presenting the terminology of adherence, statistics of non-adherence and its impact, why do patients have difficulty with treatment, how to measure and how to improve the adherence, in addition to the role of the pharmacist in improving adherence.

1. Setting up directions ..
Medication
Adherence
Ahmed Ibrahim Nouri, PharmD
MSc. Clinical Pharmacy
Universiti Sains Malaysia

4. “Drugs don't work in
patients who don't
take them”
(C. Everett Koop, MD, US
Surgeon General, 1985).
Around 400 BC,
Hippocrates was the first to note that
some patients did not take their
medicines as prescribed, and later
complained that their treatment did not
help

5. • Definitions
• Non adherence statistics
• Impact of non adherence
• Patients behavior toward treatment
• Why patients have difficulty with treatment
• Methods of measuring adherence
• Improving medication adherence
• Role of pharmacist in medication adherence
• Case study
• Take home message
OUTLINES

6. Concordance Persistence Compliance Adherence
• Used interchangeably. BUT!
• They impose different views on the relationship between the patient and
the health care professional, collection of medicines from the pharmacy,
and their appropriate intake.

7. Adherence
Concordance
Compliance
To complete an action, transaction, or process
and to fulfil a promise
Following of instructions given by prescribers
The prescriber and patient come to an
agreement about the regimen patients’ views on
medication-taking behaviour
Persistence
The ability of a person to continue taking
medications for the intended course of therapy.
Patient participation in treatment as a shared
decision-making process.The patient is under
no compulsion to accept a particular treatment

8. • In the past, only the term compliance was used.
• The term compliance was increasingly replaced by adherence.
• Concordance is NOT synonymous with either compliance or adherence.
Patient's medicine-
taking behaviour
interaction between
clinician and patient nature
Concordance
adherence

9. “The extent to which a person’s
behavior in .. taking medication,
following a diet, or executing
lifestyle changes .. corresponds with
agreed recommendations from a
health care provider”
(WHO,2003)
Despite the ongoing debate,
adherence has been the preferred term for:
• World Health Organization (WHO)
• American Pharmacists Association (APA)
• U.S. National Institutes of Health (NIH)

10. IMPACT
OF MEDICATION
NON-ADHERENCE
Disease progression
and complications
Increased health care costs
Decreased quality of life
Hospitals and long-
term care admissions
Patient’s Death

11. NON-ADHERENCE AROUND THE WORLD
• The extent of adherence varies widely.
• Studies have reported as low as 10% and up to 93%
• Approximately 50% of patients are nonadherent to chronic medications.
• In developed countries, non-adherence to long-term therapies ~50%
– Much higher in developing countries.
• Of all medication-related hospital admissions in the United States:
33 - 69% → due to poor medication adherence,
resultant cost of approximately $100 billion a year

12. NON-ADHERENCE IN MALAYSIA
• Medical care is heavily subsidized by the public healthcare system
– The adherence among patients with chronic disease is poor.
• All Malaysian citizens have access to medical care at government hospitals and
clinics, paying a minimum of RM1 to RM5 per visit.
(the cost for a visit includes a medical consultation, laboratory investigation, and
medications).

13. NON-ADHERENCE IN MALAYSIA
• In a 1997, study carried out in primary care in the district of Melaka
– 56% (n=260 of 464 patients) were noncompliant to their
medications. (antihypertensive, antidiabetics, or anti-asthmatic drugs)
• In another study at the OPD of Penang General Hospital using a
structured questionnaire:
51.3% of patients interviewed had poor adherence to prescribed
hypertensive medications.
• A National Survey On The Use of Medicines (NSUM) By Malaysian
Consumers 2015
– 73% reported nonadherence to medications
Aziz, A. M., & Ibrahim, M. I. (1999). Medication noncompliance--a thriving problem. The Medical journal of Malaysia, 54(2), 192-199.
Turki AK, Sulaiman SAS. Elevated blood pressure among patients with hypertension in general hospital of Penang, Malaysia: does adherence matter? Int J Pharm Pharm Sci. 2010;2(1):24–32

15. Degree of difficulty to have good adherence
enough for therapeutic effect
Keith & Kane J Clin Psychiatry, 2003; 64: 1308-1315

16. At
risk
Symptoms Diagnosis Early
treatment
Continue
treatment
Does not
attend/ delays
asymptomatic
screening
Delays or
Doesn’t seek
help
Reluctant to
accept
diagnosis
Reluctant to
start
treatment
Does not
follow
courses as
prescribed
PATIENTS’ BEHAVIOR TOWARDS
APPOINTMENTS AND TREATMENTS

