Helping patients follow the script

Patients with chronic disease who risk serious illness by not taking their medication correctly are the target of a pilot study to educate community pharmacists.

Pharmacy researcher Victoria Garcia Cardenas has tested measures to ensure patients with asthma and other chronic conditions take their medications as prescribed, by training pharmacists to provide education on asthma control, medication adherence and inhaler techniques.

"Pharmacists are the last healthcare provider to see the patient before they decide to take or not take the medication, so they are in an ideal place to identify and address non-adherence," says Dr Cardenas, a lecturer in the Graduate School of Health at the University of Technology Sydney (UTS).

Researchers have identified more than 200 reasons why patients do not follow their doctor's orders on medication, she says.

Dr Cardenas says medication non-adherence is broadly divided into intentional and non-intentional.

"The 'non-intentional' patients have practical barriers that prevent them taking their medications – they might forget it, for example."

She says "intentional non-adherence" is based on perceptual barriers which cause a patient to make a decision not to take medication as prescribed.

The World Health Organisation (WHO) estimates that medication non-adherence occurs in half of all patients in developed countries who have chronic conditions.

In Australia, about one in two people has a chronic disease, and about one in five has at least two chronic conditions, according to a report from the Australian Institute of Health and Welfare (AIHW). The 2014 report identified chronic disease and its causes as Australia's biggest health challenge.

Pharmacist Sally Tadros, of Five Dock, participated in one of Dr Cardenas's pilot studies and says forgetting medication or getting mixed up with medications is a common experience for elderly patients, who are otherwise well-motivated to maintain their treatment.

"I found that the people who make a conscious decision not to keep up with their medication are those aged between 30 and 55 or so," Tadros says.

Intentional non-adherence is the most difficult to modify, Dr Cardenas says.

"One common reason a patient decides not to take their medication is that they are concerned about its side effects or long-term effects. Often those decisions will be based on information gathered via the internet."

Patients can also grow despondent about the idea that they may have to take the medication forever. "That can reduce their motivation to take medication," she says.

Many patients also underestimate their risk of severe illness – particularly if they feel well – and think their chances of falling seriously ill are low.

Dr Cardenas says five key areas have been identified as contributing to medication non-adherence: socio-economic, therapy-related, patient-related or condition-related factors, and those related to the healthcare provider or health system.

"Non-adherence to asthma medications is a good example of the contribution of socio-economic factors, as the preventer medication is more expensive than the symptom-relieving medication, Ventolin, which is also fast acting," she says.

Patients with long-term chronic conditions such as asthma use cost to justify non-adherence to preventer medication, despite evidence that in most cases it is essential for effective management of the condition, she says.

"There's a lot of evidence showing the important role pharmacists play in addressing non-adherence, because they generally have regular contact with chronic patients who have medications dispensed at least once a month," she says.

Medication adherence can also change over time, Dr Cardenas says.

"Because pharmacists must keep dispensing records, they can monitor adherence over time and provide effective strategies to address non-adherence."

For Tadros, learning how to provide effective prompts for patients to keep up with their medication has been hugely satisfying.

"Educating patients about the importance of their medication, discussing side effects and providing information brings us back to what the pharmacy profession is all about," she says.