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Hidden blockbuster?

Increasing medicines adherence is a win-win situation for patients' health and pharma's profits

Round white pills There is strong evidence that, despite the introduction of new medicines, which have fewer side effects and are more convenient to use, many people still do not take them as prescribed, even when this can have life-threatening consequences. Health Information worked with pharmacy partners on a 200,000-patient study to examine the effects on patient compliance when pharmacists provided information that patients wanted.

Overview
Between 40 and 70 per cent of patients stop taking life-long medicines within 12 months of starting them. Between 33 and 50 per cent of some cancer patients take less of their anti-cancer medicine than they need to. Medicines prescribed for prevention purposes are least likely to be taken as prescribed. This may be because people do not feel immediately threatened and, in the case of symptom-less conditions such as raised cholesterol levels and hypertension, they feel no obvious benefit when medicines are taken. Only a quarter of coronary heart disease (CHD) patients take enough medication for it to be effective. Yet prevention is the core driver in the NHS Plan.

It is hard to exaggerate the cost to individuals' health, the cost in lives and the cost to society of poor understanding and non-adherence. For example, if CHD patients would learn about, and adhere to, their medication, 40,000 to 50,000 fewer people every year would have a stroke, and 25,000 would not have a heart attack.

As a result, Health Information is pioneering Pharmacy Patient Compliance Programmes to alleviate these problems.

The results of the study undertaken by Health Information showed that where a HealthInformation.nhs.uk leaflet was given to the patient and "sometimes" talked through, there was an increase in adherence of between 16 and 33 per cent within six months, over and above pharmacies that did not support the patient.

The elderly
Poor health is more common among the elderly. Around half of all NHS medicines are prescribed for people over retirement age, although they represent only about 20 per cent of the UK population. The National Service Framework on the care of older people highlighted the importance of medicine taking and effective medicines management in this section of the community.

Elderly patients are more likely than average members of the overall population to:
• Be living alone
• Have a lower literacy level than other age groups
• Be taking multiple medicines with high dose frequencies
• Have decreased dexterity and/or cognitive functioning.

The average over-65-year-old has to manage 35 prescribed medicines each year.

Despite receiving written and verbal information:
• 27 per cent of older people discharged from hospital after heart failure were classed as non-adherent within 30 days
• 50 per cent of elderly patients surveyed could not recall the dose of their medication
• Nearly two-thirds did not know what time of day to take it
• 40 per cent did not know the purpose of their medication
• Only 20 per cent knew the consequences of non-adherence
• Less than 6 per cent knew about the possible side effects of the drugs prescribed for them.

This underlines the need for ongoing, consistent patient support.

Up to two-thirds of elderly patients render their medications useless by taking them at the wrong times. With the average elderly person juggling so many medications over a year, they are imposing side effects on themselves unnecessarily. A conservative estimate states that 10 per cent of all hospital admissions result from patients not managing their medications. The cost to life, health and happiness is almost impossible to overstate.

In the study, all patients who presented a hormone replacement therapy (HRT) script in 100 pharmacies were supported with a leaflet, while the HRT patients in the control group of 100 pharmacies were unsupported. Of those patients who received a leaflet and "sometimes" an introduction by the pharmacist, the comparative uplift in sales was 33 per cent.

Cholesterol management
In cholesterol management, only a third of patients take at least 90 per cent of their lipid-lowering treatment. Adherence in statins drops to between 25 and 40 per cent after two years. Patients taking statins for what they perceive to be preventative reasons are unusually poor compliers.

Among type 2 diabetes patients, adequate adherence is found in less than one third of those prescribed sulphonylureas and/or metformin. Patients taking both drugs achieve only 13 per cent adherence.

Because of poor adherence to antihypertensive treatment, approximately 75 per cent of patients with a diagnosis of hypertension do not achieve optimum blood-pressure control. Only 28 per cent of patients treated for diabetes achieve good glycaemic control.

Complications
Patients who do not adhere to beta-blockers are 4.5 times more likely to have complications of CHD than those who do.

Those who have suffered a stroke or heart attack frequently experience disability and worse health. Between 15 and 50 per cent of stroke patients suffer with severe depression. A total of 20 per cent go on to develop dementia as a result of the stroke. Faecal incontinence is common after a severe stroke, resulting in individual and familial stress. Five per cent have untreatable severe pain that dominates their lives, and the list goes on.

In the study, all patients presenting prescriptions with statins were supported within the active pharmacies, while no patients were supported in the control group. In those supported there were uplifts of up to 25 per cent.

The evidence for a correlation between education and physical health is robust. Poor educational attainment is a key factor in the cycle of health inequalities.

Educational qualifications help to determine people's position in the labour market, their level of income and therefore their access to resources.

Basic skills

In the UK, 20 per cent of adults – or nearly seven million people – have problems with basic skills, especially functional literacy and functional numeracy, which makes the taking of medication, reading of labels, following of drug regimes, and finding out more information, impossible.

Low levels of literacy and numeracy are associated with socio-economic deprivation.

One in five of us has a long-standing illness or disability. However, more than one third of people with poor or very poor health have literacy skills of entry level 3 or below.

The study showed that it was those patients in the poorest sector (class C, D and E) of society that respond most to the pharmacist's active intervention. Class A and B patients who were fully supported (where the pharmacist sometimes introduced the leaflet), experienced a significant uplift, but only slightly more than those class A and B patients who received the leaflet with no pharmacist engagement.

In comparison, for classes C, D and E, the pharmacist's personal engagement with the patient was found to be crucial.

Mental health
Regarding mental health, less than 27 per cent of depressed patients adhere to their medication. Between 41 and 59 per cent of mentally ill patients take their medication infrequently or not at all. A total of 33 per cent of patients with schizophrenia do not take their medicine at all and 33 per cent are poor at taking it.

Patients taking typical antipsychotics tend to experience more severe side effects and are also less likely to receive information about their illness, medicines and side effects. They are, therefore, predictably more likely to be non-compliant than those receiving atypicals.

Non-adherent schizophrenic patients are 3.7 times more likely to relapse than patients who take their medication.

Clear correlation
There is a clear correlation between adherence with medication regimens and relapse rates, hospitalisation rates, re-hospitalisation rates, the incidence of serious unwanted events including suicides and violence.

In the study, all patients presenting with the antidepressant Selective Serotonin Re-uptake Inhibitors (SSRIs) were supported in the active pharmacies and no patients in the control group were supported. In those supported, there were uplifts of up to 20 per cent.

Unlocking the blockbuster
With 40 to 70 per cent of patients stopping their long-term medicines, pharma companies need to recruit thousands of new patients every month just to stand still. If they can retain 90 per cent of patients, the resultant growth experienced will give many their hidden blockbuster.

All drugs averaged across all demographics

All drugs averaged across all demographics

Example attrition rate with and without health information

Example attrition rate with and without health information

Example monthly sales with and without health information

Example monthly sales with and without health information


The Author
Dr Grace Lomax is founder and managing director of Health Information Ltd. She can be emailed at drlomax@healthinformation.uk.net
To comment on this article, email pm@pmlive.com

7th July 2009

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