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.

 

 

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