical about the motivations behind a service that involves hitting annual targets to bump up pharmacy revenues. The financial pressure to reach the annual ceiling of 400 reviews per pharmacy per year is detracting from other services, they warn.


A nationwide audit to gauge the effectiveness of MURs was launched in mid-2009 and the first results are imminent. The audit, a partnership between the Royal Pharmaceutical Society of Great Britain (RPSGB), the Royal College of General Practitioners and the Clinical Audit Support Centre, sought feedback from community pharmacy, general practice, primary care organizations and patients who have undergone an MUR.


The pharmacy skills mix


On the resource issue, the RPSGB suggests boosting the skill mix in pharmacy for example, by developing or employing accuracy-checking technicians can help by enabling the pharmacist to spend more time discussing how patients can get the most out of their medicines.


Another step forward, the Society says, would be original pack dispensing. Pharmacists feel that cutting up packs of pills to match prescriptions can lead to a loss of confidence in the medicine on the part of the patient, which in turn affects compliance.


It can also be confusing for some patients, who then do not take the medicine as intended, the RPSGB adds. And the pharmacist has to spend time sourcing and/or copying additional patient information leaflets (PILs). 


The role of pharma


Clearly there is an opportunity not to mention a strong incentive for pharmaceutical companies to step up their support for medicines adherence, be it through the supply of information and guidance to pharmacists involved in MURs (e.g., helping them target patients most likely to stray from the recommended regimen) or through other channels such as the GP or Web/text-based contact with patients.


Some companies already provide support in kind as resource packs and training materials for pharmacists in relevant areas, such as asthma management. Industry-wide, there has been a particular emphasis on ensuring patients are as informed about their medicines as possible, through channels such as PILs and the electronic Medicines Compendium, notes the Association of the British Pharmaceutical Industry (ABPI).


Zeroing in on pharmacists also helps build a relationship that will be all the more valuable to industry as responsibility for drug management/monitoring and some aspects of prescribing shifts increasingly from the GPs surgery to community pharmacies.


All the same, industry has to be careful not to let any of this activity cross the line into explicit inducements. Roche fell foul of this ambiguity last year when the ABPI ruled the company had breached the industrys Code of Practice by running a compliance scheme that involved awarding gift vouchers to children and teenagers who returned caps from the lung treatment Pulmozyme.


For more on pharmacists and patient compliance, see The Pharmacist as an Ally in Patient Adherence.