“Polypharmacy is common in older people – around 20% of people over 70 take five or more drugs” (Milton, J et al. Prescribing for older people. BMJ 2008; 336: 606-9)
With reference to both literature and your CBM experience discuss how the Primary Health Care team can work together to improve both compliance and concordance in relation to medication in patients.
Polypharmacy is defined as: “the use of a number of different drugs possibly prescribed by different doctors and filled in different pharmacies, by a patient who may have one or several health problems” [1]. The World Health Organisation estimates that only 50% of patients who suffer chronic diseases comply with treatment recommendations [2].
During day four entitled ‘A Pill for Every Ill?’ at our GP practise we discussed and learnt about the issue of polypharmacy and how it effects compliance (The extent to which the patient’s behaviour matches the prescriber’s recommendations [3] ) and concordance (a concept in which doctor and patient agree therapeutic decisions that incorporate their respective views [3] ) in patients. I also got the opportunity to interview patients about their medication use. From interviewing two patients I found that they all took a number of different drugs for several health problems not simply for one. All of the patients were over the age of sixty and had initially presented with one health problem. Later, further health complications arose that led to more health conditions/problems and consequently increased polypharmacy.
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The first patient I interviewed took eleven different tablets and had two inhalers. He had had asthma since his childhood and carried an inhaler with him. He initially presented with type two diabetes mellitus twenty years ago and was prescribed medication to help control his diabetes. However, he had a heart attack ten years ago but was unfortunately not prescribed certain preventative heart medications for nine years and consequently only began to take his full course of heart medications a year ago. He has now been prescribed with GTN spray and eight tablets including beta blockers, statins, aspirin and GTN spray. He takes five of these tablets in the morning and three at night. He is on repeat prescription for all his medications and he picks up a blister pack/ dosette box from the pharmacy every month with his medication in, so that he can remember what to take and when to take it. When asked he said he was ‘very happy’ with how clearly the tablets, inhalers and the side effects of both had been explained to him. He does not pay for his medications because he is an old age pensioner. He does not feel he suffers any side effects from the medications. He has regular appointments to have blood taken so that he can be monitored so that if necessary, changes in his medication can be made.
The second patient I interviewed took nineteen different tablets. She had presented with angina and was prescribed heart medications (beta blockers, statins, aspirin and GTN spray). She later became hospitalised due to an infection in her leg for which she was prescribed antibiotics which she was still taking at the time. Two years ago she began to suffer from severe pain up her back, at the side of her face and at the back of her head. She consulted because of this pain and after a number of follow ups with a specialist at hospital; it was found that the pain on the side of her face and back of her head, was being caused by a large vein lying on a nerve in her face causing painful muscle spasms. Due to the pain in her back, she found it hard to climb the stairs. She was prescribed codeine for the pain by sticking patches on to her skin (to change every day) to give her a continuous dose over a longer period of time than tablets would. The codeine tablets were prescribed for instances when the pain became too severe that the dose being administered by the patches wasn’t enough. The lady explained that she did not suffer any side effects from the medications she took. She is on repeat prescription for all her medications which she takes daily at different dosages for each medication, apart from the antibiotics for which she is on the last course. She does not have to pay due to her being an old age pensioner. To remember to take her medications, she keeps them all in a box by her bed. She has never been in a situation where she completely ran out of medicine because she has the help of her family who go to the pharmacy to pick up her medicines for her.
I found the interviews I conducted very interesting and helpful in understanding the important issues of compliance and concordance with patients that arose from polypharmacy. In relation to compliance and concordance, both patients gave a lot of importance to the fact that every time they were prescribed a medicine, the GP would take time to explain why they were prescribing the drug, explaining the way the drug worked, the dosage required and answering any questions they had about the medicine.