17. Almost perfect adherence to a regimen
Take nearly all doses (some timing irregularity)
Misses single day’s dose (some timing inconsistency)
Occasional omissions of doses
Frequent omissions of doses
Take few or no doses while giving the impression of good adherence
General patterns of taking medication among patients treated for
chronic illnesses who continue to take their medications

18. REASONS FOR MEDICATION NON-ADHERENCE
1. Intentional medication non-adherence
Decision is made by the patient to not use
treatment or follow treatment recommendations
2. Unintentional medication non-adherence
Unplanned behavior and is less strongly associated
with beliefs, may be the result of forgetfulness and
not knowing exactly how to use medicines
Ho, P., Bryson, C., , & Rumsfeld, J. (2009). Medication adherence: Its importance in cardiovascular Outcomes. Circulation, 119(23), 3031.

19. Why
patients have
difficulty with
treatment?
1. Socio-economic related
2. Patient related
3.Therapy related
4. Condition related
5. Healthcare system related

20. 1. Language barrier
2. Lack of family or social support network
3. Unstable living conditions; homelessness
4. Limited access to health care facilities
5. Lack of health care insurance
6. Inability or difficulty accessing pharmacy
7. Medication cost
8. Cultural and lay beliefs about illness and treatment
1. SOCIAL AND ECONOMIC DIMENSION

21. 1. Visual impairment
2. Hearing impairment
3. Cognitive impairment
4. Impaired mobility
5. Swallowing problems
2. PATIENT-RELATED DIMENSION
1. Knowledge about disease
2. Understanding reason medication is needed
3. Expectations or attitudes toward treatment
4. Perceived benefit of treatment
5. Confidence in ability to follow treatment
6. Fear of possible adverse effects or dependence
7. Frustration with health care providers
8. Motivation
Physical factorsPsychological/behavioral factors

22. 1. Complexity of medication regimen
• (number of daily doses; number of concurrent medications)
2. Treatment requires mastery of certain techniques (injections, inhalers)
3. Treatment interferes with lifestyle or requires significant behavioral changes
4. Duration of therapy
5. Frequent changes in medication regimen
6. Lack of immediate benefit of therapy
7. Side effects
3. THERAPY-RELATED DIMENSION

23. 1. Chronic conditions
2. Lack of symptoms
3. Severity of symptoms
4. Depression
5. Psychotic disorders
6. Mental retardation/developmental disability
4. CONDITION-RELATED DIMENSION

24. 1. Provider-patient relationship and communication skills
2. Lack of positive reinforcement from the health care provider
3. Weak capacity to educate patients and provide follow-up
4. Patient information materials written at too high literacy level
5. Lack of knowledge on adherence and of effective interventions for
improving it
6. Restricted formularies; changing medications covered on formularies
7. Poor system or missed appointments, long wait times
8. Lack of continuity of care
5. HEALTH CARE SYSTEM DIMENSION

25. METHODS
OF
MEASURING
ADHERENCE

26. • Directly observed therapy
• Measurement of the
level of medicine or
metabolite in blood
• Most accurate
• Patients can hide pills in the
mouth
• Variations in metabolism
and “white coat adherence”
can give a false impression
of adherence
• Expensive
DIRECT METHODS

27. INDIRECT METHODS
• Patient questionnaires
• Pill counts
• Rates of prescription refills
• Assessment of the patient’s
clinical response or marker
• Electronic medication monitors
• Data easily altered by the patient
• Prescription refill is not equivalent to
ingestion of medication
• Tracks patterns of taking drugs
• Expensive
• Simple and inexpensive
• Results are easily distorted by the
patient
• Inaccurate, many factors can affect
clinical response.

28. These are the most accurate method of measuring adherence
because they record the date and time the medication bottle was
opened through microprocessor technology embedded in the cap.
1. Easily manipulated (patient may remove more
than one dose, open more than once)
2. Very expensive & different devices are needed
for each medication.
3. Inaccurate
MEDICATION EVENT MONITORING SYSTEMS
(MEMS) – TRACK-CAP
• Impractical way to determine adherence in clinical practice

29. Measures Equations
Medication Possession Ratio (MPR) Days’ supply obtained/refill interval or fixed interval
Dichotomous variable (arbitrary cutoff value)
Continuous, Multiple Interval Measure of
Medication Acquisition (CMA)
Cumulative days’ supply obtained over a series of intervals/total days
from the beginning to the end of the time period
Continuous, Multiple Interval Measure of
Medication Gaps (CMG)
Cumulative days without any medication over a series of
intervals/total days from the beginning to the end of the time period
Continuous, Single Interval Measure of
Medication Acquisition (CSA)
Days’ supply obtained in each interval/total days in the interval
Continuous, Single Interval Measure of
Medication Gaps (CSG)
Number of days without any medication/total days in the interval
Pill count
(Number of dosage units dispensed − number of dosage units
remained)/(prescribed number of dosage unit per day × number of
days between 2 visits)
Equations of medication adherence measures involving secondary database
analysis and pill count

