Olivier Bugnon

An interdisciplinary HIV-adherence program combining motivational interviewing and electronic antiretroviral drug monitoring

Abstract To ensure successful treatment, HIV patients must maintain a high degree of medication adherence over time. Since August 2004, patients who are (or are at risk of) experiencing problems with their HIV antiretroviral therapy (ART) have been referred by their physicians to an interdisciplinary HIV-adherence program. The program consists of a multifactorial intervention along with electronic drug monitoring (MEMSTM). The pharmacists organize individualized semi-structured motivational interviews based on cognitive, emotional, behavioral, and social issues. At the end of each session, the patient brings an adherence report to the physician. This enables the physician to use the adherence results to evaluate the treatment plan. The aim of this study was to retrospectively analyze this on-going interdisciplinary HIV-adherence program. All patients who were included between August 2004 and the end of April 2008 were analyzed. One hundred and four patients were included (59% women, median age 39 (31.0, 46.0) years, 42% black ethnicity). Eighty (77%) patients were ART-experienced patients and 59% had a protease inhibitor-based treatment. The retention rate was high (92%) in the program. Patient inclusion in this HIV-adherence program was determined by patient issues for naive patients and by nonadherence or suboptimal clinical outcomes for ART-experienced patients. The median time spent by a subject at the pharmacy was 35 (25.0, 48.0) minutes, half for the medication handling and half for the interview. The adherence results showed a persistence of 87% and an execution of 88%. Proportion of undetectable subjects increased during study. In conclusion, retention and persistence rates were high in this highly selected problematic population.

Medication reviews led by community pharmacists in Switzerland: a qualitative survey to evaluate barriers and facilitators

Objective 1) To evaluate the participation rate and identify the practical barriers to implementing a community pharmacist-led medication review service in francophone Switzerland and, 2) To assess the effectiveness of external support. Methods A qualitative survey was undertaken to identify barriers to patient inclusion and medication review delivery in daily practice among all contactable independent pharmacists working in francophone Switzerland (n=78) who were members of a virtual chain (pharmacieplus), regardless of their participation in a simultaneous cross-sectional study. This study analyzed the dissemination of a medication review service including a prescription and drug utilization review with access to clinical data, a patient interview and a pharmaceutical report to the physicians. In addition, we observed an exploratory and external coaching for pharmacists that we launched seven months after the beginning of the cross-sectional study. Results Poor motivation on the part of pharmacists and difficulties communicating with physicians and patients were the primary obstacles identified. Lack of time and lack of self-confidence in administering the medication review process were the most commonly perceived practical barriers to the implementation of the new service. The main facilitators to overcome these issues may be well-planned workflow organization techniques, strengthened by an adequate remuneration scheme and a comprehensive and practice-based training course that includes skill-building in pharmacotherapy and communication. External support may partially compensate for a weak organizational framework. Conclusions To facilitate the implementation of a medication review service, a strong local networking with physicians, an effective workflow management and a practice- and communications-focused training for pharmacists and their teams seem key elements required. External support can be useful to help some pharmacists improve their service management skills. Adequate remuneration seems necessary to encourage initial investments to provide such a service. Future research in this area may help improve the process and design of training programs, as well as the monitoring of implementation for each new pharmaceutical service.

Pharmacological Treatment of Behavioral and Psychological Symptoms of Dementia (BPSD) in Nursing Homes: Development of Practice Recommendations in a Swiss Canton

OBJECTIVES In 2002, the canton of Fribourg, Switzerland, implemented a coordinated pharmaceutical care service in nursing homes to promote rational drug use. In the context of this service, a project was conducted to develop recommendations for the pharmacological management of behavioral and psychological symptoms of dementia (BPSD) in nursing home residents. DESIGN AND METHODS Selected evidence-based guidelines and meta-analysis sources related to the management of depression, insomnia, and agitation in dementia patients were systematically searched and evaluated. Evidence and controversies regarding the pharmacological treatment of the most common BPSD symptoms were reviewed, and treatment algorithms were developed. RESULTS Ten evidence-based guidelines and meta-analyses for BPSD management were identified, with none specifically addressing issues related to nursing home residents. Based on this literature, recommendations were developed for the practice of pharmacological management of depression, sleep disturbances, and agitation in nursing home residents. For depression, SSRIs are considered the first choice if an antidepressant is required. No clear evidence has been found for sleep disturbances; the underlying conditions need to be investigated closely before the introduction of any drug therapy. Many drugs have been investigated for the treatment of agitation, and if necessary, antipsychotics could be used, although they have significant side effects. Several areas of uncertainty were identified, such as the current controversy about typical and atypical antipsychotic use or the appropriateness of cholinesterase inhibitors for controlling agitation. Treatment algorithms were presented to general practitioners, pharmacists, and medical directors of nursing homes in the canton of Fribourg, and will now be implemented progressively, using educational sessions, pharmaceutical counseling, and monitoring. CONCLUSION Based on existing evidence-based studies, recommendations were developed for the practice of pharmacological management of depression, sleep disturbances, and agitation in nursing home residents. It should be further studied whether these algorithms implemented through pharmaceutical care services will improve psychotropic drug prescriptions and prevent drug-related problems in nursing home residents.

