The development and evaluation of pharmacy-led medication adherence services

Keywords Medication adherence, pharmacy services, domiciliary medicines support, health behaviour change, cognitive-based techniques, theoretical domains framework. Background Medication non-adherence has been described as a worldwide problem of striking magnitude yet a gold-standard adherence intervention remains elusive and current interventions elicit modest improvements at best. Innovative, evidence-based approaches, grounded in theory and tailored to meet individual need are therefore required. Methods This thesis included four key elements: (1) a domiciliary medicines support service was evaluated to establish the effect of a pharmacy-led service targeting non-adherence of a primarily unintentional nature. (2) A review of health psychology theory was undertaken to provide a theoretical basis for intervention design. (3) A systematic review and metaanalysis of ‘cognitive-based’ behaviour change techniques designed to improve medication adherence was undertaken to identify effective behaviour change techniques for intentional non-adherence. (4) A theory-based questionnaire to identify barriers to medication adherence was developed as a precursor to an intervention to address patient identified barriers to medication adherence. Results Medication regimen simplification, provision of adherence support and implementation of care packages, appear to be effective in reducing patients’ medication related risk of harm and improving unintentional non-adherence in domiciliary support recipients. However, these findings should be interpreted cautiously due to the ‘before-and-after’ study design. ‘Cognitive-based’ interventions may be capable of eliciting improvements in adherence beyond those yielded with the behavioural and educational interventions that form the mainstay of current practice. The theoretical domains framework has been used successfully to develop a questionnaire to identify medication adherence barriers. Conclusions At present, pharmacy-led adherence interventions tend to focus on resolving adherence difficulties of a practical nature. Whilst these approaches are of some benefit to unintentional non-adherence, intentional non-adherence requires a different approach. ‘Cognitive-based’ behaviour change techniques such as motivational interviewing could be delivered in routine pharmacy consultations to address adherence barriers identified using a theory-based questionnaire

Adherence to medication in adults with Cystic Fibrosis: An investigation using objective adherence data and the Theoretical Domains Framework

Objectives Adherence to nebulizer treatment in adults with Cystic Fibrosis (CF) is poor, and interventions are needed. This research aimed to identify the factors affecting nebulizer adherence using the Theoretical Domains Framework (TDF) and to compare these for participants with different levels of adherence. Design Data‐prompted interviews using the TDF. Methods Eighteen semi‐structured interviews were conducted with adults with CF during which objectively measured adherence data were discussed. Framework analysis was used to code the data into TDF domains, and inductive qualitative content analysis was used to code different beliefs and experiences. Aspects of the TDF that differed between participants with different adherence levels were explored. Results Factors influencing adherence to treatment included all 14 domains of the TDF, 10 of which appeared to vary by adherence level: Skills; Memory and decision‐making; and Behavioural regulation; Environmental context and resources; Social influences; Beliefs about consequences; Beliefs about capability; Reinforcement; Social role and identify; Intentions; Optimism; and Emotions. Conclusions This study is the first to use objectively measured adherence data in a data‐prompted interview using the TDF framework to systematically assess the full range of factors potentially influencing adherence. The results highlighted that interventions need to consider issues of capability, opportunity, and motivation. Interventions that challenge dysfunctional beliefs about adherence and which support the development of routines or habits and problem‐solving may be particularly useful for adults with CF

Psychological interventions for enhancing adherence to disease-modifying therapies (DMTs) in multiple sclerosis

© 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of psychological interventions designed to improve adherence to disease-modifying therapies (DMTs) in adults with multiple sclerosis (MS) in terms of adherence. This will be considered in relation to levels of adherence in a comparison group. Secondary objectives are to assess the impact of interventions on potential predictors of adherence such as motivation, self-efficacy beliefs and healthcare engagement to DMTs adherence

A drop-in clinic for patients with poorly-controlled diabetes: a community pharmacy feasibility study