Whilst studying literature on the topic, I came across an article about a randomised control trial in patients with heart failure and how the intervention of a pharmacist may possibly increase compliance with the patients [4]. It is a fact that patients with heart failure have several prescriptions and for that reason sometimes have problems being compliant and taking full courses of their medication at prescribed times. The trials objective was specifically to see if “pharmacist intervention improves medication adherence and health outcomes compared with usual care for low-income patients with heart failure” [4]. 39% of the 314 patients with low income were assigned intervention while the remaining 61% remained with usual care. Both groups were followed for 12 months. The group subject to intervention underwent 9 months of multilevel intervention by the pharmacist with a 3 month follow up period. The intervention was designed by an interdisciplinary healthcare team who helped patients with low health understanding and inadequate resources to manage their medication. The results of this trial showed that during the 9 months of intervention, compliance to take medication in the group with normal care was 67.9% whilst in the intervention group it was 78.8%. This difference of 10.9% was found to be statistically significant; therefore these results prove that intervention by a pharmacist does increase compliance in patients. However, in the 3 month follow up these results dissipated. The rate of compliance reduced to 66.7% in the group with normal care and 70.6% in the group with intervention. The difference of 3.9% between the two groups was found not to be statistically significant meaning there was no lasting effect on compliance. Medication was taken at the correct time 47.2% of the time by the normal care group and 53.1% of the time by the intervention group. This soon lowered to 48.9% and 48.6% in the normal care and intervention group respectively in the 3 month follow up [4]. For there to be a lasting effect on increasing compliance and as a subset, taking the medication at the correct times, it was necessary to continue intervention. This study was useful in helping find a method of increasing compliance; however, it was not clear exactly how this “intervention” worked. I understood it involved helping patients manage their medication better but not how exactly and also involved educating them better about the drugs. In relation to this essay, this study has these limitations but at the same time it reveals useful methods to increase compliance which I can not ignore.
There are proven reasons other than the ones explained above, for non-compliance. These include being male, being a new patient, having a shorter disease period and work and travel pressures [5]. Non-compliance entails the disadvantage of patients not following a strict routine of taking medication which consequently causes further ill health and possible bacterial resistance in the long term. Once these issues have been recognised through discussion between a patient and a practitioner; there are two interventions proven to significantly increase compliance. These methods were proven useful in a study conducted to look at ways in which compliance could be increased in patients with ulcerative colitis [5]. In both instances it is necessary for there to be a good relationship between the patient and practitioner where the patient feels comfortable to talk openly about their problems. Educational intervention can be provided [5]. This is comprised of verbal explanation of the dosage regime and how the drug itself works. Written information on the drug is also provided to educate the patient further. Once the patient feels they are sufficiently equipped with knowledge on the drug and have agreed to take it, the practitioner and patient draw up a self-management programme collaboratively. However, this method of intervention has its drawbacks due to time constraints many doctors are under. They can not find the time to go through this lengthy process with every patient. This problem could be overcome by having another member of the primary healthcare team take care of this process such as a pharmacist who is qualified to answer questions on medications.
The second intervention is based on the patient’s behaviour [5]. It involves making it easier and more memorable to take their medication. This is done with the use of calendar/blister packs which are made/provided at the pharmacy. The blister packs serve as reminders or cues. They have the day and time at which each tablet should be taken on the back so it becomes harder to get confused and to miss tablets, therefore improving compliance. This is a cheap and cost-effective method which has been proven to improve compliance. The interventions together optimised compliance when they were adapted to individual patient needs in the study involving ulcerative colitis patients.
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To investigate methods to improve compliance I first need to make clear some of the reasons for poor compliance. For this I will use a study based on the causes of non-compliance to statin therapy as a major challenge in cardiology, as my evidence [6]. This study found that there were a variety of factors that caused non-compliance. These include patient, practitioner and system factors [6]. Patient factors include comorbidities (“two or more coexisting medical conditions or disease processes that are additional to an initial diagnosis” [7]) which increase polypharmacy which decreases compliance and also financial constraints in being unable to buy prescribed medication. Practitioner factors include poor communication skills, time constraints and poor doctor-patient collaboration. System factors include medication costs, lack of clinical monitoring and drug side effects [6]. These valid points presented by the study highlight where the changes need to be made in the Primary Healthcare team to improve compliance in patients.
