503123
research-article2013
AOPXXX10.1177/1060028013503123Annals of PharmacotherapyBeloin-Jubinville et al
Research Report-Adherence
Does Hospitalization Influence Patients’ Medication Adherence and Community Pharmacists’ Interventions?
Annals of Pharmacotherapy 47(9) 1143–1152 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028013503123 aop.sagepub.com
Bianca Beloin-Jubinville, MScPharm1, Thomas Joly-Mischlich, MScPharm1, Emilie Dufort Rouleau, MScPharm1, Pascale Noiseux, MScPharm2, Lucie Blais, PhD3,4, Amélie Forget, MSc4, and Marie-France Beauchesne, PharmD3,5
Abstract Background: Medication adherence reduces disease morbidity. Data regarding changes in a patient’s adherence before and after hospitalization and how this hospitalization influences a pharmacist’s interventions are scarce. Objective: To assess changes in adherence to cardiovascular and respiratory medications in the year preceding and following a hospitalization; explore patients’ perceptions about medication adherence and the pharmacist’s role; and describe pharmacists’ interventions regarding medication adherence. Methods: This cohort study included patients hospitalized for acute coronary syndrome, acute worsening of heart failure, or acute COPD exacerbations. Adherence to cardiovascular and respiratory medications was measured by calculating the proportion of days covered (PDC) from prescription refills. Patient interviews were completed to explore their perceptions about medication adherence and the role of the pharmacist. Community pharmacists were invited to complete an online survey and to participate in focus groups to discuss interventions to improve medication adherence. Results: Medication adherence was assessed for 61 patients; the mean PDC was 69.8% 12 months before hospitalization and 72.4% 12 months following hospitalization. Patients reported that they felt the need to take their medications to prevent worsening of their disease. They were satisfied with current pharmaceutical services. A total of 136 questionnaires completed by pharmacists were analyzed and 9 participants attended the focus groups. Most pharmacists reported monitoring prescription renewals to assess adherence, with no significant influence from the hospitalization itself. The patient’s interest was reported to be an important facilitator, whereas a lack of time and face-to-face interaction with patients who had their medication delivered to their home was reported a main barrier to interventions. This study was limited by a small sample size. Conclusions: Patient medication adherence did not significantly change following hospitalization. Hospitalization does not appear to significantly influence patient and pharmacist behavior towards medication adherence. Keywords respiratory disease, cardiovascular disease, hospitalization, adherence to medication, pharmacist
Cardiovascular and respiratory diseases are leading causes of mortality worldwide.1 Poor medication adherence is problematic and increases the risk of disease morbidity and death.2-4 When looking at adherence rates to respiratory and cardiovascular medications, Krigsman et al. reported a satisfactory refill adherence for inhaled corticosteroids in only 28% of elderly patients with asthma/COPD.5 Furthermore, a meta-analysis of 20 studies assessing adherence to cardiovascular medications reported adherence rates of 50% and 66% in primary and secondary prevention, respectively (p = 0.012).6 This suggests that adherence is better in secondary prevention than in primary prevention and that being hospitalized may influence a patient’s medication adherence. However, studies describing changes in medication
adherence in the period preceding and following an acute event were not retrieved. Besides the hospitalization itself, 1
Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada 2 CSSS de l’Énergie, Shawinigan, Québec 3 Faculté de pharmacie, Université de Montréal 4 Centre de recherche de l’Hôpital du Sacré-Coeur de Montréal, Montréal, Québec 5 Centre Hospitalier Universitaire de Sherbrooke Corresponding Author: Marie-France Beauchesne, PharmD, Pharmacist, Centre Hospitalier Universitaire de Sherbrooke; Clinical Full Professor, Faculté de pharmacie, Université de Montréal. Email: [email protected]
Downloaded from aop.sagepub.com at SUNY STONY BROOK on November 14, 2014
1144
Annals of Pharmacotherapy 47(9)