Pharmaceutical Care in Community Pharmacies: Practice and Research in Switzerland

Objective: To describe the current situation and prospects for community pharmacy practice in Switzerland, a confederation of 26 cantons with a population of approximately 7 million, located in the center of Europe. Findings: For the past 10 years, the Swiss Association of Pharmacists has directed an in-depth reform of the profession, with measures such as a system of remuneration based on pharmaceutical cognitive services, a quality care program named QMS–Pharmacy, a postgraduate education program (including specific titles and certificates) and obligatory continuous education, programs of public relations and health promotion, innovative services of managed care, generics substitution, and others. Discussion: The implemented changes in management represent a pharmaceutical care solution for Swiss community pharmacies, which face intense competition and a very liberal policy regarding healthcare organization, relating in particular to the important cantonal autonomy, free establishment of ownership of pharmacies, pharmacy chains, dispensing physicians, chemist shops, mail order, and others. Conclusions: Community pharmacy in Switzerland is making modernization of its role in public health policy a clear orientation. Priorities for the future include reinforcement of education and academic research in pharmacy practice, demonstration of the added value of pharmacists, integration of new information technologies with pharmacies, and development of new pharmaceutical services for managed care network in collaboration with physicians and other healthcare professionals.

The Nine-Year Sustained Cost-Containment Impact of Swiss Pilot Physicians-Pharmacists Quality Circles

Background Six pioneer physicians-pharmacists quality circles (PPQCs) located in the Swiss canton of Fribourg (administratively corresponding to a state in the US) were under the responsibility of 6 trained community pharmacists moderating the prescribing process of 24 general practitioners (GPs). PPQCs are based on a multifaceted collaborative process mediated by community pharmacists for improving compliance with clinical guidelines within GPs’ prescribing practices. Objective To assess, over a 9-year period (1999–2007), the cost-containment impact of the PPQCs. Methods The key elements of PPQCs are a structured continuous quality improvement and education process; local networking; feedback of comparative and detailed data regarding costs, drug choice, and frequency of prescribed drugs; and structured independent literature review for interdisciplinary continuing education. The data are issued from the community pharmacy invoices to the health insurance companies. The study analyzed the cost-containment impact of the PPQCs in comparison with GPs working in similar conditions of care without particular collaboration with pharmacists, the percentage of generic prescriptions for specific cardiovascular drug classes, and the percentage of drug costs or units prescribed for specific cardiovascular drugs. Results For the 9-year period, there was a 42% decrease in the drug costs in the PPQC group as compared to the control group, representing a

Interdisciplinary Medication Adherence Program: The Example of a University Community Pharmacy in Switzerland

225,000 (USD) savings per GP only in 2007. These results are explained by better compliance with clinical and pharmacovigilance guidelines, larger distribution of generic drugs, a more balanced attitude toward marketing strategies, and interdisciplinary continuing education on the rational use of drugs. Conclusions The PPQC work process has yielded sustainable results, such as significant cost savings, higher penetration of generics and reflection on patient safety, and the place of “new” drugs in therapy. The PPQCs may also constitute a solid basis for implementing more comprehensive collaborative programs, such as medication reviews, adherence-enhancing interventions, or disease management approaches.

Exploring the implementation of a medication adherence programme by community pharmacists: a qualitative study

The Community Pharmacy of the Department of Ambulatory Care and Community Medicine (Policlinique Médicale Universitaire, PMU), University of Lausanne, developed and implemented an interdisciplinary medication adherence program. The program aims to support and reinforce medication adherence through a multifactorial and interdisciplinary intervention. Motivational interviewing is combined with medication adherence electronic monitors (MEMS, Aardex MWV) and a report to patient, physician, nurse, and other pharmacists. This program has become a routine activity and was extended for use with all chronic diseases. From 2004 to 2014, there were 819 patient inclusions, and 268 patients were in follow-up in 2014. This paper aims to present the organization and programs context, statistical data, published research, and future perspectives.

