ADVANCING
YOUR PRACTICE
Promoting
medication adherence
By Maura K. McCall, RN, BSN; Jacqueline Dunbar-Jacob,RN,
PhD, FAAN; and Kathryn Puskar, RN, CS, DrPH, FAAN
Have you ever wondered
why your patient’s medications don’t seem
to be working for him? Poor adherence may be the culprit.
Adherence refers to how closely your patient follows
his prescribed treatment. The term applies to any treatment
regimen from lifestyle changes, such as diet and exercise,
to medication. Medication adherence issues may include
timing problems, missed doses, underdosing, overdosing,
not filling the prescription, and other patient behaviors.
For example, your patient tells you, “This medication
doesn’t do a thing,” referring to an inhaler
that’s prescribed four times a day. You ask him
to demonstrate how to use the inhaler by taking a dose.
Every step is done perfectly, except one: He never removes
the lid!
In this article, we’ll
take a look at common reasons for nonadherence and provide
you with ways to recognize it and help your patient
be more adherent.
How much adherence
is enough?
How closely your patient needs to adhere to his medication
schedule depends on the prescribed medication. Certain
medications need a high level of adherence for the treatment
to be effective. Although the ultimate goal is perfect
adherence, the fact is that daily life may not allow
for it. As a result, some healthcare providers consider
dosing correctly 80% to 90% of the time or greater to
be good adherence. In order to calculate your patient’s
adherence rate for a specific medication, divide the
number of correct doses (right dose, right time) by
the number of prescribed doses. Simply put, if your
patient is ordered a daily medication and he misses
one day out of the week (6/7), he’s about 86%
adherent.
Unfortunately, the risk
of nonadherence is hard to predict. Nonadherence has
many faces: It can affect patients of both sexes and
any age, race, socioeconomic group, educational level
(from grade school to PhD), or work status. Ultimately,
the statistics of adherence don’t matter because
if you have even one patient who isn’t adhering
to his medication regimen, you have a challenge to that
patient’s health.
Common reasons
for nonadherence
Let’s take a closer look at the common reasons
for nonadherence.
Sometimes the condition
has no symptoms of which the patient is aware. Hypertension
is one of those conditions. It can prove to be quite
a task to convince someone to spend money and effort
to take a medication for a condition without symptoms,
especially when adverse reactions from the medication
produce more symptoms than the actual condition.
Missing medication can happen in a variety of ways,
but forgetting is often the reason. This can take place
at any point along the continuum: The patient forgets
to refill the prescription, forgets to take the medication
along when away from home, forgets the time, or forgets
to put the medication in his mouth.
There are strategies to
help your patient remember. Prepouring pills into a
container helps the patient who doesn’t recall
whether he took the medication. Alarms on clocks, watches,
stoves, microwaves, cell phones, and computers can be
set to alert him to the time. Strategically placed notes
may also be effective reminders. Aligning pill taking
with a routine activity, such as brushing teeth or watching
a daily TV show, can help cue him that it’s time
to take a medication. And asking for help from a family
member or friend also provides a useful reminder.
In addition, cost may be
an issue for some patients. If a patient mentions cost,
discuss it further. In fact, if you routinely ask all
your patients about costs, those who need help may feel
more comfortable coming forward. There are many ways
to reduce medication costs: prescription assistance
resources, using generic brands or samples, pill splitting,
bulk purchasing, and charities.
Just ask
By assessing your patient’s adherence, you remain
alert to the truth about his medication habits. Although
low adherence rates are common among patients with chronic
illness, it’s difficult to accurately measure
these rates. Individual adherence rates range from 0%
(not taking the medication) to over 100% (taking more
medication than prescribed). Self-report from patients
is generally overestimated and not very accurate, but
it’s a low-cost, easy method for determining adherence.
Your patient may want you to think he’s managing
well or he may truly believe he’s following his
treatment plan as ordered. Allow your patient to know
that we’re all human and we all make mistakes;
even healthcare professionals miss medications at times.
