Student Pharmacists’ Perceptions of Barriers to Medication Adherence Counseling

Introduction

Improving medication adherence among patients is quickly becoming recognized as a public health priority. ¹ In the United States, 33% to 69% of all medication-related hospital admissions are due to poor medication adherence. ² Current research on medication adherence has been primarily focused on identifying barriers that patients face when taking their medications and has not yet evaluated the barriers health care professionals may encounter in helping patients overcome these barriers. ^{2 –5} Community pharmacists are one of the most utilized members of the health care team due to their ease of accessibility to the general patient population and therefore may be ideal candidates for provision of medication adherence management services. In addition to the benefit of accessibility, recent literature has shown that targeting medication adherence during pharmacist-led counseling sessions improves patients’ adherence to medications at less expense than complex, coordinated care. ⁶

Medication nonadherence has been documented as an issue with both the initial fill of the prescription medication as well as the subsequent refills. A review of 79 studies reported that 16% of patients fail to initially fill their prescription medication. ³ With regard to medication persistence, or the length of time a medication is used after the first initial fill, approximately 50% of patients who fill a new prescription stop taking their medication within the first year of starting the therapy. ⁷ As a result, poor adherence to a medication regimen is associated with worsening of disease, death, and increased health care costs. In the United States, 33% to 69% of all medication-related hospital admissions are due to poor medication adherence that results in an approximated health care cost of $100 billion a year. ²

Patient responses to research questionnaires have shown that there are more than 100 factors observed to be associated with nonadherence. ⁸ Common reasons for not taking medications have been categorized into 3 main groups; patients feel apprehensive about the need for the medication they are prescribed, are concerned about side effects and long-term safety, or are worried about the overall cost of the medicine. ⁹ The next step in overcoming these barriers will be to implement interventions that are targeted at improving adherence and helping patients overcome their individual barriers to nonadherence.

While there are several approaches that can be taken to decrease the rate of nonadherence to a medication regimen, targeting medication adherence during pharmacist-led counseling sessions has shown promise in improving patients’ medication adherence at less expense than complex, coordinated care. ⁶ Community pharmacists have the training and the knowledge to be able to incorporate an assessment of medication adherence within a counseling session and are well positioned to do so as easily accessible members of the health care profession.

Objectives

In order to successfully initiate interventions aimed at improving medication adherence, it is important to first find areas where potential obstacles could occur. This study was aimed to identify the barriers to counseling patients on medication adherence by surveying student pharmacists who were completing a 1-month advanced practice clinical rotation in the community pharmacy setting. Student pharmacists were asked to observe the actions of the pharmacists and patients at their clinical rotation site and to note any perceived barriers with regard to the topic of medication adherence. Student pharmacists were used as the study population because they were able to both observe the actions of their preceptors and participate in counseling sessions themselves. In addition, the students were also considered to be far enough removed from the daily workflow to remain unbiased with regard to company operations and daily stressors within the pharmacy.

Methods

Results

All surveys were collected by and analyzed during the month of February 2012. Of the possible 65 surveyed student pharmacists, 26 (40%) student pharmacists completed the survey in its entirety. The student pharmacists were each assigned to complete their rotations at different store locations although information was not collected on which store the student was at in order to keep the identities of the preceptors blinded to the researchers. There were no statistical differences or correlations noted between the responses of the students from different colleges of pharmacy or based on the student demographics. Most of the students who responded to the survey (65%) all attended the same college of pharmacy. Age of the students ranged from 23 to 36 years; 77% of the respondents were female and 23% were male. Because the students were all completing the survey based on their experiences at the same supermarket chain of pharmacies, it can be assumed that responses would not differ considerably based on the principle that the stores all follow the same policies and procedures.

Discussion

The purpose of this study was to detect and classify existing barriers to counseling patients on medication adherence in the community pharmacy setting. The opinions of student pharmacists are beneficial to this study because they are knowledgeable observers who can provide feedback on their experiences within the pharmacy but are not as integrated as other pharmacy staff as a part of the normal, ongoing operations. This perspective may have allowed the student pharmacists to be less biased than a pharmacist or pharmacy technician who has been working in the same environment for a longer period of time. The main factors cited in this study as barriers to counseling patients on medication adherence include lack of time, lack of specific training in adherence management, lack of resources to provide to the patient, and overall patient disinterest in the subject of medication adherence. By recognizing obstacles that are present in the community pharmacy setting, determining possible solutions to providing medication adherence counseling and management should now be discussed among the pharmacy providers.

This study identified that while pharmacists and pharmacy staff have the knowledge on the importance of medication adherence to share with patients, they also felt that there was a limited amount of both time and resources needed to make the necessary information available to patients. Development of an additional clinical pharmacy program solely focused on medication adherence may not be a practical solution in the community setting if the time and resources are not available to dedicate to the sustainability of such a program. Community pharmacists already have the expertise to address this issue with their patients and could simply make discussing medication adherence with all patients they encounter a part of their daily routine in pharmacy practice. Pharmacists can also help monitor medication adherence by emphasizing the value of the patient’s medications, simplifying regimens, customizing regimens to the patient’s lifestyle, asking patients nonjudgmentally about medication-taking behaviors, clarifying instructions for patients, directing patients toward financial assistance programs, and through education and follow-up. ^2,10 Utilizing more specific techniques such as motivational interviewing in addition to the other types of interventions will allow pharmacists to further develop a partnership with the patient to work toward improving medication adherence rates. ¹¹ It is also important for pharmacists to tailor an adherence plan to meet the specific needs of each patient. Personal attributes of patients affect adherence at an individual level and engaging and supporting patients in improving their adherence is a critical component in improving health outcomes. ¹ Another tool that may be helpful in assisting pharmacists in quickly screening for patient adherence and barriers to adherence are patient questionnaires. The Brief Medication Questionnaire is an example of a self-report tool that asks patients questions on how they took their medicine in the past week, drug effects, and potential difficulties remembering to take their medicines. ¹²