Background Preparatory work suggests that there may be a role for the pharmacist in managing sub-optimal medication adherence and dose titration of prescribed medicines in patients with type 2 diabetes. Patients have reported that they are receptive towards pharmacists becoming involved in their care providing that this is integrated into the care received from their medical practice. Objective To determine whether a community pharmacy diabetes drop-in clinic is feasible and acceptable to patients with poorly controlled type 2 diabetes. Setting Five community pharmacies in Norfolk, UK. Method Poorly controlled patients, as defined by a national General Practitioner incentive scheme, were invited to participate in the study by a letter posted by their medical practice. One four-hour, pharmacist clinic, where participants were able to "drop-in", was conducted in five pharmacies every week for four to six weeks. Questionnaires before and after the consultation were used to determine the clinic's effect on satisfaction with, and beliefs about, medicines and adherence along with participant satisfaction. Pharmacists had the opportunity to provide feedback via "debrief" interviews. Main outcome measure As a feasibility study, a combination of outcomes were explored including informationsatisfaction and adherence. Results Thirty-three (9.6%) of the 342 patients with type 2 diabetes posted letters were recruited from four pharmacies. Follow-up questionnaire completion rate was 88%. The clinic demonstrated little change in the parameters measured over three months. All of the participants rated their general impression of the service as good or very good and all would be happy to recommend the service to others with diabetes. Sixteen participants (59%) stated that it would make them more likely to consult their pharmacist in the future. Pharmacists enjoyed providing the service as it allowed them to interact more formally, and for longer, with patients. Conclusion This research has demonstrated that a community pharmacy drop-in clinic is feasible and likely to be acceptable to both patients and pharmacists; however, cost effectiveness of such a service should be explored in future studies. Further thought should also be given to how this service can complement that provided by a nurse in the medical practice and how the pharmacist can provide additional benefit to the NHS

Can a Multifaceted Intervention Including Motivational Interviewing Improve Medication Adherence, Quality of Life, and Mortality Rates in Older Patients Undergoing Coronary Artery Bypass Surgery? A Multicenter, Randomized Controlled Trial with 18-Month Follow-Up.

BACKGROUND: Patients undergoing coronary artery bypass graft (CABG) surgery are required to take a complex regimen of medications for extended periods, and they may have negative outcomes because they struggle to adhere to this regimen. Designing effective interventions to promote medication adherence in this patient group is therefore important. OBJECTIVE: The present study aimed to evaluate the long-term effects of a multifaceted intervention (psycho-education, motivational interviewing, and short message services) on medication adherence, quality of life (QoL), and mortality rates in older patients undergoing CABG surgery. METHODS: Patients aged over 65 years from 12 centers were assigned to the intervention (EXP; n = 144) or treatment-as-usual (TAU; n = 144) groups using cluster randomization at center level. Medication adherence was evaluated using the Medication Adherence Rating Scale (MARS), pharmacy refill rate, and lipid profile; QoL was evaluated using Short Form-36. Data were collected at baseline; 3, 6, and 18 months after intervention. Survival status was followed up at 18 months. Multi-level regressions and survival analyses for hazard ratio (HR) were used for analyses. RESULTS: Compared with patients who received TAU, the MARS, pharmacy refill rate, and lipid profile of patients in the EXP group improved 6 months after surgery (p < 0.01) and remained so 18 months after surgery (p < 0.01). QoL also increased among patients in the EXP group as compared with those who received TAU at 18 months post-surgery (physical component summary score p = 0.02; mental component summary score p = 0.04). HR in the EXP group compared with the TAU group was 0.38 (p = 0.04). CONCLUSION: The findings suggest that a multifaceted intervention can improve medication adherence in older patients undergoing CABG surgery, with these improvements being maintained after 18 months. QoL and survival rates increased as a function of better medication adherence. ClinicalTrials.gov NCT02109523

Development of an intervention to increase adherence to nebuliser treatment in adults with cystic fibrosis: CFHealthHub