many factors influence medication adherence, including patient interaction with health care professionals.7 More specifically, community pharmacists are uniquely positioned to interact frequently with patients and have easy access to medication refill information. A recent systematic review of studies addressing the impact of a community pharmacist’s interventions in cardiovascular diseases and diabetes management summarized 9 studies with medication adherence as the primary end point.8 Five of these studies had positive outcomes (ie, improvement in medication adherence was statistically significant) and included interventions such as patient education, regular follow-up, medication reminders or packaging, and physician notification.8 When focusing on the context of secondary prevention, a recent study assessed the impact of an intervention that included patient education, adherence aids, and expanded communication linkages between hospital-based and community pharmacists, physicians, and patients who were hospitalized for coronary artery disease (n = 143).9 There was better adherence in using prescription refills for β-blockers in the intervention group (71% vs 49%, p = 0.03), but the difference in self-reported adherence, the primary outcome, was not significant.9 Various interventions, often timeintensive, have been studied and the benefits appear inconsistent. Therefore, the most efficient intervention that can be provided by community pharmacists to improve medication adherence is unclear. To address the issue of medication adherence and its relationship to hospitalization, we conducted this pilot study, consisting of 4 steps. The main objective was to evaluate changes in medication adherence before and following hospitalization for an acute cardiovascular or respiratory event. A second objective was to explore patient perceptions toward medication adherence and the role of the pharmacist in the context of secondary prevention. To develop and eventually assess the impact of an intervention provided by community pharmacists for patients who were hospitalized for an acute cardiovascular or respiratory event, a third objective was to describe current community pharmacist interventions to improve medication adherence in the context of secondary prevention, as well as factors (barriers/facilitators) influencing them.
Methods Patient Study We conducted a pre/post hospitalization pilot study to evaluate the changes in medication adherence between the 12-month period preceding and the 12-month period following a hospitalization for acute exacerbation of COPD, acute coronary syndrome (ACS), or acute worsening of heart failure (HF). Patients who were hospitalized in a single tertiary care institution between October 27, 2010, and January 25,
2011, for one of these acute events were screened for their eligibility. Inclusion criteria were hospitalization for acute exacerbation of COPD, ACS, or acute worsening of HF and ability to speak either French or English. We excluded patients who were younger than 18 years, had cognitive or acute psychiatric problems, reported consuming more than 14 (male) or 9 (female) alcohol beverages per week, used elicit drugs, or were receiving palliative care. Data on the following patient baseline characteristics were collected: age, sex, comorbidities using the Charlson comorbidity index,10 family income, level of education, hospitalization in the previous year, smoking status, type of drug insurance, number of prescribed medications, number of doses per day, and whether a pillbox was prepared by the community pharmacist. Adherence was measured using data on prescription refills. This type of data was found to be valid and associated with other measures of medication adherence.11 To describe medication adherence, the proportion of days covered (PDC) values were calculated for selected cardiovascular medications in patients with ACS and HF (furosemide for individuals with HF only; β-blockers, angiotensin-converting enzyme [ACE] inhibitors/ angiotensin receptor blockers [ARBs], and statins for individuals with HF and ACS) and selected classes of respiratory medicines in patients with COPD (ie, long-acting inhaled anticholinergics and a combination of long-acting β2-agonists [LABAs] and inhaled corticosteroids [ICS]). These classes of medications were selected because they have been shown to reduce disease morbidity and/or mortality. Data on prescription refills were obtained through patients’ community pharmacies. Patients were encouraged to visit only 1 pharmacy during follow-up. If a change in pharmacy occurred, we attempted to retrieve information on prescription refills from other pharmacies. If the information on prescription refills was no longer available, followup was stopped. When a medication under study was discontinued or when there was a change in drug class, followup was also stopped. The PDC was calculated by dividing the total number of days the medication was supplied by the number of days in the follow-up period. The PDC was chosen over the medication possession ratio (MPR) because the maximum value for the PDC is set at 100% and avoids overestimation of adherence. This measure has been widely used to measure adherence based on prescription refills.12 First, the mean PDCs were calculated for all patients using 1 class of medication under study (eg, mean PDC for users of long-acting anticholinergics who were admitted for an acute exacerbation of COPD). We then combined the mean PDCs for all patients who had the same diagnosis (ie, COPD = long-acting inhaled anticholinergics, LABAs, and ICS; HF = furosemide, β-blockers, ACE inhibitors/ARBs, and statins; ACS = β-blockers, ACE inhibitors/ARBs, and statins). Lastly, we calculated the mean PDC for all medications under study for all patients. Mean PDCs are reported
