Why patients do not take medication as prescribed: The complexity of medication adherence as a phenomenon

Poor medication adherence is a significant barrier to achieving the expected outcomes of a treatment. The prevalence of chronic diseases is increasing globally, and within ageing populations, both morbidity and use of medicines increase. Only about 50% of patients are estimated to treat their chronic diseases according to instructions in developed countries. Patients with multiple conditions and multiple medications are particularly challenging to healthcare professionals. A common feature of poor adherence is a tendency to stop taking the medication within a few months after the provider has prescribed it. In addition, the patients may not take the medicine as regularly as prescribed and skip doses or take lower or higher doses than prescribed. This study aimed to enhance understanding of the complexity of medication adherence as a phenomenon by studying why patients do not take their medication as prescribed. The goal was to collect information on the factors influencing medication adherence by summarizing research evidence obtained using qualitative methods (Study I) and investigating primary care physicians’ and patients’ perspectives (Studies II and III). Study I was a scoping review of qualitative studies (n=89). The literature search for eligible qualitative studies was conducted on September 23, 2019, and updated on June 9, 2021, using MEDLINE (Ovid), Scopus, and the Cochrane Library. The focus was on patients' experiences and attitudes towards medication adherence. The use of qualitative methods both for data collection and data analysis was mandatory. We used the PRISMA-ScR checklist to ensure the quality of the scoping review. Study II applied the focus group discussions (n=4) for primary care physicians (GPs, n=16). The study was conducted in the Kirkkonummi Health Centre, Southern Finland. The qualitative design was chosen to understand GPs' perceptions of medication adherence and the problems GPs thought patients might have experienced following instructions for their medicine taking. An interview guide of semi-structured questions was used to allow the GPs to discuss the topic from a personal point of view. Study III presents a study protocol of a new patient-oriented method to investigate reasons for non-adherence using pharmacist-conducted medication reconciliation in the primary care clinics as a data collection point. The study is based on pharmacist-patient communication during medication reconciliation. It will be carried out in the public primary care clinics in Vantaa, located in the capital region of Finland. By interviewing, the pharmacist will learn how the patient has been taking the prescribed medicines and whether any non-prescription medicines and food supplements have been used for self-medication. Patients aged 55 years or older will be included, as they most commonly have multiple medications and illnesses. Medication reconciliation will occur upon admission to the public outpatient clinic, usually before a physician's appointment. The search (Study I) revealed 4404 studies, of which 89 qualitative studies were included in the scoping review. The studies more often dealt with barriers than facilitators. The factors were classified as patient-specific, illness-specific, medication-related, healthcare and system-related, sociocultural, logistical, and financial. Information and knowledge of diseases and their treatment, communication, trust in patient-provider relationships, support, and adequate resources appeared to be the critical facilitators in medication adherence from the patient perspective. Patients were willing to discuss their concerns about medications. Better communication and better information on medicines appeared to be critical factors for patients. The two main themes that emerged in the focus group discussions with the GPs (Study II) were non-adherence in chronic disease care and increased need for information about medicines. The GPs (n=16) were increasingly confronted with non-adherence in the care of chronic diseases. The medication management challenges identified were related to patient-specific factors, the healthcare system, characteristics of drug therapies and the function and role of healthcare professionals as a team. The GPs offered several solutions such as improved coordination of care, better patient education and IT systems, and enhanced interprofessional involvement in the follow-up of patients. To support medication adherence and self-management, the GPs appreciated pharmacists' assistance, especially with patients with polypharmacy and chronic diseases. Study III will provide quantitative data for descriptive analysis to identify: 1) the number of