Fred M. Eckel, RPh, MS
A recent conversation with a colleague who works with breast cancer patients centered on the increasing importance of medication-taking behavior for the successful treatment of cancer. She was wondering what role the pharmacist should play in assuring adherence.
More cancer agents can now be administered orally, so patients can be at home when taking their medications. Some of these products require administration on an empty stomach, because the medication’s effectiveness is severely compromised if taken with food. Often the adjunctive therapy can upset the stomach, so these drugs are often recommended to be taken with food. This leads to a very complex medication regime that might be confusing to patients, thus increasing the possibility that a patient may not always take his or her medications correctly.
When one considers that some cancer drugs are very expensive and their effectiveness is severely compromised if taken with food or otherwise incorrectly, the consequences to the patient and/or the health care system can be significant. One can see why my colleague was wondering about how the community pharmacist might play an increasingly important role in assuring compliance. Could this link to a reimbursable role for the pharmacist who helps patients use their cancer medications correctly through both an educational as well as a monitoring role?
The complexity of the medication regimen in all diseases can often lead to unintentional medication nonadherence. Another problem is the patient who never gets his or her prescription filled. According to Michael A. Fischer, MD, MS, lead author in a recently published article, more than 20% of first-time patient prescriptions are never filled. This phenomenon has been labeled “primary nonadherence.” What was more concerning is that first-time prescriptions for some common chronic diseases are even more likely to remain unfilled. By some estimates, nonadherence costs the health care system approximately $300 billion annually when patients with a chronic disease do not take their medication correctly or get their prescription order filled.
Although the causes of nonadherence are many and the solutions can be complex to implement, some research suggests that for many patients the likelihood of nonadherence for prescription medications can be estimated using an Adherence Estimator, a tool which is available from Merck. This tool measures the 3 proximal beliefs related to intentional nonadherence: perceived concerns about medication, perceived need for medication, and perceived affordability of medications. This simple tool could be given to the patient to complete when a new prescription order is left to be filled at the pharmacy. The pharmacist could then have important information that might help develop the patient education plan to promote better patient adherence.
The question I have is—should someone on the health team take responsibility to help promote medication adherence? After all, it is primarily the patient or caregiver’s responsibility to take the medications correctly. However, a member of the patient’s care team can help increase the likelihood of the drugs being taken correctly through patient education, appropriate packaging, reminders, and other means. I believe that since this activity is centered on the drug product, the pharmacist should lay claim to this activity as part of his or her role. This would be one step toward the implementation of the profession’s Vision 2015—“Pharmacists will be the health care professionals responsible for providing patient care that assures optimal medication outcomes.” Medication adherence, it seems to me, is an important process that leads to appropriate outcomes, and the pharmacist should be at the center of this process.
Yes, I realize that nonadherence is not a simple problem. It has many different underlying causes. Tools such as the Adherence Estimator may only address a portion of the reasons patients do not always adhere to their medication regimen. Is doing something to help some patients adhere to their medication regimen better than doing nothing at all, while we wait for the ideal solution? What do you think?
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Mr. Eckel is a professor at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He serves as executive director of the North Carolina Association of Pharmacists.