[dropcap color=”white” background=”black” style=”square” size=”large”]T[/dropcap]he pharmacist has access to their patient’s refill history. With the history, the pharmacist can assess medication persistence, which is something a prescriber cannot readily assess.
Consider the following scenario: while performing final verification and doing Continuous Medication Monitoring (CMM) you notice that the patient does not appear to be taking one of their medications correctly. The patient appears to be taking roughly half of all scheduled doses. As the pharmacist, you decide to approach the patient in order to correct this compliance issue.
Before making this intervention, however, consider that you really know very little about the situation. While your data shows non-compliance, there are many possible explanations and only one of them is the patient being unwilling or unable to take the medication as prescribed.
Before approaching the patient, consider some of the possibilities. The following is representative of issues we have seen, but is certainly non exhaustive.
- Samples. Yes, there are still samples being handed out by physicians. If the patient is on a name brand drug, this is certainly a possibility.
- Mail order or another pharmacy. As pharmacists, we generally are not fans of this type of pharmacy, but the possibility that the patient has another source.
- Prescriber – Pharmacist communication. It is fairly common in our practices to have the prescriber send the patient a letter of follow-up after an office visit. Often, the prescriber makes changes to the patient’s drug therapy in these letters but fails to include the pharmacy in the correspondence. The patient may be taking the drug correctly, but the pharmacy doesn’t know it (yet)
- Medication hoarding. Often I find patients will have acquired massive stockpiles of their medications. Once they have done this, their apparent compliance starts to fall.
- Drug side-effects or adverse events. The patient will be the first one to know if a medication effects them in an undesirable way. The patient may self-adjust their dose to avoid these effects. They do not always think to share this with the prescriber or the pharmacist.
- Therapeutic goals. Related to the self-adjusted dose for ADRs, patients often adjust their dose themselves based on how they feel. As crazy as this might seem, the patient is often justified. Many patients I have seen over the years have adjusted their blood pressure and cholesterol medication doses themselves without letting anyone know. The prescriber often assumes that the dose being taken is what they prescribed. What matters here is that the patient is attaining the goals the prescriber and patient have established.
- True Non-compliance. The patient cannot or will not, for one or many reasons, take the medication as prescribed.
Understanding that there are many different possibilities for the refill pattern being observed necessarily impacts the approach used. Instead of asking the patient why they are not taking their medication as prescribed, one needs to enter into a fact finding mission.
One approach that we have found useful in our practice is the use of open ended questions. Typically we explain what we have noticed and then ask the patient to fill us in on any changes. For example:
“We noticed that your refills for this medication were often late. We are often the last to know if the prescriber made any changes. How are you taking this medication now?”
By taking blame for “not knowing” about any possible changer, we have tried to make the assessment less confrontational. Generally, this tactic helps illuminate the underlying reasons for what we have observed. Most of the time, a good reason actually exists for the late refills.
Once the reason is understood, the appropriate action can be planned. Often, the persistence data is a false-positive for a compliance issue, and the pharmacist only needs to document the reasons for the late fills. If there is are true obstacles to compliance, the pharmacist can further intervene and help coach the patient to improve compliance. Of course, this too should be documented. Lastly, the pharmacist needs to schedule a follow-up to re-assess the patient. Our practice typically re-evaluates the patient’s compliance (even false positive cases) in 90 days.
Pharmacies and pharmacists have a unique opportunity. Our businesses bring our patients to us regularly. This means we can see and interact with them at a minimum of several times a year and often several times each month. Pharmacists need to make every one of these encounters count.