discrepancies between the physician's prescription orders and the patient's self-reported use of the medicines, 2) what kind of discrepancies there are, 3) which are high-risk medicines in terms of non-adherence, and 4) why medicines were taken differently than prescribed. Based on the results, 5) a preliminary conceptual model of patient-reported reasons for non-adherence will be constructed. There is a wide range of barriers and facilitators to medication adherence, but barriers seem to be better known than facilitators. Better communication and information appear to be the most crucial factors in enhancing medication adherence. Patients wish to discuss their worries about medications. Medication reconciliation could be used more effectively to monitor medication adherence and prevent the inappropriate use of medicines in routine clinical practice. Based on the findings of this doctoral thesis, it is possible to continue developing a theoretical model related to adherence. The model could consider previous theories related to medication adherence, patient perspective and the research evidence constructed by qualitative methods. Developing new interventions should be based on an enhanced understanding of the patient's perspectives on medication adherence.Huono lääkehoitoihin sitoutuminen on maailmanlaajuinen ongelma. Väestön ikääntyessä sairastavuus ja lääkkeiden käyttö lisääntyvät. On arvioitu, että vain noin 50 % potilaista hoitaa pitkäaikaista sairauttaan ohjeiden mukaisesti. Erityisen haastavassa asemassa ovat potilaat, joilla on useita sairauksia ja useita lääkehoitoja. Tämän tutkimuksen tavoitteena oli lisätä ymmärrystä lääkehoitoihin sitoutumisesta ilmiönä järjestelmällisen kartoittavan katsauksen avulla (osatyö I) sekä tutkimalla lääkkeiden ohjeidenmukaista käyttöä perusterveydenhuollon lääkäreiden ja potilaiden näkökulmasta (osatyöt II ja III). Osatyössä I kartoitettiin potilaiden lääkehoitoon sitoutumiseen vaikuttavia tekijöitä laadullisten tutkimusten perusteella (n=89). Tutkimuksista tunnistettiin potilaisiin, sairauteen, lääkkeisiin, terveydenhuoltoon ja järjestelmään liittyviä tekijöitä sekä sosiokulttuurisia ja logistisia ja taloudellisia tekijöitä. Tutkimuksista tunnistettiin enemmän hoitoon sitoutumista estäviä kuin edistäviä tekijöitä. Osa tutkimuksista (n=17) oli käyttäytymisteorioihin perustuvia. Sairauteen ja sen hoitoon liittyvät tiedot ja taidot, kommunikaatio, potilaan ja terveydenhuollon ammattilaisen välinen luottamus, tuki ja riittävät resurssit näyttäisivät olevan potilaan näkökulmasta avaintekijöitä. Tärkeiksi tekijöiksi tiivistyivät potilaan ja ammattilaisen välinen kommunikaatio sekä lääkeneuvonta. Huono lääkehoitoihin sitoutuminen ja lääkeneuvonnan tarve nousivat pääteemoiksi terveyskeskuslääkäreiden ryhmäkeskusteluissa (n=4) (osatyö II). Lääkärit (n=16) havaitsivat hoitoon sitoutumiseen liittyviä haasteita hoitaessaan pitkäaikaissairauksia. Haasteet liittyivät potilaaseen, terveydenhuoltojärjestelmään, lääkehoitoihin, terveydenhuollon ammattilaisten yhteistyöhön ja rooliin. Lääkärit ehdottivat ratkaisuiksi parempaa hoidon koordinointia, potilaiden kouluttamista, parempia tietojärjestelmiä sekä moniammatillisuutta potilaiden lääkehoitojen seurannassa. Lääkärit toivoivat farmasian ammattilaisten osallistumista erityisesti monilääkittyjen ja monisairaiden potilaiden lääkehoitoon sitoutumisen ja omahoidon tukemiseen. Osatyö III on tutkimussuunnitelma lääkärin määräämien ja potilaan todellisuudessa käyttämien lääkkeiden välisten erojen tutkimiseksi. Kotilääkitysten selvittämisen yhteydessä käydyn keskustelun perusteella halutaan tutkia, minkälaisia eroavaisuudet ovat, mitkä ovat hoitoon sitoutumisen kannalta suuren riskin lääkkeitä ja miksi potilaat käyttävät lääkkeitä toisin kuin lääkäri on määrännyt. Tutkimuksen tarkoituksena on luoda toimintamalli, jonka avulla voidaan edistää parempaa lääkehoitoon sitoutumista kroonisten sairauksien hoidossa. Lääkehoitoon sitoutuminen on monimutkainen ilmiö, johon liittyy monia estäviä ja edistäviä tekijöitä. Tämä väitöskirjatutkimus auttaa ymmärtämään hoitoon sitoutumisen monimutkaisuutta laadullista ja potilaslähtöistä tutkimusnäkökulmaa hyödyntäen. Potilaat haluavat keskustella lääkkeisiin liittyvistä huolistaan. Tilanteen korjaamiseksi tarvitsemme parempaa potilaan ja terveydenhuollon ammattilaisten välistä kommunikaatiota ja informaatiota. Tämän väitöskirjatutkimuksen tulosten perusteella on mahdollista jatkaa hoitoon sitoutumiseen liittyvän teoreettisen mallin kehittämistä. Mallissa voitaisiin ottaa huomioon aikaisemmat lääkehoitoon sitoutumiseen liittyvät teoriat, potilasnäkökulma ja laadullisin menetelmin koottu tutkimusnäyttö. Potilaan näkemysten ja tilanteen huomioiminen on avainasemassa, kun lääkehoitoon sitoutumiseen tähtääviä toimintamalleja kehitetään

