Patient adherence

Quite a few of us know of a family member or friend who has trouble sticking to his medication routine. Patient adherence is the extent to which the patient follows the instructions of his physician…….especially with respect to taking his medication in the correct manner and completing the course.

Surprisingly, there is abundant data indicating that 40% of patients do not comply with the above. The consequences have often increased the incidence of disease worsening/multidrug-resistant infections/ avoidable hospitalization.
We can, of course, take the high ground and say they are rather silly to do so if they want to get well. But let’s try and understand why patients do this and what are some simple ways we as pharmacists can help improve patient adherence.
The reasons patients don’t take or discontinue their medicines is multifactorial and depends on the disease and drug regimen. Hence our approach too has to be multipronged rather than one size fits all. First, we need to ask, has the patient been adequately counselled on the disease process? Has he understood what the consequences of not taking his medication eg Discontinuing TB treatment midway could result in him developing resistance to the medicines and it will not be effective next time.
Very often this is lacking. Due to the very high patient to doctor ratio, the patient gets very little time in consultation with the doctor. While pharmacists at the local Pharmacy are very willing to explain various aspects of drugs, perhaps we need to have a more proactive approach where doctors (especially at crowded outpatient clinics of govt hospitals) actively recommend the patient to go to the pharmacist for counselling on drug use.

The second point of consideration; is the patient elderly and having too many medications to handle? An elderly relative was having trouble managing her medications… she was diabetic and had high blood pressure/hyperlipidemia as well and was prescribed several tablets to be taken at particular times; some once daily and some twice daily. In India, we directly buy the entire tablet strips from the pharmacy and after several tablets are taken out of the strip, the name of the drug on the strip gets obliterated leading to confusion for the patient. The timely intervention of her pharmacist saved the situation and she was recommended a simple multicompartment pill box. She was explained how to divide the tablets into the various compartments when she purchases the medicines and label correctly.
We have an advantage in India that many households have a joint family setup where elderly parents live with their adult children. Hence another way to improve patient adherence is to involve a family member in the above process of motivating and administering the medicine to the patient. This is especially important in case of (though not only) psychiatric patients. These patients often provide incorrect feedback with respect to their own adherence. Eg. A patient assured his doctor that he was following his medicine routine perfectly but a quick glance through his file revealed that if followed correctly he should have come for a prescription refill ten days back!

Another sobering consideration is that in several developing countries, the cost of medicine and illiteracy is a very big stumbling block in patient adherence. Patients discontinue their medicines because they simply cannot afford it. In this regard, various government public health outreaches like free distribution of vital drugs, DOTS for TB management, vaccine drives etc should be actively supported and increased. Patient counselling camps, like the one organized by our budding young pharmacy students for the rural population, is another important approach.
Today technology has penetrated all aspects of our life……so could we leverage this to aid in patient adherence? Various companies have come up with just such devices which are programmed to send reminder messages at the appropriate time to the patient ……….in some devices the alarm is inbuilt into the pillbox itself.

With the advent of virtual assistants like Alexa and other smart devices, it could also soon be possible to say “Alexa…what medicine do I take in the morning?” Or better still, virtual assistants saying “good morning, please take the pink tablet from the pill box……don’t forget your morning walk!”

Pharmacists can also make use of various apps to do the same too. So which method should we go for? Studies have indicated (reviewed in Curr Opin Cardiol 2011) that although introducing technology to improve patient adherence seems like an attractive option, surprisingly, or perhaps not surprisingly, automated reminders by themselves do not fare as well as when combined with in-person communication, tailoring the educational information to the patients needs. This brings us back to the urgent need to increase the involvement of pharmacists in the healthcare system and to move towards a more community pharmacist approach.

Written By:
Dr.Tina Saldanha
Assistant Professor
AISSMS Pharmacy College.