Neobook — clinical reference

Achieving health goals for chronic conditions such as asthma, diabetes, HIV and AIDS, epilepsy, hypertension, mental health disorders and TB requires attention to:

Adherence to long term pharmacotherapy – incomplete or non-adherence can lead to failure of an otherwise sound pharmacotherapeutic regimen
Organisation of health care services, which includes consideration of access to medicines and continuity of care

PATIENT ADHERENCE

Adherence is the extent to which a person’s behaviour – taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.

Poor adherence results in less than optimal management and control of the illness and is often the primary reason for suboptimal clinical benefit. It can result in medical and psychosocial complications of disease, reduced quality of life of patients, and wasted health care resources.

Poor adherence can fall into one of the following patterns where the patient:

Takes the medication very rarely (once a week or once a month)
Alternates between long periods of taking and not taking their medication e.g. after a seizure or BP reading
Skips entire days of medication
Skips doses of the medication
Skips one type of medication
Takes the medication several hours late
Does not stick to the eating or drinking requirements of the medication
Adheres to a purposely modified regimen; and
Adheres to an unknowingly incorrect regimen

Adherence should be assessed on a regular basis. Although there is no gold standard, the current consensus is that a multi method approach that includes self-report be adopted such as that below.

Barriers that contribute toward poor adherence

Barrier	Recommended support
Life style - It is often difficult to take multiple medications - A busy schedule makes it difficult to remember to take the medication	- Create a treatment plan with information on how and when to take the medications - Use reminders such as cues that form part of the daily routine
Attitudes and beliefs - The condition is misunderstood or denied - Treatment may not seem to be necessary - May have low expectations about treatment	- Remind patients that they have a long term illness that requires their involvement - Use change techniques such as motivational interviewing - Identify goals to demonstrate improvement/stabilisation
Social and economic - May lack support at home or in the community - May not have the economic resources to attend appointments	- Encourage participation in treatment support programs - Consider down referral or reschedule appointment to fit in with other commitments
Healthcare team related - Little or no time during the visit to provide information - Information may be provided in a way that is not understood - Relationship with the patient may not promote understanding and self-management	- Encourage patient to ask questions - Use patient literacy materials in the patient’s language of choice - Engage active listening
Treatment related - Complex medication regimens (multiple medications and doses) can be hard to follow - May be discouraged if they don’t feel better right away - May be concerned about adverse effects	- If possible reduce treatment complexity - Help the patient understand the condition and the role of their medication - Discuss treatment goals in relation to potential adverse effects

Although many of these recommendations require longer consultation time, this investment is rewarded many times over during the subsequent years of management.

For a patient to consistently adhere to long term pharmacotherapy requires integration of the regimen into his or her daily life style. The successful integration of the regimen is informed by the extent to which the regimen differs from his or her established daily routine.

Where the pharmacological proprieties of the medication permits it, the pharmacotherapy dosing regimen should be adapted to the patient’s daily routine. For example, a shift worker may need to take a sedating medicine in the morning when working night shifts, and at night, when working day shifts. If the intrusion into life style is too great alternative agents should be considered if they are available. This would include situations such as a lunchtime dose in a school-going child who remains at school for extramural activity and is unlikely to adhere to a three times a regimen but may very well succeed with a twice daily regimen.

Towards concordance when prescribing

Establish the patient’s:

Occupation
Daily routine
Recreational activities
Past experiences with other medicines, and
Expectations of therapeutic outcome

Balance these against the therapeutic alternatives identified based on clinical findings.
Any clashes between the established routine and life style with the chosen therapy should be discussed with the patient in such a manner that the patient will be motivated to change their lifestyle.

Note:
Education that focuses on these identified problems is more likely to be successful than a generic approach toward the condition/medicine

Education points to consider

Focus on the positive aspects of therapy, but be supportive regarding negative aspects and offer guidance on how to manage this, if present
Provide realistic expectations regarding:
- Normal progression of the illness - especially important in those diseases where therapy merely controls the progression and those that are asymptomatic
- The improvement that therapy and non-medicinal treatment can add to the quality of life
Establish therapeutic goals and discuss them openly with the patient
Any action to be taken with loss of control or when side effects develop
In conditions that are asymptomatic or where symptoms have been controlled, reassure the patient that this reflects therapeutic success, and not that the condition has resolved
Where a patient raises concern regarding anticipated side effects, attempt to place this in context with respect to incidence, the risks vs. the benefits, and whether or not the side effects will disappear after continued use

Note:
Some patient’s lifestyles make certain adverse responses acceptable which others may find intolerable. Sedation is unlikely to be acceptable to a student, but an older patient with insomnia may welcome this side effect. This is where concordance plays a vital role

Notes on prescribing in chronic conditions

Do not change doses without good reason
Never blame anyone or anything for non-adherence before fully investigating the cause.
If the clinical outcome is unsatisfactory - investigate adherence (note that side effects may be an issue)
Always think about side effects and screen for them from time to time
When prescribing a new medicine for an additional health related problem ask yourself whether or not this medicine is being used to manage a side effect
Adherence with a once daily dose is best. Twice daily regimens show agreeable adherence. However, adherence decreases as the number of administration interval increases
Keep the total number of tablets to an absolute minimum as too many may lead to medication dosing errors and may influence adherence

IMPROVING CONTINUITY OF THERAPY

Make clear and concise records
Involvement the patient in the care plan
Every patient on chronic therapy should know:
- His/her diagnosis
- The name of every medicine
- The dose and interval of the regimen
- His/her BP or other readings

Note:
The prescriber should reinforce this only once management of the condition has been established

When the patient seeks medical attention for any other complaints such as a cold or headache he/she must inform that person about any other condition/disease and its management
If a patient indicates that he/she is unable to comply with a prescribed regimen, consider an alternative - not to treat might be one option, but be aware of the consequences e.g. ethical

Patient Adherence Record

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Pill count

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2020 Edition