Patient Counseling Compliance

Gennaro AR Remington
Encyclopedia of Clinical Pharmacy
 Patient Compliance
• compliance is defined as the extent to which
an individual’s behavior coincides with
medical/health instructions/advice.
• There has been the recognition that in many
circumstances, drugs are not used in a
manner conducive to optimal benefit and
safety.
• compliance relates to instructions concerning
diet/exercise/rest and use of drugs.
 Introduction
• Compliance is……….
an understanding of how the medication is to be
used
patient is motivated to use the prescribed
treatment
because of a perceived self benefit and a
positive outcome.
Terms like adherence or concordance is also
used.
 patient noncompliance
• Hippocrates once cautioned
“Keep watch also on the fault of patients which
often makes them lie about the taking of things
prescribed.”
studies show that a large percentage of patients, do
not take their medication in the manner intended.
some patients make a conscious decision to deviate
from the prescribed regimen….. intentional
noncompliance
 Compliance and counseling

• steps must be taken to provide patients with

the counseling necessary to use their
medications as effectively and as safely.
• in a number of situations pharmacist has not
provided the patient with adequate
instructions in such a mannerthat the patient
understands them.
 Types of non compliance
Dispensing failure to have the prescription dispensed, dosage errors, incorrect
related administration, errors in the time of administration.
Patient related Some patients do not even their prescriptions to a pharmacy.
patients feel that they have recovered from the condition or otherwise don’t
need the medication.
they don’t like to take medicine,
the cost is too high.
patients already may be taking nonprescription medications…..self
medication.
Dose related omission of doses is one of the most common types of noncompliance
individual dose or frequency of administration is incorrect.
administration not using the proper technique.
of medication wrong route of administration.
Errors in the time of administration.
 Consequences of non compliance
“Drugs don’t work if people don’t take them.”
Surgeon General C Everett Koop.
Noncompliance deprive the patient of the anticipated therapeutic
benefits and results in progressive worsening of the condition being
treated.
in the overuse of a drug, there is an increased risk of adverse
reactions.
A published studies of drug-related hospital admissions reports that
indicated 22.7% of adverse drug reaction
hospitalizations were induced by noncompliance.
Noncompliance has major implications for those with HIV
infection/AIDS…Surveys demonstrated that approximately 1/3
of the patients missed doses during the 3-day period prior
to the surveys.
• manner in which patients use their medication should
be evaluated before the therapeutic regimen is
changed.
• study reported that the underuse of antihypertensive
medications is associated with hospitalization that
could have been prevented if patients had complied.
• noncompliant in results in relapse of symptoms.
• Similarly, a leading cause of death in transplant
patients is the rejection resulted from noncompliance
in using immunosuppressant medication.
• It is estimated that the costs associated with
noncompliance in the US exceed $100 billion a year.
• Accidental poisonings have resulted of drugs that are
not stored properly.
 intelligent noncompliance
• some patients may benefit from being
noncompliant.
• certain individuals have a rational basis for
altering the dosage of their medication, and
that good treatment outcomes are still
attained.
 Detection of non compliance
• The ideal detection method would measure
compliance at the time and place of the
medication-taking event.
indirect measures
Self-reports and interviews with patients. asking carefully constructed questions.
Pill counts…assessed by the difference between the number of dosage units
initially dispensed and the number remaining in the container on a return visit.
pill dumping (ie, attempts by patients to misrepresent their compliance by discarding medication)
………….return counts grossly overestimate actual compliance rates
achievement of treatment goals, when a treatment is associated with a successful outcome satisfactory
compliance with the regimen may be inferred.
toothbrush effect…patients may comply with other treatment regimens just before their return visit.
Computerized compliance monitors….
The Medication Event Monitoring System in the cap of the medication container.
Each time the patient removes the cap, the time and date are recorded.
data provides an indication of individual dosing patterns
DIRECT METHODS—
Biological markers and tracer compounds indicate patient compliance.
glycosylated hemoglobin in patients with diabetes mellitus gives an assessment of
metabolic control during the preceding 3-month period.
compliance also has been measured through determination of drug concentrations in
patients’ biological fluids.
 The Noncompliant Patient
• Every patient is a potential defaulter; compliance
can never be assumed.”
• patients may intend to take the medication but
actually not do so because they are forgetful or do
not understand the instructions.
• Patients who live alone are less likely to comply
than those who live with another family member.
• some patients develop a fear of dependence
regarding use of any drug that is to be employed
for a prolonged period.
 FACTORS ASSOCIATED WITH
NONCOMPLIANCE
Disease nature of the patient’s illness.
patients with psychiatric disorders.
studies of patients with conditions such as schizophrenia have shown a high
incidence of noncompliance
Patients with chronic disorders, particularly conditions such as hypertension.
Patient become discouraged with therapeutic programs that do not produce
cures of the conditions.
Disability caused by disease disability will motivate compliance in most
patients.

