|Year : 2020 | Volume
| Issue : 1 | Page : 39-44
Pharmacist’s contribution to medication adherence among patients with type 2 diabetes in endocrinology clinic
Winifred A Ojieabu
Department of Clinical Pharmacy and Biopharmacy, Faculty of Pharmacy, Olabisi Onabanjo University, Ago Iwoye, Ogun State, Nigeria
|Date of Submission||28-Apr-2019|
|Date of Decision||15-Jun-2019|
|Date of Acceptance||09-Jul-2019|
|Date of Web Publication||18-Dec-2019|
Dr. Winifred A Ojieabu
Department of Clinical Pharmacy and Biopharmacy, Faculty of Pharmacy, Olabisi Onabanjo University, Ago Iwoye, Ogun State.
Source of Support: None, Conflict of Interest: None
Background: Elderly people are prone to have chronic diseases requiring continuous medications. Adherence is a key factor in managing these patients. Improved adherence to medicines has a positive impact on the reduction of their hospital visits and health-related quality of life. Objective: This study investigated the potential of the pharmacists to improve medication adherence and to optimize treatment outcomes among patients with type 2 diabetes. Materials and Methods: A randomized controlled study comprising patient- and physician-focused intervention was carried out at the endocrinology clinic of Olabisi Onabanjo University Teaching Hospital in Nigeria. At baseline and six months, each group had 75 eligible patients. Patient’s self-reported adherence level to medications was assessed with modified Morisky four-item adherence scale, clinical variables were determined, and the likely reasons for nonadherence and required information were assessed. Outcome measures: Variation in adherence scores, mean clinical variables and improved patients’ knowledge base. Results: No significant differences were observed in adherence scores between control and intervention groups at baseline. High and low adherence scores in both groups were 33.3% versus 36.0% (P = 0.873) and 26.7% versus 25.3% (P = 1.000), respectively. Patients’ response at the end of intervention revealed significant score differences across board between the groups. High and low adherence scores in both groups were 34.7% versus 88.0% (P = 0.001) and 21.3% versus 2.7% (P = 0.002), respectively. Conclusion: The intervention was successful in improving adherence scores, clinical variables, patients’ knowledge base, and indication of pharmacists’ potential to bring about positive outcomes among patients with chronic diseases. There is a need for professional collaboration in disease management for the improved outcomes of patients.
Keywords: Elderly patients with type 2 diabetes, improvement, medication adherence, pharmacist
|How to cite this article:|
Ojieabu WA. Pharmacist’s contribution to medication adherence among patients with type 2 diabetes in endocrinology clinic. J Diabetol 2020;11:39-44
| Introduction|| |
Diabetes mellitus has been estimated globally to increase from 366 million in 2011 to 552 million in 2030. The World Health Organization (WHO) also estimated that within the next few years in Nigeria, death from diabetes may likely increase by 52%, whereas that from other chronic diseases may increase by 24%. Elderly people are prone to chronic diseases requiring continuous medications throughout their lives, most of which may be prone to inappropriate use. Such diseases include diabetes, hypertension, hyperlipidemia, osteoporosis, and cardiovascular diseases.
Prescribed medicines need to be taken correctly as directed by the prescriber and counseled by the pharmacist for the patient to derive the desired benefits or outcomes. Therefore, adherence becomes a key factor in managing patients with chronic diseases. The WHO describes adherence as “the extent to which a person follows agreed recommendations made with a healthcare provider in taking his medications, diet, and observing lifestyle modifications.” Cases of nonadherence have been found to be overwhelmingly higher than that of adherence., Previous findings have also shown that adherence of patients needing indefinite medications falls significantly after six months of commencement., Another report stated that nonadherence in patients may be intentional (e.g., not wanting to take prescribed doses or wrong timings) or unintentional (e.g., not able to buy the medication or mere forgetfulness). Poor or nonadherence to medications can lead to high rate of hospitalization and death in patients with diabetes and other related chronic diseases.
