We have recently undertaken a study of the use of medication compliance devices by district nursing services. The report of the study presents a critical review of the literature relating to medication compliance devices as well as the findings of a survey which examined the use of compliance devices by district nursing services and the arrangements of community health trusts have for their use by older people living at home.
Non-adherence with precribed medication is a significant problem in primary care, wasting scarce resources and occasioning therapeutic failure. Although there is no evidence to support the notion that non-adherence is greater in older adults, the self-management of complex medication regimens is sometimes too demanding for patients experiencing changes in vision, memory and manual dexterity.
Health professionals can employ a combination of strategies to promote patient adherence to prescribed medication. One intervention is the provision of a medication compliance device which may be loaded by a carer or a professional. However, there are a number of issues which make the loading of compliance devices by primary care nurses problematic. These include:
Medication compliance devices are commonly supplied by community pharmacists. But, anecdotally, it seems that in areas where pharmacist-filled systems cannot be negotiatied, district nurses are loading these devices themselves. There is no literature to indicate to what extent either system is used in primary care.
The objective of the survey was to gain information on policies related to the use of compliance devices by district nursing services. A self-administered questionnaire was sent to the directors of nursing in a sample of 50 community health trusts. Information was also sought from pharmacy advisers in the corresponding 26 health authorities. The response rate was 94 per cent and 88 per cent, respectively.
Despite concerns regarding their safety and effectiveness, nurse-loaded medication compliance devices were used by 39 per cent of district nursing services in the sample. Respondents came from a wide range of geographical, demographic and commissioning environments giving no reason to suppose that these findings would not be replicated if a similar survey were conducted in other parts of England or the UK.
Although nurse respondents were aware of UKCC guidelines advising against the use of nurse-loaded complaince devices, the survey revealed surprisingly few mentions of error or clinical risk in relation to their use. In only one area was error cited as a factor influencing this change in practice and only two respondents cited it as a key reason for devloping local protocols.
For older patients living at home, 65 per cent of trusts had arrangements with community pharmacists to load daily dose reminder devices and 43 per cent to supply monitored dosage systems. The majority of nurse respondents were unclear about how community pharmacists were remunerated for providing this service. However, responses from the pharmacy advisers revealed that a combination of funding arrangements operated within most areas. Pharmacist filled systems were frequently supplied free of charge or funded through weekly GP prescriptions; rarely was health authority funding available. The greatest barrier to the establishment of pharmacist filled systems, cited by both nurse respondents and pharmacy advisers, was remuneration for community pharmacists.
During the literature search for this survey, it became clear that there are significant gaps in the evident base linked to the use of medication compliance devices for older people living in the community. For example, there has not been sufficient research to demonstrate the effectiveness of compliance devices in improving adherence among this patient population. Neither has their been any investigation to measure nurses' understanding of the pharmacological stability of medicines loaded into compliance devices. There appear to be no published data on the frequency and type of medication errors when using compliance devices, particularly when these devices are used by older people receiving complex community care packages from multiple service providers. Furthermore, there is little literature describing the roles and responsibilities district nurses assume when fostering patient adherence to prescribed medication.
As primary care groups get to grips with prescribing budgets and such aspects of clinical governance as clinical effectiveness and risk reductions, the debate about the loading of compliance devices will attract greater attention. However, in the light of the lack of knowledge about so many aspects of supporting older people in medicines administration, further research evidence is needed to inform clinical decision making and service planning.
Ms McGraw is nurse research fellow and Ms Drennan is senior lecturer in primary care nursing in the department of primary care and population sciences at University College London, based at the Royal Free and University College medical school, London