Bruce A. Berger

Medication adherence and persistence : A comprehensive review

Estimates of adherence to long-term medication regimens range from 17% to 80%, and nonadherence (or nonpersistence) can lead to increased morbidity, mortality, and healthcare costs. Multifaceted interventions that target specific barriers to adherence are most effective, because they address the problems and reinforce positive behaviors. Providers must assess their patients’ understanding of the illness and its treatment, communicate the benefits of the treatment, assess their patients’ readiness to carry out the treatment plan, and discuss any barriers or obstacles to adherence that patients may have. A positive, supporting, and trusting relationship between patient and provider improves adherence. Individual patient factors also affect adherence. For example, conditions that impair cognition have a negative impact on adherence. Other factors—such as the lack of a support network, limited English proficiency, inability to obtain and pay for medications, or severe adverse effects or the fear of such effects—are all barriers to adherence. There are multiple reasons for nonadherence or nonpersistence; the solution needs to be tailored to the individual patient’s needs. To have an impact on adherence, healthcare providers must understand the barriers to adherence and the methods or tools needed to overcome them. This report describes the barriers to medication adherence and persistence and interventions that have been used to address them; it also identifies interventions and compliance aids that practitioners and organizations can implement.

Dispensing errors and counseling quality in 100 pharmacies

OBJECTIVE To evaluate the dispensing accuracy and counseling provided in community chain pharmacies. DESIGN Cross-sectional study. SETTING Community chain pharmacies in large metropolitan areas of Florida, Georgia, New Jersey, and New York. PARTICIPANTS Community chain pharmacies and trained shoppers. INTERVENTIONS Trained shoppers presented a new prescription order for one of five study drugs to each randomly selected pharmacy, and all encounters with pharmacy staff were recorded on video by ABC News 20/20 staff using hidden cameras. MAIN OUTCOME MEASURES Dispensing errors on prescriptions for selected medications were the indicator of prescription dispensing accuracy. Frequency of verbal counseling and information categories discussed or included in written information were used to assess the quality of counseling. RESULTS Of 100 prescriptions dispensed, 22 had one or more deviation from the physicians written order, for a 22% dispensing error rate. Three of the errors were judged to be potentially harmful when dispensed to a typical patient requiring these therapies. A total of 43 shoppers (43%) received verbal counseling, including 16 cases in which the shopper prompted counseling. All shoppers received written information with their prescription, covering an average of 90% of the required topics. Some 68% of the warfarin shoppers purchased aspirin without the pharmacist verbally warning about taking the drugs simultaneously. CONCLUSION The dispensing error rate of more than one in five prescriptions is similar to the rate found in a similar study conducted 14 years ago, but counseling frequency has decreased significantly during the period.

Evaluation of Software-Based Telephone Counseling to Enhance Medication Persistency among Patients with Multiple Sclerosis

OBJECTIVE To evaluate the effect of a software-supported intervention based on the Transtheoretical Model of Change and motivational interviewing on decreasing discontinuation (or increasing persistency) of Avonex (interferon beta-1a--Biogen), a medication for treatment of multiple sclerosis (MS). DESIGN Randomized controlled experimental design comparison of software-based telephone counseling (intervention group) and standard care (control group). SETTING United States. PARTICIPANTS 366 patients with MS. INTERVENTION Software-based telephone counseling. MAIN OUTCOME MEASURE Discontinuation of Avonex treatment and movement among stages of the Transtheoretical Model of Change. RESULTS Patients in the software intervention group demonstrated a statistically significantly lower proportion of Avonex treatment (1.2%) discontinuation than the standard care group (8.7%). In addition, stage movement away from discontinuation of Avonex (i.e., toward continuation of therapy) was significantly higher in the treatment group. CONCLUSION The Transtheoretical Model of Change constructs and motivational interviewing processes were effectively incorporated into a software-based intervention program, and this significantly decreased the proportion of patients who discontinued treatment of MS with Avonex. The integration of behavioral theory with information systems offers a promising approach for pharmacists and other providers to promote medication persistency.

Predicting Treatment Discontinuation Among Patients with Multiple Sclerosis: Application of the Transtheoretical Model of Change

OBJECTIVE To delineate factors associated with discontinued use of the multiple sclerosis (MS) medication Avonex (interferon beta-1a--Biogen) as part of an effort to develop an intervention to promote treatment persistency. DESIGN In-depth telephone interviews followed by a 12-page written questionnaire delivered by mail. SETTING United States. PARTICIPANTS Of 946 patients with MS who were contacted, 531 (56%) completed questionnaires; 79% of respondents were currently using Avonex for treatment of MS. MAIN OUTCOME MEASURE Discontinuation of Avonex treatment, with analysis based on the theoretical framework of the Transtheoretical Model of Change. RESULTS Four key variables (pros of Avonex use, cons of Avonex use, highest level of education completed, and level of disability) accurately identified 82% of patients who discontinued Avonex use, while also correctly identifying 81% of patients who stayed on the drug. CONCLUSION Constructs from the Transtheoretical Model of Change were effective in differentiating patients who had discontinued their Avonex treatment versus patients who continued treatment. This behavioral model likely would be an effective framework for a medication persistency intervention.

Readiness for Change: Implications for Patient Care: Many health care providers erroneously assume that all patients are ready to take action to manage illness.

The strategic position of pharmacists within the community allows frequent interactions with many patients, thus making pharmacists potentially valuable resources for assisting patients in making behavioral changes regarding adherence to treatment. The Transtheoretical Model is a behavior-change model that provides a functional approach through which pharmacists can help patients to reach specific behavioral goals. The model is described and stage-specific examples of patient-pharmacist dialogue are provided to show how the model may be used to promote progression through the stages.