Factors Contributing to Medication Adherence in Patients with a Chronic Condition : A Scoping Review of Qualitative Research

Introduction: Medication adherence continues to be a significant challenge in healthcare, and there is a shortage of effective interventions in this area. This scoping review studied the patient-related factors of medication adherence. Methods: We searched Medline Ovid, Scopus, and Cochrane Library from January 2009 to June 2021 to find the most recent original qualitative studies or systematic reviews that addressed the patient-related factors of medication adherence in treating chronic conditions. We used the PRISMA-ScR checklist to ensure the quality of the study. Results: The initial search revealed 4404 studies, of which we included 89 qualitative studies in the scoping review. We inductively organized the patient-related factors causing barriers, as well as the facilitators to medication adherence. The studies more often dealt with barriers than facilitators. We classified the factors as patient-specific, illness-specific, medication-related, healthcare and system-related, sociocultural, as well as logistical and financial factors. Information and knowledge of diseases and their treatment, communication, trust in patient-provider relationships, support, and adequate resources appeared to be the critical facilitators in medication adherence from the patient perspective. Discussion and conclusions: Patients are willing to discuss their concerns about medications. Better communication and better information on medicines appear to be among the critical factors for patients. The findings of this scoping review may help those who plan further interventions to improve medication adherence.Peer reviewe

Why medicines are used differently from prescribed : a protocol for a prospective patient-oriented observational case study to investigate reasons for non-adherence in primary care

Publisher Copyright: © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.INTRODUCTION: Patients do not always tell the physician if they have used medicines differently from prescribed. The challenges that patients experience in medication self-management and adherence have been prioritised globally as among the most crucial factors influencing the effectiveness and safety of pharmacotherapies. METHODS AND ANALYSIS: This study protocol presents a new patient-oriented method to investigate reasons for non-adherence using pharmacist-conducted medication reconciliation in a primary care clinic as data collection point. By interviewing, the pharmacist will learn how the patient has been taking the prescribed medicines and whether any non-prescription medicines and food supplements have been used for self-medication. The pharmacist will document the findings of the conversation to the electronic patient record in a structured format. The pharmacist will collect data related to the characteristics of the patients and outpatient clinics, patients' diseases and medications, and medication discrepancies. These data will be analysed for descriptive statistics to identify (1) the number of discrepancies between the physician's prescription orders and the patient's self-reported use of the medicines, (2) what kind of discrepancies there are, (3) which are high-risk medicines in terms of non-adherence and (4) why medicines were taken differently from prescribed; based on the results, (5) a preliminary conceptual model of patient-reported reasons for non-adherence will be constructed. TRIAL REGISTRATION NUMBER: NCT05167578.Peer reviewe