30. Questionnaire and scales Target population(s) Advantages Disadvantage(s)
Brief Medication
Questionnaire
Diabetes
Depression
Self-administration
Evaluate multidrug regimes
Reduce practitioner’s
training
Time-consuming
Hill-Bone Compliance Scale
(Hill-Bone)
Hypertension specific,
black patients
High internal consistency in
both primary and
outpatient setting
Limited generalizability
8-item Morisky Medication
Adherence Scale (MMAS-8)
All validated conditions
Higher validity and
reliability in patients with
chronic diseases than MAQ
Medication Adherence
Questionnaire (MAQ)
All validated conditions
Quickest to administer
Validated in the broadest
range of diseases
Validated in patients with
low literacy
Comparatively short,
mainly suitable for initial
screening
The Self-Efficacy for
Appropriate Medication Use
Scale (SEAMS)
All validated chronic
conditions
High internal consistency in
patients with high or low
literacy
Time-consuming
Medication Adherence
Report Scale (MARS)
Chronic mental illness,
especially with
schizophrenia
Simplistic scoring Strong
positive correlations
compared to DAI and
MAQ
Limited generalizability
Summary of
self-report
questionnaire
and scales

31. IMPROVING
MEDICATION
ADHERENCE
Unintentional nonadherence
Intentional nonadherence
Long-termTreatments
Short-termTreatments
Elderly
Several interventions have
been reported in the
literature to improve
nonadherence

32. ASSESSMENT
Assess all medications
INDIVIDUALIZATION
Individualize the regimen
DOCUMENTATION
Provide written communication
EDUCATION
Provide accurate and continuing
education tailored to the needs of
the individual
A
I
D
E
S
SUPERVISION
Provide continuing supervision of
the regimen
Bergman-Evans B.AIDES to improving medication adherence in
older adults. Geriatr Nurs 2006; 27: 174–82
Adherence
in older
adults

33. INTENTIONAL AND UNINTENTIONAL NONADHERENCE
• Unintentional nonadherence
– Technology (Mobile apps)
– Simplification of regimen
– Drug packages
– Proper counseling
• Motivational interviewing for improving intentional nonadherence
– Method used to explore the reasons for barriers to medication intake
– Intended to stimulate behavioral change.
– Increasing knowledge about the disease and its treatment
– Explore patient concerns or fears about potential side effects
– Motivate them to resolve their problems and prevent future intake problems.
Directing Supporting
Motivational interviewing
EncouragingAdvising

34. Roles of
Pharmacist in
Medication
Adherence

35. • The best known function of the pharmacist is (Medication Dispensing)
BUT
• Pharmacists through patient counseling, medication therapy management,
disease management, have important role in patient care.
• As social pharmacy links clinical pharmacy, basic sciences and social sciences,
pharmacy practice able to improve patients’ adherence and therapeutic
outcomes
• Enhancing pharmacist-prescriber and pharmacist-patient communication can
lead to significant breakthroughs in adherence

36. PHARMACIST-PRESCRIBER RELATIONSHIP
• Pharmacists collaborate with providers in:
– Community settings
– Ambulatory settings
– Hospital settings.
• Prescriber acceptance rates vary greatly
between patient care settings

37. Michaels NM, Jenkins GF, Pruss, DL, et al. Retrospective analysis of community pharmacists' recommendations in the North Carolina
Medicaid medication therapy management program. J Am Pharm Assoc (2003). 2010 May-Jun;50(3):347-53.
• Ambulatory care and inpatient pharmacist medication
recommendations are well-received
(acceptance rates by physicians ranging 70-90%)
• Community pharmacist recommendations have lower acceptance
rates ranging from 42-60%
• Community pharmacist is vital for improving and monitoring
adherence:
– Accessible to patients
– Direct insight into prescription histories

38. • Identify the patient’s concerns
• patient’s preferences
• Explain the treatment options
• Involve patients in decisions
• One size doesn’t fit all.
• Adjust drugs timing and dosage
• Minimize adverse effects
• Provide support, encouragement
and follow-up
• Epilepsy, DM, HTN, Cancer, Asthma
• Written instructions, drawings,
and illustrations
• Pill boxes
• Reminders via email or telephone
• Ask about problems with drugs
• Ask specifically about missed doses
• Ask about thoughts of discontinuation
• With the patient’s consent, consider
direct methods: pill counting
Basic Communication Condition-specific intervention
Evaluating Adherence Reminding

39. • Self-management includes a psychomotor skill such as
administering a shot or using an inhaler
• Self-management needs to be supported by healthcare providers
• The patient need to be competent to get the benefit .
• Demonstrations, written instructions, illustrations.
• Praise & positive feedback a pharmacist gives to the patient as
new skills are return demonstrated.
Self Management Support

40. POLYPHARMACY
• Use of multiple medications.
• Complex dosing schemes.
• Changes in drug regimens that occur during hospitalization.
• Cognitive and functional impairment associated with aging.
• The need to manage potential drug-drug interactions.