Background Cystic fibrosis (CF) is a life-limiting genetic condition in which daily therapies to maintain lung health are critical, yet treatment adherence is low. Previous interventions to increase adherence have been largely unsuccessful and this is likely due to a lack of focus on behavioural evidence and theory alongside input from people with CF. This intervention is based on a digital platform that collects and displays objective nebuliser adherence data. The purpose of this paper is to identify the specific components of an intervention to increase and maintain adherence to nebuliser treatments in adults with CF with a focus on reducing effort and treatment burden. Methods Intervention development was informed by the Behaviour Change Wheel (BCW) and person-based approach (PBA). A multidisciplinary team conducted qualitative research to inform a needs analysis, selected, and refined intervention components and methods of delivery, mapped adherence-related barriers and facilitators, associated intervention functions and behaviour change techniques, and utilised iterative feedback to develop and refine content and processes. Results Results indicated that people with CF need to understand their treatment, be able to monitor adherence, have treatment goals and feedback and confidence in their ability to adhere, have a treatment plan to develop habits for treatment, and be able to solve problems around treatment adherence. Behaviour change techniques were selected to address each of these needs and were incorporated into the digital intervention developed iteratively, alongside a manual and training for health professionals. Feedback from people with CF and clinicians helped to refine the intervention which could be tailored to individual patient needs. Conclusions The intervention development process is underpinned by a strong theoretical framework and evidence base and was developed by a multidisciplinary team with a range of skills and expertise integrated with substantial input from patients and clinicians. This multifaceted development strategy has ensured that the intervention is usable and acceptable to people with CF and clinicians, providing the best chance of success in supporting people with CF with different needs to increase and maintain their adherence. The intervention is being tested in a randomised controlled trial across 19 UK sites

Barriers to medication adherence in patients prescribed medicines for the prevention of cardiovascular disease: A conceptual framework to support intervention development

ObjectivesTo identify barriers to medication adherence in patients prescribedmedicines for the prevention of cardiovascular disease and map these to theTheoretical Domains Framework (TDF), to produce a conceptual frameworkfor developing a questionnaire-based medication adherence tool.MethodsA scoping review of barriers to medication adherence in long-termconditions was conducted to generate an initial pool of barriers. After prelimi-nary mapping to the TDF, these barriers were presented to two focus groups ofpatients prescribed medicines for the prevention of cardiovascular disease(n=14) to stimulate discussion. The group discussions enabled the patients’interpretations of the adherence barriers to be determined, provided validityfrom the patient perspective and identified additional barriers unrepresented inthe scoping review.Key findingsThe preliminary pool of adherence barriers was identified from 47studies across a range of long-term conditions. The majority of TDF domainswere represented by these literature-identified barriers except ‘social/professionalrole and identity’ and ‘behavioural regulation’. Barrier mapping was largelyendorsed by focus group participants, who also contributed additional barriers,including those relating to not having a ‘system’ in place for managing theirmedicines and the negative emotions evoked by medicine taking.ConclusionThe TDF enabled full exploration of adherence barriers includingthose relating to emotions which have received limited attention in the litera-ture. This work has provided a conceptual framework for developing a ques-tionnaire to identify an individual’s adherence barriers which may then becoupled with appropriate behaviour change techniques to deliver a theory-based intervention tailored for individual need

Barriers to medication adherence in patients prescribed medicines for the prevention of cardiovascular disease: a conceptual framework

