PF1011 Pharmacy Practice I Medication Adherence and Health Literacy PDF

PF1011: Pharmacy Practice I Medication adherence and Health Literacy Prof L J Sahm, Vice Dean [email protected] Definitions Compliance = the extent to which the patient’s behaviour matches the prescriber’s recommendations Concordance = two-way exchange between healthcare professional and the...

PF1011: Pharmacy Practice I Medication adherence and Health Literacy Prof L J Sahm, Vice Dean [email protected] Definitions Compliance = the extent to which the patient’s behaviour matches the prescriber’s recommendations Concordance = two-way exchange between healthcare professional and the patient whereby the prescriber and the patient agree therapeutic decisions that incorporate their respective views. Patient’s preferences and beliefs are taken into account. Definitions Adherence = the extent to which the patient’s actions meet the prescriber’s recommendations or expectations. Healthcare professionals should accept that the patient’s beliefs, preferences and prior knowledge influence medicine-taking. ‘In-between’ compliance and concordance. Importance of Adherence Drugs don’t work in patients who don’t take them. — C. Everett Koop, M.D. Importance of Adherence Non-adherence Limits benefits of medicines Costs can be significant (personal and public costs) Approx. 30% (some sources say up to 69%) of drug- related hospital admissions due to non-adherence In renal transplant patients, 91% of non-adherent patients had organ rejection/died versus 18% of patients who adhered to their medication regimen Increase in symptoms, deterioration in overall health Adherence Measurement of ‘rate’ of adherence ✓ % of prescribed doses actually taken, OR ✓ % of prescribed doses taken at the correct time of the day Adequate adherence rates are hard to define: Some clinical trials aim for 80% adherence Other clinical trials aim for >95% adherence e.g. HIV drugs Adherence rates are on a continuum from 0% to over 100% Nonadherence Multifactorial Two main categories 1. Unintentional (involuntary) or behaviour (forgetting) 2. Intentional (voluntary) or cognitive (concerns about side effects) Non-adherence seen to a greater extent in chronic conditions Example: 50% of patients on statins discontinue their medicines within 6 months of starting How adherent are people to their medication regimens? Using monitors on medicine containers to see how people take medication, researchers found 1/6th have perfect adherence 1/6th take nearly all doses with some timing irregularity 1/6th miss occasional single day’s doses with some timing irregularity 1/6th take drug ‘holidays’ 3-4 times per year with occasional other omissions 1/6th take drug holidays at least monthly with frequent additional dose omissions 1/6th take few/no doses but give the impression of good adherence Identifying Poor Adherence Is a patient not responding to treatment? Consider having a non-judgemental conversation with patients who may be collecting medicines at varying intervals: Do you ever miss any doses of your medicines? Assure them it can be hard to always remember to take medicines (for everyone). Discuss with patients why they are taking the medicines they are on – find out what they know themselves about their medicines Provide patients with the list of benefits of their medicines Give an honest explanation to patients about what side-effects patients may experience How do we measure patient adherence? There are two main ways to measure adherence: 1. Direct methods – these are rarely used and are reserved for assessment of adherence to medicines which need to be taken for not only the health of the individual, but also for public health e.g. highly active anti-retroviral therapy (HAART) or anti-tuberculosis drugs Measurement of patient adherence by a combination of methods maximises the accuracy of the measurement Direct Methods of Measuring Adherence i. Directly Observed Therapy ii. Measurement of the concentration of the drug or a metabolite in plasma iii. Measurement of the concentration of a biological marker which has been added to the drug These are: Expensive Burdensome Susceptible to distortion by the patient How do we measure patient adherence? There are two main ways to measure adherence: 2. Indirect methods – these are used most often, but have the limitation of potentially misrepresenting adherence leading to overestimation Measurement of patient adherence by a combination of methods maximises the accuracy of the measurement Indirect Methods of Measuring Adherence Indirect Method Advantage Disadvantage Patient questionnaires/self- Simple, inexpensive Susceptible to error (memory reports (or parent for child) lapse), results can be inaccurate Pill counts Objective, quantifiable, easy Results can be inaccurate (pill dumping) Rates of prescription refills Objective, easy Not equivalent to ingestion of medication, closed pharmacy system required Assessment of patient’s Simple, easy Factors other than adherence clinical response can affect it Electronic medication Precise, results quantifiable, Expensive, return visits monitors patterns can be tracked required to download data Measurement of physiologic Easy Factors other than adherence markers (e.g. heart rate) may affect it Patient diaries Helps correct poor recall for Easily altered by patient other methods Osterberg and Blaschke. N Engl J Med 2005;353:487-97. Medication Event Monitoring System Medication Event Monitoring System Adherent to medication (twice daily dose) Non-adherent to medication (twice daily dose) Bouvy et al. Journal of Cardiac Failure Vol. 9 No. 5 2003 Barriers to Adherence Barrier % Possible contributory factors Forgetfulness 30 Complex regimens Other priorities 16 Lack of consideration Decision to omit doses 11 given to patient’s Lack of information 9 lifestyle/cost of about