Validating your patient’s
frustration in following his treatment regimen lets
him know that you’re listening and that you understand.
Using open-ended questions is helpful because they permit
him to tell you about the problem. Try the following:
- “It can be a
challenge to take this medication. What kind of trouble
do you have?”
- “Sometimes folks
can’t afford these pills. How are you doing
with that?”
- “Working shifts
can be tough when you take medicine. What do you do
to fit in your pills?”
Pay close attention to
the clues your patient gives you, such as BP measurements
that are still high despite his report of following
treatment. However, clues may not be so obvious; that’s
when good listening skills are essential. The patient
might tell you that he hasn’t taken his pills
and why, but more likely, he’ll allude to the
problem without being direct. He may make a comment
regarding life in general such as, “I get so busy
that I lose track of time.” That’s your
cue to ask a follow-up question: “It sounds as
if you’re very busy. When do you find time to
take your pills?”
Most patients know they
should take their medications, so scolding them won’t
help. The trick is to enable your patient to minimize
the disruptions as best he can. By conducting a nonjudgmental,
empathetic dialogue with your patient, you’ll
keep the lines of communication open and enable him
to become a contributing member of his healthcare team.
Following through
After your patient goes home, he’s responsible
for carrying out the prescribed regimen. However, just
because he’s been told to do something doesn’t
mean it will be done or done correctly. Sometimes the
patient doesn’t fully comprehend the drug regimen,
as was the case with the inhaler example at the beginning
of this article. Or your patient may have some difficulty
interpreting instructions. If a health behavior isn’t
being done correctly, you need to speak up while emphasizing
your patient’s positive behaviors. Try this: “It’s
great that you take your diuretic on most days, but
it’s very important for your heart to take it
every day. What do you think you can do to fit it in
on days you’re away from home?”
Be patient; most behavioral
changes take time and work. Problem solving is a skill
that’s learnable, but not innate. Make suggestions
on how to handle challenges that interfere with his
treatments and remember that change doesn’t happen
overnight.
Here are some follow-up
points to consider:
- Did your patient fill
the prescription?
- Is the medication too
expensive?
- What’s the pill-taking
schedule? Have him describe what he does each day.
- How does the medication
regimen fit into his schedule?
- Is he having any difficulty
with the regimen?
When you assess the medication
routine, ask about all the medications your patient
is taking. For example, several patients in our adherence
study took the generic and the product name of the same
drug because they thought they were two different medications.
If your patient can’t effectively describe the
pill-taking process, then you may need to ask further
questions.
Stick it to nonadherence
Now that you’ve filled your professional arsenal
with skills to battle nonadherence, you can use them
to have a positive impact on your patient’s health.
Remember, it’s possible to improve the lives of
our patients by helping them improve their medication
adherence.
Learn more about
it
Murray MD, Young J, Hoke S, et al. Pharmacist intervention
to improve medication adherence in heart failure: a
randomized trial. Ann Intern Med. 2007;146(10):714-725.
O’Connor PJ, Gray RJ, Maciosek MV, et al. Cholesterol
levels and statin use in patients with coronary heart
disease treated in primary care settings. Prev Chronic
Dis. 2005;2(3):A05.
Piette JD, Heisler M, Ganoczy D, McCarthy JF, Valenstein
M. Differential medication adherence among patients
with schizophrenia and comorbid diabetes and hypertension.
Psychiatr Serv. 2007;58(2):207-212.
Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact
of medication adherence on hospitalization risk and
healthcare cost. Med Care. 2005;43(6):521-530.
Weissman EM, Dellenbaugh C. Impact of splitting risperidone
tablets on medication adherence and on clinical outcomes
for patients with schizophrenia. Psychiatr Serv.
2007; 58(2):201-206.
Source:
Nursing made Incredibly Easy! September/October
2009.
|