Integrating technology into patient care, communicating with patients and interdisciplinary cooperation were key themes at the 38th ESCP Symposium on Clinical Pharmacy held in Geneva in November 2009
Laurence A Goldberg
The patient is best served when physicians and pharmacists collaborate, recognising each other’s roles, according to Jon Merrills (pharmaceutical consultant, Nottingham, United Kingdom). Describing models for multidisciplinary working, he said that there were three types of collaboration- genuine collaboration, extended roles, and pseudo-collaboration. The first two required pharmacists to use their skills and knowledge in a clinical setting, working alongside colleagues who recognised their abilities. Pseudo-collaboration described a shift of boundaries for the convenience of one profession. For example, community pharmacists in the UK had undertaken repeat dispensing – a process that relieves physicians of a clerical task but does not involve the use of the pharmacist’s clinical expertise.
Good teamwork is essential but simply putting people together does not necessarily produce successful interdisciplinary working, warned Mr Merrills. Mutual trust and respect, open minds and physical proximity are critical factors. Moreover, if health care practitioners are expected to work in teams then they should be educated in teams. What is needed is a common first degree for all health care professionals, followed by specialisation, he suggested.
Dr Gillian Mead (reader in geriatric medicine, University of Edinburgh, Scotland) and Ms Anne Kinnear (stroke specialist pharmacist, NHS Lothian; honorary lecturer, Strathclyde University, Scotland) described how a multidisciplinary managed clinical network is responsible for the care of stroke patients in Edinburgh. The pharmacist is a key member of the stroke team and provides advice on a range of matters including warfarin dosing, selection and adjustment of anticonvulsants for post-stroke seizures, nasogastric drug administration and interactions between drugs and parenteral feeds. A number of research projects have been undertaken to develop services and to increase understanding of the needs of patients and carers.
Pharmacist participation in the renal transplant team has led to increased compliance with renal dosing guidelines, Anna Carollo (clinical pharmacist, Mediterranean Institute for Transplantation and Advanced Specialised Therapies (ISMETT), Palermo, Italy) told the audience. In her hospital, a pharmacist is a member of the on-call renal transplant team and contributes to the care of transplant patients throughout their hospital stay.
During a panel discussion that followed a questioner asked whether pharmacist prescribing, such as occurs in the UK, was a help or hindrance to successful collaboration. Ms Kinnear said that it was helpful because missed items could be prescribed immediately and if, for example, dose changes were needed for nasogastric administration, these could also be made by a prescribing pharmacist. Mr Merrills said that if drugs are the predominant mode of treatment then pharmacists should be in charge of it. “The quality of decisions will determine who gets to do the job (of prescribing) in the long-term”, he added.
Communicating with patients about medication adherence
Researchers have suggested that improvements in non-adherence are likely to have more effect on health than improvements in traditional biomedical treatment, said Sarah Clifford (lecturer in medicines in health, Department of Practice and Policy, School of Pharmacy, University of London). Approximately 30% of patients receiving chronic treatment are non-adherent and this can lead to poor health, impaired quality of life and increased costs, she continued.
There is not a ‘typical non-adherent patient’ and adherence can vary within the same patient. Non-adherence can be intentional, based on the patient’s beliefs about the disease and its treatment, or unintentional, as a result of factors such as language, complexity of the regimen or poor memory.
Patients’ beliefs and the communication styles adopted by healthcare professionals are major factors in adherence, explained Dr Clifford. For example, the medical view of hypertension is that it is an asymptomatic, chronic condition that could lead to heart and kidney disease and which requires control with long-term treatment. In contrast, the lay view of hypertension can be that it is a disease characterised by headaches and flushing, caused by stress and high tension; it does not make people feel particularly ill and treatment is only required when feeling stressed. If patients perceive that treatment is necessary and have few concerns about adverse effects than adherence will result, she said.
Healthcare professionals should adopt a biopsychosocial communication style, encouraging input from the patients and discussing psychosocial issues during the consultation, because this is associated with good adherence. In contrast, the biomedical style which emphasises the healthcare professional’s perspective and spends little time on psychosocial issues, leads to poor adherence. When treatment is prescribed, pharmacists should:
- Give information about the condition and the effects (and side-effects of medicines).
- Involve the patient in decision-making.
- Rationalise medicines to once or twice daily if possible.
- Anticipate practical barriers to medicine taking.
A randomised study involving patients receiving treatment for a chronic condition has shown that a pharmacy-led telephone intervention designed to provide information and discuss beliefs improved adherence and reduced the number of medication-related problems by about one third.