A Focus Group Study about Oral Drug Administration Practices at Hospital Wards—Aspects to Consider in Drug Development of Age-Appropriate Formulations for Children

Oral drug administration to pediatric patients is characterized by a lack of age-appropriate drug products and the off-label use of medicines. However, drug administration practices at hospital wards is a scarcely studied subject. The aim of this study was to explore the oral drug administration practices at pediatric hospital wards, with a focus on experiences and challenges faced, methods used to mitigate existing problems, drug manipulation habits, perceptions about oral dosage forms and future needs of oral dosage forms for children. This was a qualitative study consisting of focus group discussions with physicians, nurses and clinical pharmacists in a tertiary university hospital with the objective of bringing forward a holistic view on this research topic. These healthcare professionals recognized different administration challenges that were classified as either dosage form-related or patient-related ones. A lack of depot formulations developed especially for children as well as oral pediatric dosage forms of drug substances currently available as intravenous dosage forms was recognized. The preferred oral dosage forms were oral liquids and orodispersible tablets. Patient-centered drug administration practices including factors facilitating drug administration both at hospital wards and at home after patient discharge were identified. Among all healthcare professionals, the efficient cooperation in drug prescribing and administration as well as in educating the child’s caregivers in correct administration techniques before discharge and improving the overall discharge process of patients was emphasized. This study complements the prevalent understanding that new dosage forms for children of varying ages and stages of development are still needed. It also brings a holistic view on different aspects of oral drug administration to pediatric patients and overall patient-centered drug administration practices

A Focus Group Study about Oral Drug Administration Practices at Hospital Wards—Aspects to Consider in Drug Development of Age-Appropriate Formulations for Children

Oral drug administration to pediatric patients is characterized by a lack of age-appropriate drug products and the off-label use of medicines. However, drug administration practices at hospital wards is a scarcely studied subject. The aim of this study was to explore the oral drug administration practices at pediatric hospital wards, with a focus on experiences and challenges faced, methods used to mitigate existing problems, drug manipulation habits, perceptions about oral dosage forms and future needs of oral dosage forms for children. This was a qualitative study consisting of focus group discussions with physicians, nurses and clinical pharmacists in a tertiary university hospital with the objective of bringing forward a holistic view on this research topic. These healthcare professionals recognized different administration challenges that were classified as either dosage form-related or patient-related ones. A lack of depot formulations developed especially for children as well as oral pediatric dosage forms of drug substances currently available as intravenous dosage forms was recognized. The preferred oral dosage forms were oral liquids and orodispersible tablets. Patient-centered drug administration practices including factors facilitating drug administration both at hospital wards and at home after patient discharge were identified. Among all healthcare professionals, the efficient cooperation in drug prescribing and administration as well as in educating the child’s caregivers in correct administration techniques before discharge and improving the overall discharge process of patients was emphasized. This study complements the prevalent understanding that new dosage forms for children of varying ages and stages of development are still needed. It also brings a holistic view on different aspects of oral drug administration to pediatric patients and overall patient-centered drug administration practices

HIV-potilaiden lääkeneuvonnan erityispiirteet ja farmaseuttien osaamistarpeet sairaala-apteekin avoapteekissa