medicines medicines/conditions Emotional factors 7 Failure to explain benefits and side-effects No reason given 27 Poor therapeutic relationship between healthcare professional and patients Barriers to Adherence Osterberg and Blaschke. N Engl J Med 2005;353:487-97. Specific Challenges with Adherence HIV treatment Need 95% adherence to HAART at a minimum Hypertension treatment Asymptomatic condition, treated with medicines which have side-effects Consider more ‘forgiving’ antihypertensives for non-adherent patients Psychiatric illness 50% of patients on antidepressants don’t take them within 3 months of starting therapy Consider use of depots for non-adherent patients Paediatric patients Pharmacist role Education Communication Pharmacist Interventions for Non- Adherence Simplifying medicine usage Review Factors Affecting Behaviour (COM-B Model) Behaviour change required = improved adherence to medication regimens Capability = the psychological/physical ability to actually perform the activity e.g. can the patient remove the tablet from the container or swallow the tablet/ can the patient administer the eyedrops? Opportunity = factors not specific to the individual which make it possible for the person to perform the activity e.g. can the patient find transport to the doctor to get a prescription/ is the patient able to afford the medicine on the medicine scheme in their jurisdiction? Motivation = conscious and unconscious processes that direct behaviour e.g. a patient is less likely to take a prophylactic treatment rather than an active treatment Adherence Support from Pharmacist Practical strategies Address ‘capability’ of patient to adhere to medication regimen (COM-B model) Sometimes address ‘motivation’ of patient to adhere to medication regime Unintentional non-adherence Clinical Decision Aid - Statins CHD = coronary heart disease https://www.nice.org.uk/guidance/cg181/resources/patient-decision-aid-pdf-243780159 Clinical Decision Aid – Statins CHD = coronary heart disease https://www.nice.org.uk/guidance/cg181/resources/patient-decision-aid-pdf-243780159 Definitions Health Literacy (HL) - the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. (WHO) Personal health literacy - the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Organizational health literacy - the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Ref: www.nala.ie Health literacy is important because … Report poorer overall health Are less likely to Have lower make use of adherence to medical regimens People with screening limited literacy and numeracy Have poorer Present in later understanding of skills stages of disease treatment Are more likely to be hospitalised Reference: Rima Rudd, NALA Health and Literacy Conference, 2002 Two elements Ref: www.nala.ie When patients access health services Ref: www.nala.ie What are the stats? 5. ? European Health Literacy Survey 2019-21 HLS19 | M-POHL - WHO Action Network on Measuring Population and Organizational Health Literacy Across all participating countries, 46% had either inadequate or problematic health literacy In Ireland, that figure is 43% Literacy and Mortality Risk. 100 90 80 70 Adequate Marginal 60 Inadequate 50 0 20 40 60 80 Months Baker DW, Wolf MS, Feinglass J, Gazmararian JA, Thompson JA. Arch Intern Med 2007; 167: 1503-1509. Literacy and Mortality Risk. 100 90 80 STRONGER INDICATOR OF MORTALITY RISK 70 THAN YEARS OF SCHOOLING Adequate Marginal 60 Inadequate 50 0 20 40 60 80 Months Baker DW, Wolf MS, Feinglass J, Gazmararian JA, Thompson JA. Arch Intern Med 2007; 167: 1503-1509. Factors contributing to health literacy What is the best approach? Ensures that Has a role from a everybody receives research or public information in an health perspective accessible way, and a BUT Measuring good baseline level of is onerous on the health support person, and can lead literacy BUT to feelings of shame is time intensive or embarrassment Universal when resources are Precautions stretched Approach Health literacy tool shed https://healthliteracy.bu.edu/ Know your audience Culture and language Emotions and cognition Hearing loss Vision problems Literacy and/or numeracy Older adults Children and youth Reference: Health Literacy from A to Z by Helen Osborne Look out for possible signs Asking for information that is Unwillingness to approach the already displayed in writing front desk or counter Uneasy body language including Confused about their illness, how facial expressions many tablets to take and when to take them Giving excuses to avoid reading or Describing medication by colour writing in front of you Reluctance to fill in forms or Not attending meetings or doing stopping after name and address medicine reviews (not coming for refill, too many left) Not filling out forms completely “My wife looks after that.” Ref: www.nala.ie Subtle cues in language Doesn’t respond when use teach back Health literacy approaches Verbal (e.g. tone of voice, body Written (e.g. language, language, invitations offered) formatting, visual considerations) Digital (e.g. apps, phone Organisational functions, online offerings) (e.g. polices, training, environmental changes) General tips for using plain English 1. Think of whom you are writing to and why. 2. Be personal and direct. 3. Keep it simple and define any essential jargon and abbreviations. 4. Use a clear font such as Arial or Verdana, not Times New Roman 5. Keep sentences to an average of 15 to 20 words. 