This necessitates the combined efforts of all health-care professionals to ensure patients’ rational use of their prescribed medications. An improved adherence to medicines has a positive impact on reduction in the frequency of patient’s hospital visit, personal spending, and health-related quality of life. Pharmacists with clinical knowledge, trainings, and orientations have the ability to enhance medication and adherence to lifestyle modification in patients with chronic diseases to prevent or reduce disease deterioration. It is of necessity to note that pharmacists in this and many other hospitals in Nigeria do not practice pharmaceutical care in their settings. They also do not take part in the combined ward rounds with the physicians or other health professionals. The main reasons advanced for this include (1) physicians do not welcome the pharmacists’ presence during their ward rounds and (2) the pharmacists’ constant excuse of lack of adequate work force and lack of time. It is imperative that all health professionals and caregivers work together to deliver essential and beneficial care services to patients. A patient-focused (patient education, counseling, phone calls to patients, and incentives) and physician-focused (pharmacist’s interactions with prescribers) intervention was implemented by this researcher to investigate pharmacist’s potential to improve medication adherence, clinical data, and optimize treatment outcomes among patients with type 2 diabetes.
| Materials and Methods|| |
This was a randomized controlled study carried out at the endocrinology clinic of Olabisi Onabanjo University Teaching Hospital (OOUTH) in Nigeria. The clinic opens to patients with diabetes twice weekly (Wednesdays for inpatients and Tuesdays for outpatients). Each clinic day has one consultant, five doctors, a pharmacist, and two nurses. The clinic has an attendance of 40–50 patients on an average each clinic day and service by attached functional pharmacy and laboratory units. Activities on Tuesdays include the following: (1) retrieval of patients’ case files by those in the record department, (2) measurement of fasting blood sugar (FBS) and blood pressure (BP) levels of patients using Accu-Chek Active (Acon Laboratories, San Diego, California) and sphygmomanometer, respectively, by nurses while the intervention pharmacist documents the figures, (3) a coordinating staff gives the general briefing while welcoming the patients, (4) the physicians see the patients, (5) the intervention pharmacist assesses the prescriptions for correctness and rational prescribing, and (6) the hospital pharmacist calculates the costs and dispenses the medications.
Following approval to carry out the study from the Ethics Review Committee of OOUTH and after obtaining signed consent forms from patients, 150 outpatients with type 2 diabetes who met the age inclusion criteria and were accessing treatment at the clinic for at least the previous three months were enrolled into a six-month randomized controlled study. These patients included those referred to the clinic from either private or other public hospitals in Nigeria before the study. Eligible patients were assigned into control and intervention groups, each comprising 75 patients. Patients aged 50 years and older were enrolled into the study adopting the stated age of old or older person by the WHO. At baseline and six months, the patients’ medication adherence score, mean FBS, BP, and body mass index (BMI) were determined, whereas patients’ probable reasons for lack of adherence and likely areas where patients needed information were assessed with questionnaire. Three final-year pharmacy students trained on data collection procedures assisted the researcher on collection of relevant data. A patient-focused (patient education, counseling, phone calls to patients, and incentives) and physician-focused (pharmacist’s interactions with prescribers) intervention by the researcher commenced at the baseline after assessment of the parameters and continued to the sixth month.
Subject inclusion/exclusion/withdrawal criteria: Outpatients with diagnosis of type 2 diabetes mellitus, have received hypoglycemic agents for at least three months from the commencement of the study, signed the informed consent form, receiving medical care from this clinic for diabetes and who were 50 years and above old during the study period were included into the study. Excluded criteria included patients who refused to sign the informed consent form, who had mental incompetence and acute comorbidities other than hypertension, and who could not be followed up through the study period. Subjects were allowed to withdraw voluntarily from the study if they so wish or the investigator may terminate a subject’s participation if the subject meets an exclusion criterion (either newly developed or not previously recognized) that precludes further study participation. None of the participants however withdrew from the study.
Strategies for patient retention: As appropriate, N500.00–N2000 per patient was made available to five patients who complained of not being able to attend clinic as scheduled on account of lack of money for transport or drugs.
Study intervention: (1) Patient-focused intervention was in two stages: (a) Before consultation with the physician: All patients in the intervention group were educated on diabetes and hypertension, their preventive measures as well as non-pharmacological and medication management. (b) After consultation with the physician, that is, during collection of medications. This was individualized where each patient’s prescription was reviewed for drug dosing, duration, drug interactions, addition/removal of any drug, side effects, adverse drug effects on the patient, patient’s understanding of the prescription, or inability to pay for drugs. Each patient was counseled according to his/her needs on medication and treatment adherence, such as clinic visits and lifestyle modifications, including diet and exercise. Three sessions of such interventions were held with each patient. Reminder phone calls were placed to all participating patients a week before their clinic visit days and a day to each actual visit. Patients were given opportunity to ask questions/clarifications concerning all areas of the intervention at each visit. (2) Physician-focused intervention: Those prescriptions needing attention were taken to the particular prescribers by the researcher pharmacist with suggested alternatives, which were resolved in all cases. The control group was denied all the intervention strategies except the phone calls and financial assistance.