Adherence: a review of education, research, practice and policy in Switzerland

Background Medication adherence has been identified as an important factor for clinical success. Twenty-four Swiss community pharmacists participated in the implementation of an adherence support programme for patients with hypertension, diabetes mellitus and/or dyslipidemia. The programme combined tailored consultations with patients about medication taking (expected at an average of one intervention per month) and the delivery of each drug in an electronic monitoring system (MEMS6™). Objective To explore pharmacists’ perceptions and experiences with implementation of the medication adherence programme and to clarify why only seven patients were enrolled in total. Setting Community pharmacies in French-speaking Switzerland. Method Individual in-depth interviews were audio-recorded, with 20 of the pharmacists who participated in the adherence programme. These were transcribed verbatim, coded and thematically analysed. Process quality was ensured by using an audit trail detailing the development of codes and themes; furthermore, each step in the coding and analysis was verified by a second, experienced qualitative researcher. Main outcome measure Community pharmacists’ experiences and perceptions of the determining factors influencing the implementation of the adherence programme. Results Four major barriers were identified: (1) poor communication with patients resulting in insufficient promotion of the programme; (2) insufficient collaboration with physicians; (3) difficulty in integrating the programme into pharmacy organisation; and (4) insufficient pharmacist motivation. This was related to the remuneration perceived as insufficient and to the absence of clear strategic thinking about the pharmacist position in the health care system. One major facilitator of the programme’s implementation was pre-existing collaboration with physicians. Conclusion A wide range of barriers was identified. The implementation of medication adherence programmes in Swiss community pharmacies would benefit from an extended training aimed at developing communication and change management skills. Individualised onsite support addressing relevant barriers would also be necessary throughout the implementation process.

Adherence to Antiretroviral Treatment Decreases During Postpartum Compared to Pregnancy: A Longitudinal Electronic Monitoring Study

Nonadherence to medication treatment regimens is a major preventable risk behavior in both acute and chronic diseases. Community pharmacists are facilitators in community care for promoting medication adherence and they should implement interdisciplinary medication adherence programs. To do so, pharmacists should be educated in medication adherence, and new pharmaceutical care policies should be implemented. The healthcare system should evolve to better meet the specific needs of patients. Aims: this article describes what has been undertaken in the last decade in medication adherence in terms of education, research, practice and policy in Switzerland. Methods: Medline was searched, with the search limited to Switzerland. The three Swiss pharmacy schools were also contacted to collect information about the medication adherence content of both their courses and research programs. National policies related to medication adherence were also reviewed for relevant content. Results: Education: two pharmacy schools offer courses devoted specifically to medication adherence. The number of hours dedicated to the topic varies between 4 to13. Research: a total of 16 studies met the inclusion criteria. Chronic patients were the focus of 9 studies. Medication adherence was the primary outcome of all studies; 10 studies also measured clinical outcomes. Nine studies evaluated the prevalence of medication nonadherence; three studies evaluated the feasibility of new technologies for monitoring adherence; three studies evaluated medication adherence enhancing programs. Policies: three cognitive pharmaceutical services are reimbursed by healthcare insurers, which are directly related to medication adherence. Conclusions: Pharmacists in Switzerland have been actively involved in medication adherence research since the mid ‘90s. Specific medication adherence courses have entered the curriculum of pharmacy schools, and policies in Switzerland are slowly beginning to meet needs of chronic patients by the introduction of pharmaceutical cognitive services and reimbursement fees.