Some of the causes of decreased compliance above have apparent solutions. Financial constraints on patients could lead to a means tested system where patients that earn less than a certain amount receive medications free. This would eliminate the problem of patients not being able to obtain their medications. Practitioners could be sent on courses to improve their communication skills so that patients feel they are being listened to more and so they feel they understand the drugs and side effects so they feel comfortable being compliant. The idea of communication courses for doctors will also have a good impact on doctor-patient collaboration thereby increasing compliance. Medication costs could only be decreased when patents on specific drugs run out and other drugs companies compete for business thereby decreasing costs. Drug side effects are simply a limitation of the technology companies have at the moment, to formulate drugs. When technology advances, so will mans ability to decrease the number and severity of side effects. However, doctors can also regularly review medication to reduce side effects by switching a patient’s medication to another drug with similar effects but fewer side effects. This will increase compliance because drugs will increasingly only have the desired effects and little or no side effects.
Many of the system factors that lead to decreased compliance are in fact not in the control of the primary healthcare team, such as controlling the medication costs which are set by the drugs companies and drug side effects. The patient factors leading to decreased compliance are very personal and individual to the patient. However, the primary healthcare team can be useful in helping these problems to be overcome by, for example, sorting medicines into a dosette box for a patient who is very forgetful. The practitioner factors that lead to decreased compliance are indeed the same reasons that cause decreased concordance as well as other reasons.
Improving concordance is linked to improving compliance. In fact improved compliance in certain cases is a direct consequence of improving concordance. For this reason tackling the problem of decreased concordance is a key issue in the primary healthcare team.
Decreased concordance is a result of intentional non-compliance by patients [8] due to time constraints a doctor is under, poor doctor-patient relationship, poor communication skills of the doctor including poor explanation of the patient’s conditions [9] and the drugs they are taking and poor appearance/professionalism. Time constraints are a problem because GP’s feel pressured to rush everything necessary leaving the patient feeling ill prepared. Government initiatives to set a minimum time limit on how long any consultation should last, could be a possible answer to this problem. This would give doctors more of an opportunity to ask more open questions and more probing questions into how the patient’s life is affecting their health/compliance. Patients are given the choice of asking to have appointments with doctors they believe they have better relationships with, however, if it is noticed that a pattern is emerging when a certain doctor is consistently not asked for, then a review can take place to investigate why the care given by a particular doctor is not good enough. The doctor can be sent on courses in improving care and be sanctioned if deemed necessary by the General Medical Council through fitness to practise measures.
If the NHS makes sure that the doctors are provided with more than enough information to educate them on the drugs they prescribe, the likelihood of poor explanations by doctors to patients on their medications is more unlikely. Doctors’ should also avoid the use of medical jargon and use simpler language that the patient is likely to understand to improve concordance [9]. If this is the reason for poor communication of doctors then poor concordance is also solved. However, poor communication on the part of the doctor can be due to number of different non-intentional problems including family problems. If this is the case then support services can be made available to the doctor to improve his condition/practise. This has the wider effect of improving appearance/professionalism if this is also suffering.
Compliance and concordance are of great importance because a decline in either can lead to an exacerbation of the underlying illness or in many cases of polypharmacy, an exacerbation of comorbidities. In conclusion, there are many simple methods in improving compliance, in certain cases as a result of improving concordance. The doctor-patient relationship is key in improving compliance as it involves a mutual understanding and importantly lends help in listening to complaints of patients and finding methods for them to remain compliant. The simplest methods such as the use of dosette boxes, having doctors that are knowledgeable about the drugs they prescribe and taking the time to explain them to patients, are the most useful methods of improving compliance and concordance.
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