Instrument: Modified Morisky Adherence Predictor Scale, as adapted by an earlier researcher, was used to assess the self-reported adherence level of patients to medications. Subjects were administered response versions of the four-item self-report scale with the binary response option (yes/no). The theory defined in this measure was that drug errors of omission could occur in any of the several ways: forgetfulness, carelessness, stopping the drug when feeling better, or starting the drug when feeling worse. The tendency in responding to questions about their regimen adherence is for the patients to give the health-care providers positive answers because providers usually phrase their questions in a way that the answers they want to hear is “yes.” By reversing the wording of four questions about the ways patients might experience drug omissions, the sum of “yes” answers would provide a composite measures of nonadherence. Rather than attempting to overcome the “yes” bias, this approach attempts to use it to obtain disclosures of nonadherence. Scores for the scale range from 0 to 4 with higher scores are indicative of worse adherence. Responses were coded so that “yes” represents nonadherence, whereas “no” represents adherence.
Outcome measures: Changes in adherence scores, mean clinical variables, and improved patients’ knowledge.
Statistical analysis: Responses to questionnaires and other data collected were coded and entered into Microsoft Excel for sorting, and the Statistical Package for the Social Sciences (SPSS) software, version 16, (SPSS, Chicago, Illinois) was used for further analysis. Data were analyzed using descriptive and comparative analyses. Chi-squared and Fisher’s exact tests were used for the comparison of proportions, whereas Student’s t-test was used for the comparison of mean values as appropriate. For each patient, BMI was calculated by dividing weight (in kilogram) by height (in meter square). At 95% confidence interval, P ≤ 0.05 was considered statistically significant. Results are presented in mean and in percentage formats.
Ethical approval: The Ethics Review Committee of the hospital gave approval to conduct the research, to administer questionnaire to the patients, and to use patients’ informed consent designed by the researcher for the study. Maximum confidentiality of information was assured by excluding the names of the respondents or any information that could be linked to anybody in the questionnaire.
| Results|| |
The adherence questions asked were: Ever forget to take your medications? Careless at times about taking your medications? If feel better stop taking your medications? If feel worse do you stop taking medications?
No significant differences in adherence scores were observed between the control and intervention groups at baseline. High and low adherence scores in both groups were 33.3% versus 36.0% (P = 0.873) and 26.7% versus 25.3% (P = 1.00), respectively [Table 1]. Patients’ response to the coded adherence questions at the end of the pharmaceutical care intervention revealed significant differences in the scores between the control and intervention groups. High and low adherence scores in both groups were 34.7% versus 88.0% (P = 0.001) and 21.3% versus 2.7% (P = 0.002), respectively [Table 2].
|Table 1: Patients’ response to the four-item modified Morisky Adherence Scale at baseline|
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|Table 2: Patients’ response to the four-item modified Morisky Adherence Scale at six months|
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The mean clinical variables at six months (post-intervention) were significantly lower than the baseline values without exception (P < 0.05). Mean FBS at baseline was 159.5 ± 46.8 versus 155.7 ± 43.1 (P = 0.606) as compared to the values at six months, 145.1 ± 45.6 versus 89.5 ± 16.4 (P ≤ 0.000) [Table 3]. Patients were assessed on eight likely questions that could have made them nonadherent to their medications. Some of the questions asked included medications too expensive, nonavailability of drugs, use of herbal drugs, forgetfulness, and health professionals’ attitude to patients. Two of the questions (use of herbal drugs and health professionals’ attitude to patients) were not affected by the intervention (P > 0.05). Their values were 93.3% versus 90.7% (P = 0.907) and 61.3% versus 50.7% (P = 0.499) at baseline, 86.7% versus 78.7% (P = 0.717) and 49.3% versus 38.7% (P = 0.461) at six months, respectively. There were however extreme significant differences in all the remaining six responses between baseline and six months, P < 0.000 [Table 4]. Patients were also asked to indicate where they needed information in the following areas: about my disease, how to use my drugs, how to reduce drug side effects, and how to improve my health. The results indicated patients in both groups needed more information at almost the same rate at the baseline (P > 0.05), with the percentage needing this same information in the intervention group reduced drastically as compared to the number at baseline. For example, how to improve my health at baseline, 90.7% versus 86.7% (P = 0.905) and at six months, 88.0% versus 24.0% (P = 0.000) [Table 5].,
|Table 4: Patients’ likely reasons for lack of medication adherence at baseline and six months|
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|Table 5: Areas where information is needed from health-care professional at baseline and six months|
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| Discussion|| |
