How Health-System Pharmacists Can Improve Adherence in ACS Patients

Jane Doe experiences acute coronary syndrome (ACS), heads to the hospital, and is faced with a barrage of new medical terms she’s never heard of, explanations about the ACS event from physicians, plus medications and instructions from the pharmacist.

She may leave the hospital with 4 or 5 new medications and may not fully understand how to use them or what their purpose is. That’s where pharmacists can step in to be proactive about her adherence and to manage her health literacy.

Christopher Betz, PharmD, BCPS, FKSHP, FASHP, a professor at Sullivan University College of Pharmacy, told Pharmacy Times that some of the ways pharmacists can use motivational interviewing to improve adherence in ACS patients.

“Adherence is key with outcomes of acute coronary syndrome,” Dr. Betz said, whether it’s dual antiplatelet therapy, statins, or beta-blockers. “If they’re not adhering to it, we’re going to have another event.”

Dr. Betz uses the OARS technique to ensure patients understand and follow their medication regimen:

“O” stands for open-ended questions.

They can help form a partnership between the pharmacist and patient during motivational interviewing. Dr. Betz suggested that giving patients time to explain what they’re thinking can also help the pharmacist gauge their ability to be adherent.

“A” stands for affirmation.

“It’s so much easier to have someone change their behavior if you tell them what they’re doing well first,” Dr. Betz said. “No one likes to be told what they’re doing is wrong.”

He suggested starting the conversation off by listing what the patient is doing correctly, then focusing on where he or she can make improvements.

“R” stands for reflective listening.

This is where pharmacists’ empathy comes in. Through reflective listening, pharmacists can better understand what issues the patient is concerned about, and they can also build a stronger connection. One way to show reflective listening is to use a phrase like, “It sounds like X is happening, which I understand can be frustrating. Do I have that right?”

“S” stands for summary.

Dr. Betz pointed out that this can also work as a teach-back strategy to make sure patients understand what they’re supposed to be doing with their new treatments and to measure their buy-in to the medication regimen.

“If they say they can’t do it, changes can be made before they’re discharged,” he said.

Beyond the OARS method, pharmacists can help their ACS patients by assessing their health literacy.

Dr. Betz pointed out that most patients will probably have some difficulty reading the materials they’re sent home with. Often, a health literacy assessment may not be done because the focus is on solving the cardiovascular problem, and it’s easy to forget to assess the patient’s ability to understand the information related to the care of the heart.

“These patients are scared,” he said. “Their ability to comprehend what’s going on is going to be diminished anyway because they had a life-changing event.”

One technique Dr. Betz suggested was the single-item literacy screener (SILS), which he likes because the pharmacist can ask it once and quickly get a response, even if the patient is angling to get out of the room or leave the counter.

The SILS involves asking the patient, “How often does somebody have to help you read and understand materials given to you by your doctor or pharmacist?”

Dr. Betz posited that if the patient responds saying never or seldom, the pharmacist can counsel him or her normally. However, if the patient says often or always, the pharmacist knows to be more concerned about the patient’s ability to comprehend the materials they are receiving. With this knowledge, the pharmacist can better tailor the counseling.

Dr. Betz offered a few other tips for offering more targeted counseling for those with low health literacy:

• Try to refrain from using complicated medical terminology (eg, angiotensin-converting-enzyme inhibitor)
• Avoid multiple-syllable words if possible
• Slow down
• Use pictures
• Always use the teach-back method
• Aim for around 3 “need-to-knows” If the patient needs more information than those 3 pieces, Dr. Betz suggested scheduling a follow-up visit or engaging other family members to help explain the medication regimen.