Association of disclosure of HIV status with medication adherence

Dear Editor: As recently published in your Journal, the LILAC prospective cohort study showed a decrease in self-reported adherence between pregnancy and postpartum in South America.1 Interestingly, our smaller study with a longitudinal measure and analysis of adherence to antiretroviral treatment confirms these findings. Antiretroviral therapy (ART) during pregnancy and postpartum involves two issues: prophylaxis of perinatal transmission and treatment of maternal infection.2 Adherence, defined as “the process by which patients take their medications as prescribed,” is crucial to address these concerns.3,4 Pregnancy and the first months of motherhood cause important changes in a womens life, which might impact ART adherence. Most frequently cited barriers to adherence were competition with other issues including family obligation and hectic lifestyle. Conversely, the babys health was cited as a motivator for adherence.5 During postpartum, women tend to miss more medical visits, and adherence tends to be lower than during pregnancy.1,6–10 Between 10% and 50% of the women stopped their ART after childbirth, part of them on their own without physicians approval.7–10 Most of published studies are based on pill count or self-reported adherence. To our knowledge this is the first study assessing electronically the dynamics of adherence in a continuum from pregnancy to postpartum along with clinical data. This exploratory, retrospective study was approved by the Swiss Ethic Commission (Vaud) for clinical research. It aimed at comparing adherence to the entire ART—during pregnancy and postpartum—using continuous electronic drug monitoring data. The community Pharmacy of the Department of ambulatory care and community medicine in Lausanne has been running an adherence-enhancing program since 2004, which combines electronic drug monitoring and semistructured, repeated motivational interviews.4 All pregnant HIV-positive women having taken part in the program between 2004 and 2012 were retrieved. The maximal observation period extended from first adherence visit after last menstruation to 6 months after childbirth. Sociodemographic and clinical data were collected from the Swiss HIV Cohort Study database. Percent of attended visits were compared between pregnancy and postpartum using the McNemar test. Electronic data on medication adherence, extracted from the adherence-enhancing program database, were reconciled with pill count and interview notes in order to include reported pocket doses. For each woman, adherence was described with a binary variable (1=correct number of daily opening(s) of all electronic monitors; 0=less daily openings than prescribed). Data were analyzed via a piecewise logistic mixed effect model. Mixed effect models are methods of choice for analyzing data with repeated measures for each participant. They take into account the interindividual variability of the measures and can deal with unbalanced data due to missing values. In particular, a piecewise logistic mixed effect model allowed us to estimate the probability of taking ART as prescribed, for each day d of pregnancy and postpartum periods.11 Adherence at days 0–3 from childbirth has been replaced by missing values before entering the model, because of the bias due to hospitalization. Analysis of change in CD4 over time was performed using a piecewise polynomial mixed effect model. A qualitative inspection of viral RNA individual trajectories was made only graphically, as the large interindividual variability and the small number of data prevented the application of a mixed effect model. We used the Stata/IC software (v12.0, StataCorp, College Station, TX) for data description and the R system for computation and graphic of mixed effect models (v2.12.1, www.r-project.org/, library “nlme”). Among 400 patients referred to the adherence program, 29 pregnant women (7%) were screened and 25 (86%) were included. Three women who did not use electronic monitors were excluded, and one underwent an early pregnancy interruption. Median age was 29 (interquartile range [IQR]: 26.5, 32.0). Seventeen women (68%) were black and 11 (44%) were ART naive. ART included protease and nucleoside reverse transcriptase inhibitors (n=24; 96%). Six women (24%) stopped the program during pregnancy, 3 (12%) at childbirth and 4 (16%) during the postpartum period. Among these 13 women, 8 (62%) were kept on ART, 3 stopped ART after childbirth according to guidelines, and 2 stopped ART without physicians agreement. All these women were considered in the analysis. The percentage of unattended visits increased from 17% during pregnancy to 38% during postpartum (p=0.001). Probability of correct ART intake was continuously high during pregnancy (97% [95% CI: 0.94–0.98]), decreased to 93% (95% CI: 0.87–0.96) at childbirth (p of the difference=0.006), and increased again during postpartum (p of the slope coefficient=0.009) (Fig. 1A) to reach the same probability than during pregnancy after 164 days. A sensitivity analysis with the 10 women who were continuously monitored during pregnancy and postpartum confirmed the decrease in ART intake after childbirth. FIG. 1. Change in drug intake, viral load, and CD4 count over time. (A) Percentage of women with correct number of daily opening(s) of the electronic monitors over time. Curves in bold represent the prediction±95% confidence interval, (days 0–3 ... CD4 count increased during pregnancy, decreased around 40 days after childbirth then increased again (p of the linear, quadratic and cubic coefficient <0.005; Fig. 1B). Individual ARN curves decreased during pregnancy. Within the 13 continuing women after childbirth, 4 (31%) had at least one worsening viral load (range, 25–344 copies per milliliter; Fig. 1C). In summary, our data describe adherence during pregnancy and postpartum from a real-life medication adherence clinic. Our model predicts that 97 women of 100 take all doses of ART during pregnancy versus 93 women 3 days after childbirth. Our results also mean that missing doses increased from 1 per month (i.e., 3 per 100 days) during pregnancy to 2 per month (i.e., 7 per 100 days) at beginning of postpartum. We could show a lag time during postpartum before women were able to reach the same probability of adherence than during pregnancy. Strength of our analysis results from: (1) a day-by-day adherence monitoring to entire ART, (2) reconciliation of electronic data with pill count and interview to reflect actual drug intake, and (3) the use of advanced statistics. Our main limitation is due to the fact that 9 women stopped the program before or at childbirth. Fortunately, it did not impact the adherence level during pregnancy as confirmed by a sensitivity analysis. External validity is limited by the fact that women were included in an adherence-enhancing program. Drop in adherence during standard care might be more significant. Our data show that a major event such as childbirth impacts adherence transiently, which may result in viral rebound. Of note, 4 women of 13 had at least one worsening viral load. These preliminary results need to be confirmed by larger studies. Although much attention in clinical care is devoted to pregnant women, emphasis should be put on postpartum care as well.