Therapeutic MULTIPLE DRUG FREQUENCY OF DURATION OF ADVERSE EVENTS

Regimen THERAPY ADMINISTRATION THERAPY— development of
greater the More frequent treatment period unpleasant effects
number of drugs medication..less is long..less of a drug
appearance (eg, compliance. compliance.
size, color, or patients with
shape) of certain chronic disorders
drugs
SYMPTOMS COST OF ADMINISTRATION TASTE OF
SUBSIDE MEDICATION OF MEDICATION MEDICATION
Patient/Health Quality/effectiveness of the interaction of these health professionals with
Professional the patient are major determinants of the patient’s understanding.
Interaction patient’s greatest needs is psychological support provided in a
compassionate manner.
patients comply with the instructions of a physician they know well and
respect.
FAILURE TO COMPREHEND THE IMPORTANCE OF THERAPY.
Importance of the drug therapy/potential consequences of medication not
used according to instructions should be impressed upon the patient.
If therapy does not meet patient’s expectations they are more likely to
become noncompliant.
POOR UNDERSTANDING OF THE INSTRUCTIONS
How should instructions to take one tablet three times a day be
interpreted?
every 8 hr/ with meals/possibly some other schedule?
patient may not understand the meaning of auxiliary instructions.
Pharmacists should make patients familiar with special considerations
pertaining to the particular dosage form dispensed.
-not chewing or crushing controlled-release capsules or tablets.
patient in confusion are given medicine by the wrong route
eg, instilling oral pediatric antibiotic drops into the ear for an ear infection
 IMPROVING COMPLIANCE
• health professionals must believe that noncompliance
is an important problems and willing to make efforts
that will help their patients be compliant.
• communication of the pharmacist with the patient is
sometimes weak because pharmacists are too
busy/not interested in talking with the patient.
• Improving communications must be considered the key
to increasing compliance.
• Pharmacists have valuable opportunity to encourage
compliance since they are the last health professional
to see the patient prior to the time taking medicine.
Identification of recognize individuals who are most likely to be noncompliant.
Risk Factors These factors should be taken into account in planning the patient’s
therapy.
So that regimen compatible with the patient’s normal activities can
be developed.
Development of more complex the treatment regimen, the greater is the risk of
Treatment Plan noncompliance.
use of longer-acting drugs in dosage forms that are administered
less frequently…simplify the regimen.
Compliant patients see themselves as active members of the
team involved in their care.
Don’t make patients feel as passive victims of a disease
and the health-care system.
Regimen should be so that the doses frequency matches the time
that correspond to daily schedule of the patient.
directions that are subject to misinterpretation should be avoided.
Patient Education pharmacists should have a larger role in patient education and advise
their patients to expect counseling.
provide information what information should be provided to patients?
that the patient is too comprehensive/detailed/inapropriately presented information the
able to understand may discourage patient from taking the medications.
and use. Patients should be encouraged to participate in discussion, and be
brought in on the decision-making process.
1. What is the name of the medicine, and what
is it supposed to do?
2. How much of the medicine should I take,
when should I take it and for how long?
3. What foods, beverages, and other medicines
should I avoid while taking it?
4. What are the possible side effects, and what
should I do if they occur?
5. What written material is available about the
medicine?
ORAL directly involves both the patient and the
COMMUNICATION/ pharmacist in a two-way exchange.
COUNSELING provides the patient an opportunity to raise questions.
Conduct in a setting that provides privacy and is free of distractions.
Pharmacies should have patient consultation area.
compliance clinics………
WRITTEN specific instructions for use should be placed on the
COMMUNICATION prescription label.
Provision of supplementary written information is effective in
improving compliance with short-term therapeutic regimens (eg,
antibiotic therapy).
many patients cannot read.
Written instructions and information also must be viewed as one-way
communication.
CONTROLLED hospitalized patients be given the responsibility for self- medication
THERAPY prior to discharge.
patients go from a complete dependence on others for the
administration of their medication.
Sometimes, also ambulatory patients who are expected to be
responsible for their own treatment are not provided with adequate
information.
Special programs of providing information for individuals including
sight-impaired and hearing-impaired patients.
 Patient Motivation
Information must be provided to patients in a best comprehensive educational efforts will not be
manner that is not coercive, threatening, or effective if the patient cannot be motivated to
demeaning. comply with the instructions.

