FIP Congress 2005
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The Community Pharmacy Section organised a pre-congress satellite symposium on September 3 to look at what affects adherence and what works in the community pharmacy sector for improving it. James McElnay reports
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 The World
Congress of Pharmacy and Pharmaceutical Sciences was
organised by the International
Pharmaceutical Federation in association with the Syndicate
of Pharmacists of the Arab Republic of Egypt.
It took place in
Cairo from September 2 to 8, 2005 |
Who cares about compliance, adherence or concordance? The pharmacist cares
In a keynote speech, Ross Holland, from the US, addressed the poor use
of the terms compliance, adherence and concordance within the published
literature. This
has led to the terms being incorrectly used interchangeably.
“Adherence,” he explained, “is the now generally accepted
terminology to describe the extent to which a patient’s behaviour,
in terms of taking medicines, following diets or executing lifestyle
changes, coincides with advice given by health care professionals. It
is preferred over the more paternalistic connotations implied by the
term ‘compliance’. Concordance on the other hand describes
a new way to define the process of successful prescribing and medicine
taking, based on a partnership with the patient.”
Dr Holland sees adherence as the aim, concordance as the process and
compliance as the outcome.
In explaining that adherence to long-term therapy for chronic illness
in developed countries averages 50 per cent, Dr Holland was strongly
of the opinion that “raising this rate to just 60 per cent would
lead to a major improvement in public health”. He picked out eight
chronic diseases for which he had major concerns regarding poor outcomes
as a result of non-adherence, namely
asthma, cancer (palliative care), depression,
diabetes, epilepsy, HIV/AIDS, hypertension and tuberculosis.
Other areas of concern
Other areas of concern were acute diseases, tobacco smoking cessation,
obesity
control, methadone programmes and birth control.
The reasons for non-adherence, he believed, could be classified into
patient-related factors (eg, ill-informed beliefs about medication),
provider-related factors (eg, inadequate advice given to patient) and
regimen-related factors (eg, pill burden). Dr Holland explained the need
for excellent adherence in HIV/AIDS in which adherence rates of >95
per cent were required to achieve optimal impact on viral loads.
“Missing just two doses every two weeks will be sufficient to bring
adherence rates below this optimum with a dramatic drop-off in therapeutic
effects,” he
said.
He believed that delivery of structured pharmaceutical care was the best
way forward to address the issue of non-adherence from the perspective
of the community pharmacist. This care should involve a “concordant
partnership” with the patient.
“The terminology doesn’t really matter but the process does.
Compliance, adherence, concordance — who cares? The pharmacist cares,” concluded
Dr Holland.
Health care professionals need tools to find out if patients adhere to their medication regimens
Foppe Van Mil: biological markers are the ultimate proof of medication
use |
In a second keynote lecture, on the topic of detecting non-adherence
in daily practice, Foppe Van Mil, of the Netherlands, explained that
without putting measurement tools in place “pharmacists, doctors
and nurses really don’t know if a patient is adherent. Their impressions
are often unreliable as are patient reports, be they spontaneous or in
the form of patient diaries.”
Measurement of biological markers is the “ultimate proof of medication
use”, he suggested.
However, this approach also has many disadvantages, not least the need
for access to clinical testing facilities and usually such measurements
only reflect the moment of taking the sample. Questionnaires were helpful,
if validated, as were refill dates from pharmacy-held medication records
and pill counts.
The use of electronic devices (MEMS — medication event monitoring
systems) was helpful in some cases. However, this approach “proves
that the container was opened, but does not prove that the medicine was
taken. A computer is needed to read the data, the devices are expensive
and patients have been known to sabotage the caps containing the chip
that records the times of opening the container,” Dr Van Mil said.
In summary Dr Van Mil said that reliability increased going from third
party impressions (eg, doctor, pharmacist, nurse, family), through patient
reports (verbal, diary, questionnaire) and calculations (refills, pill
counts, checking compliance boxes) to monitoring (MEMS and drug levels),
but that a mix-and-match approach probably gave the most accurate results.
He warned, though, that regardless of the method used it is hard to detect
intentional non-adherence. “Don’t try it in daily practice,” he
suggested, “because everyone has a right to be non-adherent.”
The final aspect of the programme involved three case studies: safe and
effective medicine use in Denmark; promoting patient’s adherence
to treatment in a pharmacist/physician network in Switzerland; and adherence
in resource-limited countries. The last addressed such diverse issues
as the costs of antiretroviral therapy (it may take six months income
to pay for a one month course of treatment in a developing country),
difficulties in access to medicines (eg, the average distance to a clinic
in Ecuador is 10.3km) and the increasing problem of counterfeit medicines.
Issues like these play important roles in medication adherence in resource-limited
situations. |
The
Pharmaceutical Journal