Objectives To identify barriers to medication adherence in patients prescribed medicines for the prevention of cardiovascular disease and map these to the Theoretical Domains Framework (TDF), to produce a conceptual framework for developing a questionnaire‐based medication adherence tool. Methods A scoping review of barriers to medication adherence in long‐term conditions was conducted to generate an initial pool of barriers. After preliminary mapping to the TDF, these barriers were presented to two focus groups of patients prescribed medicines for the prevention of cardiovascular disease (n = 14) to stimulate discussion. The group discussions enabled the patients’ interpretations of the adherence barriers to be determined, provided validity from the patient perspective and identified additional barriers unrepresented in the scoping review. Key findings The preliminary pool of adherence barriers was identified from 47 studies across a range of long‐term conditions. The majority of TDF domains were represented by these literature‐identified barriers except ‘social/professional role and identity’ and ‘behavioural regulation’. Barrier mapping was largely endorsed by focus group participants, who also contributed additional barriers, including those relating to not having a ‘system’ in place for managing their medicines and the negative emotions evoked by medicine taking. Conclusion The TDF enabled full exploration of adherence barriers including those relating to emotions which have received limited attention in the literature. This work has provided a conceptual framework for developing a questionnaire to identify an individual's adherence barriers which may then be coupled with appropriate behaviour change techniques to deliver a theory‐based intervention tailored for individual need

Developing person-centred consultation skills within a UK hospital pharmacy service: evaluation of a pilot practice-based support package for pharmacy staff

A person-centred approach to care is central to NHS England’s health policy agenda and a standard for pharmacy practice from the General Pharmaceutical Council. Health coaching is a method of delivering person-centred care. A pilot of a health coaching support package, including a 2-day course and practice-based follow-up, was delivered to 70 London North West Healthcare NHS Trust pharmacy staff between December 2015 and July 2017. Objectives: To evaluate the support package, identifying key themes from course feedback, evaluating staff perception and evidence of application in practice. To identify key benefits of the support package. Methods: Qualitative analysis of written course feedback was undertaken to identify staff learning themes about person-centred care. The themes were used to design a survey, administered to support package recipients (staff), exploring staff perception of the package. Qualitative review of written examples highlighted use of person-centred themes in practice. Results: Twelve person-centred themes emerged from 49 course evaluations forms, describing what participants learnt about patient-centred care. Of 24 surveys completed, respondents reported increased awareness of themes; however, use in practice varied between themes. Overall, respondents valued the support package and rated practice-support more highly than the course for ongoing development. Patient examples described the use of themes in practice. Conclusions: The support package increased awareness of person-centred themes, portrayed within the practice examples submitted. While the course provided a foundation for use of a person-centred approach, continuing practice-based support is desired by staff to embed learning into day-to-day practice

A meta-analysis of cognitive-based behaviour change techniques as interventions to improve medication adherence

Objective To describe and evaluate the use of cognitive-based behaviour change techniques as interventions to improve medication adherence. Design Systematic review and meta-analysis of interventions to improve medication adherence. Data sources Search of the MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Library databases from the earliest year to April 2013 without language restriction. References of included studies were also screened to identify further relevant articles. Review methods We used predefined criteria to select randomised controlled trials describing a medication adherence intervention that used Motivational Interviewing (MI) or other cognitive-based techniques. Data were extracted and risk of bias was assessed by two independent reviewers. We conducted the meta-analysis using a random effects model and Hedges’ g as the measure of effect size. Results We included 26 studies (5216 participants) in the meta-analysis. Interventions most commonly used MI, but many used techniques such as aiming to increase the patient's confidence and sense of self-efficacy, encouraging support-seeking behaviours and challenging negative thoughts, which were not specifically categorised. Interventions were most commonly delivered from community-based settings by routine healthcare providers such as general practitioners and nurses. An effect size (95% CI) of 0.34 (0.23 to 0.46) was calculated and was statistically significant (p?<?0.001). Heterogeneity was high with an I2 value of 68%. Adjustment for publication bias generated a more conservative estimate of summary effect size of 0.21 (0.08 to 0.33). The majority of subgroup analyses produced statistically non-significant results. Conclusions Cognitive-based behaviour change techniques are effective interventions eliciting improvements in medication adherence that are likely to be greater than the behavioural and educational interventions largely used in current practice. Subgroup analyses suggest that these interventions are amenable to use across different populations and in differing manners without loss of efficacy. These factors may facilitate incorporation of these techniques into routine care