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VOLUME 9 NUMBER 4 • NOVEMBER 2012
MEDICATION REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
WAYS TO IMPROVE PATIENT INVOLVEMENT AND ADHERENCE
The government is keen to involve patients and carers in shared deci-
sion-making about their treatments and has introduced the catch phrase:
‘
No decision about me without me’.
The National Institute for Health and Clinical Excellence (NICE) has de-
veloped a guideline on medicines adherence that offers practical advice on
increasing patient involvement and shared decision making; assessing and
increasing medicines adherence; and conducting medication reviews.
SHARING INFORMATION
The NICE guideline points out that taking medicines is a complex human
behaviour. As a result, it suggests that unwanted and unused medicines
reflect inadequate communication between professionals and patients
about health conditions and how they might be treated, as well as about
patients’ continuing assessment and experience of treatments. Patients
need to be offered information about their condition; the available treat-
ments; possible side effects, dosing frequency, intended duration of
treatments, and possible alternatives.
It is essential to deliver this information in a form the patient can access
and understand. This may be achieved by giving verbal or written informa-
tion, enrolment in a group education programme, or by access to a website
or DVD. However the information is delivered it is essential to ensure the
patient has understood the underlying messages. Asking patients to repeat
instructions back to you is a practical way to confirm this has occurred.
FACTORS AFFECTING ADHERENCE
Many factors affect whether or not patients take their medications as
prescribed (Table 1). These factors can be intentional or unintentional and
are influenced by physical, psychological and social issues. Exploring and
understanding these factors can improve patients’ adherence with their
prescribed medicines.
THE NO TEARS APPROACH TO THE MEDICATION REVIEW
Medication reviews are generally conducted every 12–15 months for
patients prescribed repeat medicines and at least six monthly for people
over the age of 75 taking four or more medicines. They can be carried out
by the practice nurse, GP or pharmacist.
There are many points to remember in a relatively short time when con-
ducting a medication review. A systematic approach can make the process
more effective and time-efficient. The NO TEARS tool (see Table 2) was
designed to be used in the 10-minute consultation and can be tailored to
the individual practitioner’s consultation style.
NEED AND INDICATION
The first area to check is why the drug is being prescribed and whether
the patient benefits from taking it. The questions to ask are:
Has the diagnosis been established and does it still apply?
•
lIs the drug still needed, and was it intended for long- or short-term
•
use?
Is the dose appropriate? Should it be increased or reduced?
•
Would non-pharmacological treatments be better?
•
OPEN QUESTIONS
Asking open questions such as: ‘How are you getting on with your tablets?’
enables patients to express their views and share any problems they might be
experiencing. This will help you understand how they take their medicines.
Ask about what they are actually taking, including prescribed and over-the-
counter medicines. Does this match with the computer record? Do they think
their tablets work? And do they have any worries or concerns about taking
their medication?
It is also important to explore the patient’s adherence with treatment. Ask
whether they miss any medications? Is it difficult to access their prescription,
open the packaging or swallow the tablets? Is cost a problem? If so, are they
eligible for free prescriptions, and would a pre-payment certificate help?
Finally, allow patients to raise their own concerns by asking whether
they have any questions and if there is additional information they would
like about their medicines.
Table 1.
Factors affecting medicines adherence
•
The patient feels well and so is unsure whether the medication is really
needed
•
Experience of, or being fearful of, unpleasant side effects
•
Poor dexterity resulting in difficulty getting tablets out of their packaging
or picking them up
•
Difficulty in swallowing (which affects two-thirds of elderly people)
Psychological
•
Personal beliefs about their condition and treatment, family views, peer
pressure
•
Depression may reduce motivation to take medicines
•
Difficulty following instructions due to poor memory and understanding,
poor hearing or eyesight
•
Confusion over multiple drugs with complicated dosing regimens
Social and practical
•
Drugs interfering with the daily routine
•
Daily distractions meaning patients simply forget
•
Cost of prescription items may lead to patients collecting only some of
their prescribed drugs
•
Access to pharmacy or collecting repeat prescriptions
•
Confusion when dispensed repeat medications are a different colour or
shape depending on the manufacturer supplying the pharmacist
Table 2.
The NO TEARS approach
N
O
T
E
A
R
S
Need and indication
Open questions
Tests and monitoring
Evidence and guidelines
Adverse events
Risk reduction and prevention
Simplification and switches
1...,22,23,24,25,26,27,28,29,30,31 33,34,35,36,37,38,39,40,41,42,...52