July/August 2012

Enlist Pharmacists to Improve Medication Adherence

By Steven P. Hiemenz, RPh, MBA, CGP, BCPS
Aging Well
Vol. 5 No. 4 P. 6

When she was young, one of my daughter’s favorite books told the story of a mother rabbit and her children. They were playing in a field one day when a storm came up very quickly. They were trapped by the storm and unable to get home. The story continues as other animals try to shelter the rabbits, but none of them understands what the rabbits need for a comfortable home. I am reminded of this story frequently as I work in my daily practice as a pharmacist.

Medications are an effective tool for treating disease—but only if they are taken correctly. Clinicians are constantly becoming aware of patients who were provided the right medicines for their disease states but were not in environments optimal for taking medications correctly.

Public Health Concerns
Medication-related problems and medication mismanagement are a massive public health problem in the United States. Experts estimate that 1.5 million preventable adverse events occur each year that result in $177 billion in injury and death. Medication nonadherence cost estimates for the United States are as high as $300 billion annually.1 This staggering amount includes hospitalizations and emergency department costs in addition to lost employee productivity and the cost of less-than-optimal patient outcomes.

Many articles have been written about factors that can compromise a patient’s ability to take medications correctly. These reasons range from affordability concerns to unmet expectations to complexity and a multitude of others factors. I was reminded of this recently as I read the article “Inadequate Health Literacy Among Paid Caregivers of Seniors” in the Journal of General Internal Medicine. In the article, Lindquist et al describe the many duties older adults’ caregivers perform. Accompanying the older adult to physician appointments and receiving related instructions as well as assisting with medication administration were among the duties identified.

The authors measured the health literacy of paid, unrelated caregivers using the Test of Functional Health Literacy in Adults. Among other domains, caregivers were asked to demonstrate their skill in medication use by following directions on pill bottles and sorting medications into pillboxes. The authors found inadequate health literacy in 35 of 98 caregivers, who were unable to follow written and verbal instructions to properly fill the medication boxes.

For the study, health literacy was referred to as “how well patients comprehend health care information, and is defined as an individual’s ability to read, understand, and use health care information to make effective health care decisions and follow instructions for treatment.” Low health literacy has been associated with multiple negative outcomes, including but not limited to incorrect medication use2-4 and poor self-management of chronic disease.5-8 The article concluded that physicians and staff should evaluate caregivers’ level of health literacy prior to assigning them health-related tasks. What if the caregiver, in the clinician’s opinion, cannot safely handle all aspects of medication management?

Improving Medication Adherence
Clinicians can benefit from enlisting pharmacists to assist in the care of patients whose caregivers lack adequate health literacy. There are two important services currently available at many pharmacies nationwide that can provide immediate improvement to patient care in this circumstance. Medication adherence packaging and comprehensive medication review services can be of great benefit to improve medication adherence and patient safety overall.

Physicians should remember that medication adherence packaging is available at many local pharmacies. In general, the packaging service removes the medications from their vials and instead groups them in “bubbles” packaged according to administration time. Rather than receiving a bag full of pill bottles, the patient receives a bubble pack with each bubble identifying the medication by the name, date, and time to be taken.

Comprehensive medication reviews are increasingly available at community pharmacies and hospitals and through private practice pharmacists. The reviews are known by other names as well, such as medication therapy management and pharmacist consultation. Regardless of the moniker, the process is generally the same. The providing pharmacist obtains a medication history and a current medication list, including nonprescription and herbal medications.

This information is obtained through patient interview and physician records and becomes a part of the patient’s personal medication record. This record should be printed and presented to the patient and faxed or e-mailed to physicians. It is valuable to reconcile the personal medication record at each physician appointment.

During the patient interview, pharmacists take care to ascertain how the patient feels about his or her medication regimen. Are administration times convenient? Are there any dosage forms that are difficult to swallow? This information is known as the patient’s medication experience. All recommendations should consider whether the patient is willing and able to comply with medication directions. After complete information is collected, the pharmacist performs a comprehensive review to identify any potential drug therapy problems.

Recognition of drug therapy problems and the recommended interventions are known as the medication action plan. Pharmacists can communicate suggested interventions to the appropriate physician(s) for consideration. The final step is documenting the recommendations and following up with everyone involved in a patient’s care.

The comprehensive medication review is a highly effective means of coordinating care among all providers and is an important educational tool for patients and their caregivers. Professional fees apply for this service, and rates can vary.

Final Thoughts
The services described above are valuable tools to assist caregivers in providing optimal care for older adults. How can a clinician find pharmacists who provide these services? Pharmacies that provide adherence packaging can be located through advertising, and many geriatric care managers become familiar with the pharmacies in their area that provide adherence packaging. Some certified geriatric pharmacists provide comprehensive medication review services. Such pharmacists can be found through the Commission for Certification in Geriatric Pharmacy’s locator service at www.ccgp.org.

Physicians consider multiple factors in providing accurate diagnosis and treatment plans, but inadequate health literacy and the resulting lack of adherence can compromise outcomes. Physicians should strongly consider referral to a local pharmacist when these risk factors are present.

— Steven P. Hiemenz, RPh, MBA, CGP, BCPS, is president of Hinsdale Pharmacy Associates, Inc; part owner of Elm Plaza Pharmacy; and vice president of PRN Pharmacy Associates, Inc. He is a board-certified pharmacotherapy specialist and a certified geriatric pharmacist, providing services to patients through his community pharmacy practice and as a private practice consultant pharmacist.

References
1. Balkrishnan R. The importance of medication adherence in improving chronic-disease related outcomes: what we know and what we need to further know. Med Care. 2005;43(6):517-520.

2. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors associated with medication refill adherence in cardiovascular-related disease: a focus on health literacy. J Gen Intern Med. 2006;21(12):1215-1221.

3. Davis TC, Wolf MS, Bass PF 3rd, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145(12):887-894.

4. Persell SD, Osborn CY, Richard R, Skripkauskas S, Wolf MS. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523-1526.

5. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008-1015.

6. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51(3):267-275.

7. Juzych MS, Randhawa S, Shukairy A, Kaushal P, Gupta A, Shalauta N. Functional health literacy in patients with glaucoma in urban settings. Arch Ophthamol. 2008;126(5):718-724.

8. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2):166-172.