Johdanto Ihmisen immuunikatovirus (HIV) on nykyään krooninen sairaus, jonka hoidon onnistumisen edellytyksenä on potilaan sitoutuminen lääkehoitoonsa. HIV-infektiolääkkeet toimitetaan yleensä sairaala-apteekista. Tämän tutkimuksen tavoitteena oli selvittää HUS Apteekin avoapteekissa asioiville HIV-infektiota sairastaville potilaille annettavan lääkeneuvonnan erityispiirteitä ja lääkeneuvontaa antavien farmaseuttien osaamistarpeita. Aineisto ja menetelmät Tutkimus toteutettiin HUS Apteekin avoapteekin farmaseuteille keväällä 2020. Tutkimusme- netelmäksi valittiin sekä kvantitatiivinen kysely että laadullinen teemoitettu ryhmähaastattelu. Kysely mahdollisti vastausten saamisen mahdollisimman monelta tutkimusjoukon farmaseutilta anonyymisti. Kvalitatiivisen ryhmähaastattelun avulla syvennettiin verkkokyselyssä saatuja tie- toja. Ryhmähaastattelu nauhoitettiin ja litteroitiin, minkä jälkeen aineisto analysoitiin indukti- ivisen sisällönanalyysin kautta. Tulokset Kyselyyn (n=6) ja haastatteluun (n=3) osallistuneiden farmaseuttien mukaan HIV-hoitokäytän- töjen osaaminen on lääkeneuvonnan perusta. HIV-lääkeneuvonnan erityispiirteiksi tunnistet- tiin hoitoon sitoutumisen tärkeys ja sen tukeminen lääkeneuvontatilanteessa. Potilaiden häpeä sairaudesta ja leimautumisen pelko voivat aiheuttaa haasteita lääkeneuvonnalle. HUS Apteekin asiakaskunta on laaja ja monikulttuurinen, ja HIV-potilaiden ikääntyessä riski monilääkitykselle lisääntyy. Potilaan kokonaislääkityksen hallinta saattaa olla hankalaa, koska sairaala-apteekin farmaseuteilla ei ole vielä pääsyä reseptikeskukseen eivätkä lääkereseptit ole sähköisiä. Potilaat hakevat muut lääkkeet avohuollon apteekeista, joissa ei myöskään ole tietoa potilaan HIV-lää- kityksestä. Farmaseutit kokivat oman perusosaamisensa perehdytyksen jälkeen riittäväksi, mutta kai- pasivat päivittyvää tietoa erityisesti HIV-lääkehoidon erityistilanteista, kuten raskaana olevien, lasten ja nuorten sekä AIDS-vaiheen potilaiden lääkehoidoista. Tietokantojen ja -lähteiden käy- tön lisäksi lääkeneuvontaan toivottiin työkaluiksi helppokäyttöisiä piktogrammeja ja potilasoh- jeita eri kielillä. Johtopäätökset HIV-potilaiden lääkeneuvonta vaatii monenlaista osaamista ja osaamisen jatkuvaa kehittämistä. HUS Apteekin farmaseuttien osaaminen on heidän oman käsityksensä mukaan hyvällä tasolla, mutta tukea, työkaluja ja lisäkoulutusta tarvitaan etenkin päivittyvien hoitokäytäntöjen ja eri- tyisryhmien lääkehoidon osalta. Farmaseutin vastaanottomallin kehittäminen sekä uusien tie- tojärjestelmien mahdollistamat farmaseuttien lääkehoitojen eritasoiset tarkistukset ja arvioinnit voisivat tulevaisuudessa olla osa HUS Apteekin avoapteekin tarjoamia farmaseuttisia palveluita.Peer reviewe

A Focus Group Study about Oral Drug Administration Practices at Hospital Wards-Aspects to Consider in Drug Development of Age-Appropriate Formulations for Children