Tuberculosis and non compliance health care professionals assume that patients
Noncompliance is the greatest challenge. who are knowledgeable about their illness/
therapeutic regimen are
“Sometimes it takes a little imagination. Give them likely to be compliant.,…..not true
a cup of coffee. Talk to them. Pay them So…
an honorarium to come in and take the medicine. motivate patients to use the knowledge
If the public doesn’t want drug-resistant TB, then I they have acquired to achieve optimum benefit
say bribe them. from their therapy.
Compliance Aids
LABELING accuracy and specificity of the information on the label of the prescription container
must be not noted.
Auxiliary labels….. Information regarding the use, precautions, storage of the
Medication.
Leaflets………understanding of information regarding medications.

Labeling medication calendars…. to monitor self-administration of the drugs.

tools for MEDISET container…. 4 compartments for different time periods..an alarm and flashing
compliance. light.
Talking Rx, ScripTalk, and Aloud Talking Prescription Labels for For patients with vision
impairment.
 COMPLIANCE PACKAGING
• a prepackaged unit that provides one treatment cycle of
the medication to the patient in a ready-to-use package.
• usually is based on blister packaging using unit-of-use
dosing.
• make it easier for patients to understand and remember
to take their medications correctly at home.
• Medicine-On-Time system....example.
• these systems have been very useful in the distribution
and administration of medications.
difficulty opening some foil- Example…elderly patients with conditions like arthritis
packed drugs. and parkinsonism, have difficulty opening some of these
Pharmacists should be alert to containers
such problems
 DOSAGE FORMS—Compliance
• development of longer- acting, controlled-
release dosage forms of numerous
medications.
• The use of transdermal delivery systems
permits less-frequent administration of the
drugs.
• these agents, which facilitates compliance.
 Monitoring Therapy

SELF-MONITORING Patients should be educated about the importance of self

monitoring their treatment regimen.
“If your medicine isn’t working. . . . It may not be the medicine at
all. It could be you!”
PHARMACIST The pharmacist is in an excellent position to detect noncompliance
MONITORING pertaining to drugs.
the brown bag program
National Council on Patient Information and Education (NCPIE) have
encouraged older consumers to put all their medicines in a bag and
take them to their health professional for a personalized medicine
review.
 NCPIE Recommendations for Action to
Advance Prescription Medicine Compliance
Physicians and Coordinate patients’ medication regimens with pharmacists working in
Medical care facilities or in the pharmacy.
Schools Train physicians to communicate with other members of the health care
team to ensure continuity of care
Pharmacists, Become proactive about gathering and providing medicine information.
Pharmacy- Ask questions that stimulate dialogue, discuss care plans with patients.
Providers and use information about patients to make better decisions.
Educators Provide compliance monitoring and documentation for at least one at-risk
patient per month.
Share your findings with the patient and with his/her health care providers.
Work with management to redesign facilities to increase
pharmacist/patient contact.
Incorporate patient communication skills into undergraduate courses and
continuing education programs.
Work with other HCP schools/organizations to develop interdisciplinary
compliance education programs.
Integrate behavioral and clinical sciences in educating pharmacists about
compliance.
Nurses and Collaborate with other health care providers, including prescribers and
Educators pharmacists, about patient compliance issues.

All Health Respect a patient’s right to confidentiality when sharing medication

Professionals compliance experience with others.
Pharmaceutical as an industry, develop a public service advertising campaign promoting
Manufacturers patient medication compliance with therapy.
Support health professionals’ education to develop effective
communicators in a patient-centered health care system.
Recognize and promote role models who can demonstrate improved
compliance from a patient-centered approach.
Support interdisciplinary teams that provide patient education and
programs for compliance.
Patients Become an active participant in making treatment decisions and solving
problems.
Talk to your health professionals about why and how to use your
prescription medicines.
Give them information about your medicine use and health to HCPs.
If you stop or change a prescribed treatment, tell them and explain why
you did this.
Recognize, accept, and carry out your responsibilities in the treatment
regimen.
Managed Care Use existing databases to profile the extent of medicine noncompliance.
Organizations Develop and implement programs for patient compliance support.
and Hospitals Keep health care providers informed about these programs.
Develop/implement innovative programs that teach patient’s responsibility
for and involvement in his/her health care.
Identify, implement, and evaluate compliance-promoting organizational
practices and policies.
Review drug use policies, such as formulary policy guidelines.
Revise policies accordingly to facilitate compliance.
Develop and implement computerized systems