Some of the major factors mentioned previously that end up contributing to patient nonadherence could easily and effectively be reconciled through the use of medication therapy management services (MTMSs) in the community pharmacy setting. Community pharmacists are both well-trained and highly regarded health care professionals who are able and willing to implement extended medication services including pharmaceutical care and pharmacy-based disease state management programs. ⁹ There is a vital need to not only reconcile prescribed regimens for patients with coexisting disease states taking multiple medications but also help the patient understand what they are actually taking and for what reason. ¹ Pharmacists can help improve adherence rates with relatively simple tasks such as helping patients switch therapy to cost-saving alternatives, decreasing pill burden, enrolling into automatic refill/reminder programs, helping patients align refill dates to minimize visits to the pharmacy, or by assisting patients in making effective dosing schedules. Most of these responsibilities are things that pharmacists are trained to do every day without recognizing that these strategies may help patients overcome individual barriers that may be causing them to be nonadherent. This study indicated that student pharmacists felt that they were not adequately trained to manage adherence, yet they were completing a rotation at a supermarket pharmacy chain that provides MTMS at all of its stores. The students may not have been aware that the topic of adherence management was a part of their training for MTMS, as the main focus of the training was on utilization of the MTMS platforms. As part of their orientation, students were trained at the beginning of the month on the MTM procedures and MTMS platforms used at the supermarket chain and were encouraged to participate in MTMS during their rotation even if their store was not actively providing MTMS on a regular basis. Nonadherence is one of the issues that is identified by the MTMS platforms used in the supermarket chain and therefore students were trained during orientation on how to manage these claims. The opinions on the perceived lack of training may have varied had the survey been administered to pharmacists who have been practicing longer and have MTMS incorporated into their practice setting.

Pharmacists in the community setting have a unique opportunity to play a role in improving the rates of medication adherence; however, it was noted in this survey that patients are not currently aware of the importance that adherence has on their overall health or that patients generally do not seem concerned about this topic. National patient advocacy programs such as Script Your Future are working to increase patient awareness of the importance of being adherent to their medications, how to manage nonadherence, and providing patients with resources to help improve their overall health. ¹³ Script Your Future is a multiyear public campaign that focuses on raising awareness of the importance of taking medications as prescribed for patients affected by diabetes, respiratory disease, and cardiovascular disease. The tools and resources available on their Web site (http://scriptyourfuture.org) are beneficial for use with any nonadherent patient, not just those with the featured disease states.

Limitations of this study include a small sample size, low response rate, and the length of time spent at the students’ rotation. All student pharmacists who completed an APPE rotation at the supermarket pharmacy chain in the state of Ohio were included in the survey distribution. The length of time of the students’ rotation may have biased their perceptions of follow-up being performed by their preceptors as the students were only in the location for 1 month. A possibility for future research may include surveying student pharmacists across the country or outside of the supermarket pharmacy chain. Opinions of student pharmacists may differ from those of the pharmacists who are employed by the supermarket pharmacy chain. Responses indicating any feelings of not being adequately trained or not having access to resources may only be accurate for that of the surveyed population and not of pharmacists in general. In addition, data may not be generalizable to other states or community pharmacy chain settings as the study was only performed within 1 supermarket pharmacy chain among a limited market area. The responses of this study are only accurate for the surveyed population, student pharmacists, and not of pharmacists in general and are only accurate for those student pharmacists surveyed. Results could not be extrapolated to include other student pharmacists outside of the study population. A future area for research includes surveying pharmacists who work in the community setting to gather their opinions and perceptions on the barriers to counseling patients on medication adherence. As data on whether or not the computer system was supportive of identifying nonadherence were inconclusive, this may additionally prompt further research of identifying computer support systems that more clearly support the overall assistance in adherence management within the pharmacy.

Conclusion

Most pharmacists attempt to counsel on medication adherence within the pharmacy but do not follow-up with patients to assess continued management. Surveyed students indicate they were constrained for time to counsel patients on adherence and to perform continued follow-up with patients after the initial counseling session or after the patient has left the pharmacy. Providing the patient with the tools to manage adherence at a counseling session may help the patient maintain initial adherence to their regimen, but it has been proven that the most successful long-term interventions have been multifaceted and resource intensive. ¹⁴ This reiterates the need for personalized adherence plans based on the patient’s lifestyle as well as the need for diligence in providing follow-up care to the patients identified as nonadherent. Patients generally respect the profession of pharmacy and their relationship with the pharmacist and building upon and maintaining this mutual respect in the pharmacist–patient relationship will be key to increasing awareness on the importance of medication adherence and will hopefully invite the patients to more openly discuss their difficulties and challenges with adherence with all of their health care providers.