Oral drug administration to pediatric patients is characterized by a lack of age-appropriate drug products and the off-label use of medicines. However, drug administration practices at hospital wards is a scarcely studied subject. The aim of this study was to explore the oral drug administration practices at pediatric hospital wards, with a focus on experiences and challenges faced, methods used to mitigate existing problems, drug manipulation habits, perceptions about oral dosage forms and future needs of oral dosage forms for children. This was a qualitative study consisting of focus group discussions with physicians, nurses and clinical pharmacists in a tertiary university hospital with the objective of bringing forward a holistic view on this research topic. These healthcare professionals recognized different administration challenges that were classified as either dosage form-related or patient-related ones. A lack of depot formulations developed especially for children as well as oral pediatric dosage forms of drug substances currently available as intravenous dosage forms was recognized. The preferred oral dosage forms were oral liquids and orodispersible tablets. Patient-centered drug administration practices including factors facilitating drug administration both at hospital wards and at home after patient discharge were identified. Among all healthcare professionals, the efficient cooperation in drug prescribing and administration as well as in educating the child's caregivers in correct administration techniques before discharge and improving the overall discharge process of patients was emphasized. This study complements the prevalent understanding that new dosage forms for children of varying ages and stages of development are still needed. It also brings a holistic view on different aspects of oral drug administration to pediatric patients and overall patient-centered drug administration practices.Peer reviewe

Strategies for improving medication safety in hospitals: Evolution of clinical pharmacy services

Background Medication safety risks are the most important preventable factors jeopardizing patient safety. To manage these risks, extending pharmacists’ involvement in patient care and patient safety work has been systematically addressed in patient safety initiatives since the early 2000s. Objective To explore the extent and range of clinical pharmacy services in Finnish hospitals to promote medication safety: 1) in 2011, when the first National Patient Safety Strategy, the new Health Care Act and the Medicines Policy 2020 had been recently enacted; and 2) five years later in 2016. Methods The study was conducted in 2011 and 2016 as a national online survey targeted to hospital pharmacies (n = 24) and medical dispensaries (n = 131 in 2011; n = 28 in 2016). The questions were analyzed using descriptive statistics and qualitative content analysis. Results Overall response rate was 60% in 2011 and 52% in 2016. Clinical pharmacy services were provided by 51% of the responding units in 2011, whereas by 85% in 2016. The reported number of clinical pharmacists had increased during the five years. The most notable increase in reported tasks occurred in conducting medication reconciliations (+63% increase in the number of providing units). By 2016 pharmacists had extended their tasks particularly towards system-based medication safety work: e.g. developing instructions for medication-use (91% of the responding units), creating and updating medication safety plans (87%) and using medication error reports in developing the process of medication use safer (78%). Pharmacists’ participation in long-term continuing education became more common in 2016, which was perceived as helpful in extending their responsibilities to improve medication safety. Conclusion Pharmacists’ involvement in patient care and system-based medication safety work was reported to become more common in Finnish hospitals during 2011–2016. This development is in line with patient safety policy initiatives and its impact on patient care outcomes should be followed up.Peer reviewe

Benefits and Prerequisites Associated with the Adoption of Oral 3D-Printed Medicines for Pediatric Patients : A Focus Group Study among Healthcare Professionals

The utilization of three-dimensional (3D) printing technologies as innovative manufacturing methods for drug products has recently gained growing interest. From a technological viewpoint, proof-of-concept on the performance of different printing methods already exist, followed by visions about future applications in hospital or community pharmacies. The main objective of this study was to investigate the perceptions of healthcare professionals in a tertiary university hospital about oral 3D-printed medicines for pediatric patients by means of focus group discussions. In general, the healthcare professionals considered many positive aspects and opportunities in 3D printing of pharmaceuticals. A precise dose as well as personalized doses and dosage forms were some of the advantages mentioned by the participants. Especially in cases of polypharmacy, incorporating several drug substances into one product to produce a polypill, personalized regarding both the combination of drug substances and the doses, would benefit drug treatments of several medical conditions and would improve adherence to medications. In addition to the positive aspects, concerns and prerequisites for the adoption of 3D printing technologies at hospital settings were also expressed. These perspectives are suggested by the authors to be focus points for future research on personalized 3D-printed drug products.Peer reviewe

Lääkitysturvallisuuden kansallisen koordinaation tarve Suomessa

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