41. Case Study

42. Age, Gender 57 years old, Male
Past medical History Type 2 diabetes
Mild proteinuria
Dyslipidemia
Hypertension
Ischemic heart disease (prior MI)
Social History White, smoker, obese
Medications Atenolol 50 mg twice daily,
Hydrochlorothiazide 25 mg daily,
Simvastatin 20 mg at night,
Glyburide10 mg twice daily.
Aspirin 81 mg once daily
Current regimen: Calorie- fat-salt reduced diet
Regular exercise
Self-monitoring of blood glucose and blood pressure
Quit smoking

43. The patient attended a routine follow-up.
He complains of some urinary frequency, including nocturia 2 to 3 times
a night, but otherwise feels well.
He provides a record of 11 self assessed blood glucose readings in the
past month, with a range of 90 to 216 mg/dL (5-12 mmol/L).
• On examination:
Weight 109 kg
Blood pressure: 172/98mmHg,
Funduscopy: scattered dot hemorrhages
Monofilament testing: decreased sensation feet

44. • NOT able to lose weight despite attempting to follow a calorie-restricted diet and
walking about half a mile once or twice a week.
• When asked whether he had missed taking any of his medications during the past
week, he indicated that he “might have missed 1 or 2 on Saturday night when
he was out at a movie.”
• The patient’s blood glucose meter is checked at the visit and found to be giving
falsely low readings.
LabTest Results
Hemoglobin A1c 12.3%
Total cholesterol 264 mg/dl (6.84 mmol/L)
Triglycerides 186 mg/dl (5.5 mmol/L)
Serum creatinine 1.4 mg/dl (124 μmol/L)
Urinary microalbumin/creatinine ratio 61.9 mg/g (7 mg/mmol) (normal 26.8
mg/g [3 mg/mmol])

45. • This patient’s difficulties include low adherence to:
1. Prescribed diet
2. Exercise regimen
3. Antismoking advice
4. Medications.
• Indications of his low adherence include:
1. His persistently high weight
2. Self-report of little regular exercise
3. Missing pills
4. Discrepancy between his self-reported blood glucose and the hemoglobin A1c
5. Infrequent self reported glucose monitoring
6. He has been prescribed a very complicated regimen of diet, exercise, smoking
cessation, and medications (8 pills per day.)

46. 1. Glyburide → Metformin. (weight gain)
2. Thiazide diuretic (increase insulin resistance) → Ramipril
(reduces cardiovascular risk and incipient nephropathy, lowers blood pressure)
3. Diet, exercise, and smoking cessation can be deferred until blood glucose is controlled.
4. Managing the dyslipidemia may also be deferred for now!
(the lipids may come under control as the blood glucose improves)
5. Patient’s blood glucose meter should be replaced and encouraged to report more.
6. Written instructions of what to start and what to stop should be provided.
7. The patient should be requested to take all medications as prescribed, to the best of his
ability, follow-up visit should be scheduled for a review and reassessment.
What should be done to him?

47. • The regimen was consistent with practice guidelines and commonplace to prescribe,
BUT few are able to follow such a regimen closely for any length of time.
• The new approach is insufficient compared with the guideline of making diet and
exercise the foundation for diabetes control.
• Complexity and behavioral demand of the regimen are strong determinants of
low adherence
• Simplification of the regimen is often needed to achieve adequate adherence.
• Improving adherence for short periods by giving clear instructions about regimens,
and for longer periods by reinforcing the importance of high adherence, negotiating
priorities with the patient, and providing an opportunity for follow-up reinforcement
sooner rather than later.

49. Take Home
Messages

50. • The consequences of poor adherence to long-term therapies are poor
health outcomes and increased health care costs
• Improving adherence enhances patients’ safety by avoiding side effects.
• Patients need to be supported, not blamed!

51. • Adherence is influenced by several factors.
• Patient-tailored interventions are required
• Health professionals need to be trained in adherence
• Family & community are key factors for success in improving adherence

52. THANK YOU..
Dr. Ahmed Ibrahim Nouri, PharmD
MSc. Clinical Pharmacy (USM)
25/02/2018

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