From Mrs J. M. Nunney, MRPharmS, and Dr D. K. Raynor, MRPharmS
SIR, - A recent "Broad Spectrum" article highlighted some important issues associated with the use of compliance aids, focusing on the role of the district nurse (McGraw and Drennan, PJ, March 4, p368). We conducted a complementary in-depth study recently, looking at the context of pharmacist-filled aids in one health authority area (funded by a Royal Pharmaceutical Society Galen award). Our work suggests that there may be more than 100,000 patients living in their own homes nationwide whose medicines are dispensed in a multi-compartment compliance aid (MCA).
Most widely used is a monitored dosage system (MDS) device, rather than a conventional MCA. This probably relates to the MDS which individual pharmacies use for residential and nursing homes. The most commonly used conventional MCA was the Dosett, with significantly less use of the Medidos, despite some evidence that patients prefer the latter. Four-fifths of the pharmacists had a preferred MCA, although this was not an evidence-based choice and only one patient reported that they have been able to choose the type of MCA used. Clearly, choice of device should be related to patient needs and not those of the health professionals. There is an urgent need for research assessing patient acceptability of the various devices, particularly between conventional aids and MDSs.
We found that only half of the pharmacists would visit the patient to assess their suitability for an MCA. This is unfortunate as it appears essential that the first question should be, "Is an MCA appropriate or would another option be more appropriate?". This concurs with McGraw and Drennan who note that health officials can employ a combination of strategies to promote patient adherence to prescribed medication; provision of a medicine compliance aid is just one of a number of possible interventions.
If this process shows that such a device is appropriate, then the next question should be, "Which MCA?", and this may need a domiciliary assessment. Although simplification is a key strategy for tackling unintentional non-compliance (and may be sufficient on its own to meet patients' needs), only one in 10 of the pharmacists would try out a simplified regimen first in conventional containers. However, it is important to note that pharmacists are responding to the situation as best they can - the lack of an accepted system for MCA use (including appropriate remuneration) puts them in an impossible position.
McGraw and Drennan note that there is an absence of research demonstrating the effectiveness of compliance devices in improving adherence among older people living in the community. Our work identified a number of possible negative effects, including that over two thirds of the patients did not know the names of any of their medicines in the MCA. These devices remove the ownership by patients of their treatment, which in some cases become an anonymous collection of variously coloured and sized tablets, about which they know little.
We agree that the emergence of primary care groups (and their need to get to grips with prescribing budgets) intensifies the need for an evidence base associated with medication compliance devices. They are widely used, despite a lack of evidence for their effectiveness, and appear not to be targeted in any particular way. Patients should not be issued with an MCA without first being assessed.
The medicines management problems of many patients currently using MCAs may be able to be managed in another way, which requires less resource and allows them to keep ownership of their medicines. MCAs can be useful in some patients, but they must be seen in the wider context of medicines management and pharmaceutical care.
It is unlikely that sufficient NHS resources are available properly to fund all patients currently using MCAs at home, but an evidence-based mechanism for their use - for the small number who really need them - might mean that sufficient funding is available. Only then can pharmacists play an appropriate part in ensuring that compliance aids are used effectively, rather than taking the brunt of the criticism, as a result of having to implement imperfect solutions in a situation not of their making.
A copy of the executive summary of the report entitled "Multi-compartment compliance aids in primary care: Building an evidence base" is available from the authors.
Jacky Nunney
Theo Raynor
Division of Academic Pharmacy Practice, University of Leeds, 10 Clarendon Road, Leeds LS2 9NN
(e-mail D.K.Raynor@leeds.ac.uk)