6. Use signposts – for example, table of contents, headings and bulleted lists NALA website on Plain English www.simplyput.ie  http://www.hpra.ie/homepage/medicines/special-topics/biosimilar-medicines/questions-and-answers-for- patients https://www.nala.ie/plain-english/plain-english-tips/ Formal assessments of health literacy Rapid Estimate of Adult Literacy in Medicine (REALM) The Test of Functional Health Literacy in Adults (TOFHLA) eHealth Literacy Scale (eHEALS) Assessment Time Measure Parts Scoring Language REALM 3-5 min Reading 66 medical terms to 0-18, ≤3rd-grade level; English pronounce 19-44, 4th-6th-grade; 45-60, 7th-or 8th-grade level; 61-66, ≥ 9th -grade level REALM 1-2 min Reading 8 medical terms to ≤6, risk of poor health literacy English Revised pronounce TOFHLA 22 min Reading 3 prose passages and 0-59, inadequate; English/ and 17 numeracy items 60-74,marginal; Spanish numeracy 75-100, adequate Short 12 min Reading 2 prose passages and 0-59, inadequate; English/ TOFHLA and 4 numeracy items 60-74, marginal; Spanish numeracy 75-100, adequate NVS 3 min Reading 6 questions relating to 0-1, probably inadequate; English / and a nutrition label 2-3, possibly inadequate; Spanish numeracy 4-6 adequate eHEALS N/A 8 questions about Correlation based analysis English patients knowledge, comfort, and perceived skills at finding and evaluating electronic health information. eHEALS Questionnaire  REALM Revised “Sometimes in the health care system, medical words are used that many people are not familiar with. I would like to get an idea of what medical words you are familiar with” Fat Osteoporosis Anaemia Colitis Flu Allergic Fatigue Constipation Pill Jaundice Directed Fat, flu and pill are not scored. These words are placed at beginning of tool to ease anxiety, increase confidence. Score is based on 8 words (osteoporosis – constipation). Score ≤6 indicates subject at risk of poor health literacy Ireland National Adult Literacy Association (NALA) Raise awareness of health literacy amongst the public and health practitioners Stimulate funding with the HSE and other groups Stimulate innovative policies which promote evaluation Generate new information about health literacy in Ireland through research. Crystal Clear Award Ireland 20% of Irish people are not fully confident that they understand all the information they receive from their healthcare professional (doctor, nurse or pharmacist). 43% of people would only sometimes ask their healthcare professional to clarify information if they did not understand something they had said. 10% of people admitted taking the wrong dose of medication because they didn’t understand instructions. (NALA / MSD 2007) NALA Video Prognosis? Chronic condition? https://www.youtube.com/watch?time_continue=64&v= q1MrL8GS2Jw General literacy doesn’t automatically imply health literacy Remember! Health professionals may not be able to change the literacy levels of their patients but….. “ they can however work to improve their own communication skills, the procedures followed for communicating with and interacting with people, and the forms and materials they write” Rudd 1999 Health Coaching Patient-centred consultation method Supports shared decision-making, self-care, self-management Increases patients awareness of their health issues Empowers patients to take responsibility for managing their health Patients should be given the choice about which aspects of their health they want to manage Pharmacist should provide patient with the space to find their own solution to an issue (rather than providing the solution) Skills needed for health coaching Active listening Creating rapport/trust Challenging resistance/limiting beliefs Patient Consultations about Adherence Pharmacist’s role in counselling patients to promote adherence: Not just about imparting information Should aim to empower patients to make their own decisions regarding their health and medications When counselling patients regarding adherence, think of the ‘Four E’s Triangle’ to structure the consultation. 1.EXPLORE 2.EDUCATE 3.ENABLE 4.EMPOWER 1. Explore Asking questions to understand what the patient already knows about their medicines: What do you know about your condition? What do you know about your medicine? Have you found any information on the internet about your medicine/condition? How do you think your medicine will help you? What worries you about taking your medicine? What do you hope your medicine will allow you to do? If trying to find out about adherence, ask questions as per last lecture. If you have access to test results which indicate level of adherence, e.g. HbA1c or BP readings, use these during this conversation. 2. Educate Providing the most important information about the medicine to the patient – try not to overload the patient with information! Tailored to what the patient knows and their level of health literacy. What would you like to know about your medicine? Provide information on the following, as appropriate: Basic information – drug name, formulation, strength How it works – no jargon! Use of the medicine – how much to take, when to take, with food/water/other administration advice, storage Side-effects – common side-effects, managing side-effects, serious side-effects and actions to take Drug interactions 3. Enable Enabling the patient to be more adherent to their medications – figuring out obstacles to adherence and putting in place strategies (where possible) to simplify medication taking. How will you fit your medicines into your day? When will you take them? How will you remember? Where will you keep them? How will you know if your medicine is working for you? 4. Empower This is patient-centred care following the exploration of the patient’s knowledge of medicines and the education provided by the pharmacist. At this step, the patient is given the choice about their medication/managing their condition. What would you like to do about taking your medicine? What have you decided about this medicine? At the end of the consultation, to consolidate information, can provide: Written information (produced by pharmacy) Written information from other reputable sources e.g. advocacy groups/self-help organisations Suggest suitable websites/sources of information