The results obtained in this study are indications of the values that the clinical pharmacist could add to the treatment outcomes of patients with chronic diseases as exemplified by diabetes disease. The pharmacist mainly used patient education, counseling, and other pharmaceutical care strategies. Patients in the developing countries such as Nigeria need constant interactions, encouragement, and monitoring for specifics such as adherence to clinic visits and medications each time they come to seek medical care, especially those with chronic disease conditions. This is because majority of them are educationally and economically disadvantaged, resulting in inability to obey health-care instructions. High medication adherence rate (36%–88%) obtained in this study compares favorably to what was called adequate/good adherence rate (36%–93%) by previous researchers., Patients would always need information, no matter how trivial it might be. Patients with required health information will certainly thrive better on medication and lifestyle modifications, leading to a better outcome. It has been revealed that the most effective method of diabetes treatment could be combination of effective medication management coupled with diet and lifestyle modifications.,
Clinical pharmacists have adequate knowledge and pharmaceutical care skills to make the necessary effective changes/modifications to achieve positive outcomes in disease management both in acute and chronic cases. This in addition is the fact that they are the first ports of call in many countries, especially in less developed countries, as well as operate-free consultations for patients/clients, and are community friendly. These make it necessary for pharmacists to be easily integrated into health-care provider groups as patients are likely to listen to their education, counseling, instructions/directives, information, advice, and treatment modifications they might need to make. Implementation of pharmaceutical care practice in chronic disease treatment such as diabetes can help reduce patient’s nonadherence rate through monitoring clinic attendance, actual prescription filling, and medication usage adherence among others.
The need to be cordial and cautious with patients at all times was seen in this study as patients could not be convinced that health professionals’ attitude toward them was for their good and not necessarily that of insensitivity to their plight nor a show of superiority. Patients have feelings just like the health professionals. In most cases, they could easily be irritated due to their illness state. They can only listen to us when we empathize with them and see it as our professional duty to willingly and readily respond to their queries and allay their fears. Earlier studies found mode of approach by health-care professionals could be an important factor in patients’ nonadherence., A similar research stated that patients could be motivated to follow adherence directives when they find pleasant experiences and trust from health-care providers. Another culprit of nonadherence identified was the co-use of herbal medicines with prescribed drugs. In this part of the world, many indigenes believe in the efficacy of herbal products and prefer them to orthodox medicines or at best use both as combinations. They also find them easily accessible, affordable, and less toxic. These may make it difficult to convince them on the dangers of using unstandardized medications in the treatment of chronic diseases such as diabetes. A review found populations comprising mainly older adults with chronic diseases prefer to use combination of herbal and conventional drugs to treat their ailments. According to another study, roughly 75%–80% of the world, especially those of developing countries, rely on herbal medicines for primary health care due to cultural acceptability and less side effects.
Patients are in need of information as per their diseases and management as shown by the response obtained in this study. The continuous and satisfactory information supplied them during education and counseling empowered and made them informed medication consumers. This is an indication of satisfaction on their part and positive outcome for the pharmacist. The periods of interaction with patients provided opportunity for strong therapeutic relationship that gave the patients the liberty to unburden their minds to the pharmacist without reservations on issues concerning their treatment, a way for improving adherence. Pharmacist-managed patients have been adjudged to do well or better than those managed by other health-care professionals., Similar measurable improvements achieved by clinical pharmacists in hospitals and clinics in quality of patient care as well as in outcomes have also been reported. There is, however, a great need for pharmacists to keep up their gains of interventions through sustained pharmaceutical care activities. This is to prevent significant fall in adherence after some months as reported in previous studies., It has however been noted that despite these bundles of positive reports on patient outcomes, tangible collaborative work is yet to be found between the pharmacist and other health professionals or viable integration on their ward rounds in this part of the globe.
| Conclusion|| |
The intervention was successful in improving adherence rate of elderly patients indicating the potential of the pharmacist to bring about positive outcomes through patients adherence to instructions. This paves the way for enhanced role of the pharmacist in diabetic care and other chronic diseases. Clinical pharmacists are now seen to add value to patients’ treatment outcomes through education and counseling, review of prescriptions, provision of needed information for patients and other health-care professionals, in addition to enhancing medication adherence as well as lifestyle and dietary modifications. Their usefulness cannot be overemphasized in chronic disease management, especially among the elderly patients who use medications for relatively greater part of their lifetime. Hence, the need for professional collaboration for patients improved outcomes translating to improved quality of life and reduction in resource wastage.
I would like to sincerely appreciate the respondents who participated in this study as well as the supporting pharmacy students, the nurses, and the management of Olabisi Onabanjo University Teaching Hospital (OOUTH), Ogun State, Nigeria.
Financial support and sponsorship
This work was self-funded.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]