Misconceptions and adherence
Misconceptions and adherence issues with oral targeted therapies are critical issues for chemotherapy patients, according to Mikael Daouphars, (Cancer Centre Henri Becquerel, Rouen, France). The numbers of oral anti-cancer drugs have increased rapidly in recent years and it is estimated that a quarter of the antineoplastic drugs now in development fall into this category. Patients generally prefer oral treatment and hospitalisation costs are reduced. Moreover, now that some cancer treatment is long-term there is merit in having oral dosage forms. Studies have shown that although patients value the convenience of oral dosing they are clear that this should not be at the expense of efficacy. However, the preference for oral treatment is sometimes based on the assumption that oral therapy is associated with fewer side-effects. Some patients assume that oral chemotherapy is not “real” chemotherapy and is more akin to taking a vitamin or antibiotic and this is borne out by under-notification of side-effects such as fatigue, neutropaenia, hand-foot syndrome by patients, said Dr Daouphars.
Studies have clearly shown that adherence is inversely related to the number of doses that are taken each day, but health literacy can also have a critical impact on adherence. One study examined patients’ abilities to understand and demonstrate instructions found on labels of common prescription medications. Part of the study was designed to test whether patients could accurately read and state the instructions for guaifenesin (“Take two tablets by mouth twice daily”) and could also correctly demonstrate how many tablets were to be taken daily. Although 71% of patients with low literacy correctly stated the instructions, only 35% could demonstrate the number of tablets to be taken daily. Low and marginal literacy were significantly associated with misunderstanding, explained Dr Daouphars.
Both adherence and persistence are important in medicines taking. Whilst adherence describes the extent to which dosing instructions are followed, persistence is defined as the length of time from starting to discontinuation of treatment. For this, 80% is usually regarded as being achievable or acceptable.
The ADAGIO (Adherence Assessment with Glivec: Indicators and Outcomes) study assessed prospectively the level of non-adherence to imatinib treatment in patients with chronic myeloid leukaemia (CML). One objective was to examine whether the response to treatment was affected by adherence levels. The results showed that one-third of patients were non-adherent and this was associated with sub-optimal responses. Only 14.2% of patients were completely adherent and took 100% of prescribed imatinib. Key determinants of non-adherence were age, months since diagnosis of CML and living alone.
Dr Daouphars concluded that ongoing communication efforts, such as telephone contacts, that keep the patient engaged in healthcare may be one of the simplest and most cost-effective strategies for improving adherence.
Walter Haefeli (Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Germany) described how errors in drug treatment could be reduced through the introduction of computerised physician order entry (CPOE) and clinical decision support.
Medication errors affect one in 20 patients and the prescribing and administration steps are the most error-prone stages of the medication use process. Before introducing CPOE, Professor Haefeli’s team first introduced a drug information system with clinical support. An early finding was that the search engine had to be error tolerant because doctors misspelled many drug names and almost one fifth of searches were unsuccessful as a result. Another concern was over-alerting and consequent “alert-fatigue”. For example, patients receiving amiodarone or verapamil should not receive doses of simvastatin greater than 20mg per day. Early systems alerted doctors over combinations containing any dose of simvastatin and 95% of alerts were ignored. New software designed to filter out combinations involving simvastatin doses of less than 20mg reduced the number of alerts by 55% but doubled the number of appropriate responses. Further developments included software to calculate individualised maximum recommended therapeutic doses instead of giving multiple alerts for renal failure, hepatic failure and drug interactions, alerts about inappropriate splitting of tablets and decision support for pain management.
The way in which doctors were told about the computerised systems had a major influence on uptake. Initially users were emailed-“we did not realise that 80% of emails are not read”, said Professor Haefeli. Alternative styles were tested for notification of a module on drugs in pregnancy. A plain message (in Courier font) was associated with 12% uptake whereas static images illustrating the message elicited a 29% uptake.
Rational use of drugs
Drug usage patterns are influenced up to a point by price controls but managing, prescribing and ensuring the rational use of drugs are also of critical importance, according to Richard Laing (medical officer for policy, access and rational use at WHO, Geneva).
Describing patterns of drug usage he emphasised that 18% of the world population consumes 80% of medicines (by value) whilst the poorest 10% consumes 0.5%, he noted. The uptake of generic medicines after patent expiry varies widely with the UK and USA making most use of unbranded medicines. Some countries, such as Denmark, have high usage of branded generics and in others the originator reduces the price to maintain its market share.
Availability of medicines remains a problem in many low-income countries. Contrary to popular belief, prices are not inflated as a result of inefficiency and corruption in these countries. In fact, mean procurement prices are similar between low-income and upper middle-income countries, explained Dr Laing. However, patients may have to pay up to three times the procurement price in the public sector and between 20 and 60-fold the procurement price in the private sector. In some African countries the equivalent of eight days wages can be required for 60 glibenclamide 5mg tablets and this has a serious impact on affordability. In many developing countries high prices for patients are the result of many tiers of taxes and duties and not because of the pricing policies of pharmaceutical companies, emphasised Dr Laing. ‘Why would a government choose this regressive form of taxation?’ he asked.
In developed countries drug prices tend to be low but overall expenditure is high, often as a result of inappropriate overuse. Rational use of drugs is still a problem and this is where clinical pharmacists could have an impact, said Dr Laing. He concluded by urging pharmacists to concern themselves not only with immediate patient care and but also with policy and society.