Downloaded from aop.sagepub.com at SUNY STONY BROOK on November 14, 2014
1145
Beloin-Jubinville et al for the 12-month period before hospitalization and for the 0- to 3- (months 1, 2, and 3), 3- to 6- (months 4, 5, and 6), 6- to 12- (months 7, 8, 9, 10, 11, and 12), and 0-to 12-month periods following hospitalization. We used different time periods to determine whether adherence increased in the first months following hospitalization and decreased afterwards. Our hypothesis was that adherence would decrease after the first 3-month period following hospitalization. Paired t-tests were performed to compare changes in medication adherence before and after hospitalization (ie, for the different time periods under study). Adherence to cardiovascular medications was compared pre- and posthospitalization between patients who had their medication dispensed in a pillbox prepared by the community pharmacist and those who did not. Statistical analyses were completed using SAS software. We intended to recruit 73 subjects to have 80% power to detect a change of 10% (with a standard deviation of 15%) in the overall mean PDC pre- and posthospitalization (using a paired t-test and an α value of 5%). Patient interviews. Semistructured interviews were conducted, with a sample of the subjects recruited for an indepth exploration of 5 dimensions related to medication adherence and the pharmacist’s role: (1) perceptions about medication therapy, (2) perceptions about the community pharmacist’s role, (3) relationship with the community pharmacist, (4) medication adherence, and (5) the influence of hospitalization on medication adherence. Subjects were selected sequentially based on age (
research-article2013
AOPXXX10.1177/1060028013503123Annals of PharmacotherapyBeloin-Jubinville et al
Research Report-Adherence
Does Hospitalization Influence Patients’ Medication Adherence and Community Pharmacists’ Interventions?
Annals of Pharmacotherapy 47(9) 1143–1152 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028013503123 aop.sagepub.com
Bianca Beloin-Jubinville, MScPharm1, Thomas Joly-Mischlich, MScPharm1, Emilie Dufort Rouleau, MScPharm1, Pascale Noiseux, MScPharm2, Lucie Blais, PhD3,4, Amélie Forget, MSc4, and Marie-France Beauchesne, PharmD3,5
Abstract Background: Medication adherence reduces disease morbidity. Data regarding changes in a patient’s adherence before and after hospitalization and how this hospitalization influences a pharmacist’s interventions are scarce. Objective: To assess changes in adherence to cardiovascular and respiratory medications in the year preceding and following a hospitalization; explore patients’ perceptions about medication adherence and the pharmacist’s role; and describe pharmacists’ interventions regarding medication adherence. Methods: This cohort study included patients hospitalized for acute coronary syndrome, acute worsening of heart failure, or acute COPD exacerbations. Adherence to cardiovascular and respiratory medications was measured by calculating the proportion of days covered (PDC) from prescription refills. Patient interviews were completed to explore their perceptions about medication adherence and the role of the pharmacist. Community pharmacists were invited to complete an online survey and to participate in focus groups to discuss interventions to improve medication adherence. Results: Medication adherence was assessed for 61 patients; the mean PDC was 69.8% 12 months before hospitalization and 72.4% 12 months following hospitalization. Patients reported that they felt the need to take their medications to prevent worsening of their disease. They were satisfied with current pharmaceutical services. A total of 136 questionnaires completed by pharmacists were analyzed and 9 participants attended the focus groups. Most pharmacists reported monitoring prescription renewals to assess adherence, with no significant influence from the hospitalization itself. The patient’s interest was reported to be an important facilitator, whereas a lack of time and face-to-face interaction with patients who had their medication delivered to their home was reported a main barrier to interventions. This study was limited by a small sample size. Conclusions: Patient medication adherence did not significantly change following hospitalization. Hospitalization does not appear to significantly influence patient and pharmacist behavior towards medication adherence. Keywords respiratory disease, cardiovascular disease, hospitalization, adherence to medication, pharmacist
Cardiovascular and respiratory diseases are leading causes of mortality worldwide.1 Poor medication adherence is problematic and increases the risk of disease morbidity and death.2-4 When looking at adherence rates to respiratory and cardiovascular medications, Krigsman et al. reported a satisfactory refill adherence for inhaled corticosteroids in only 28% of elderly patients with asthma/COPD.5 Furthermore, a meta-analysis of 20 studies assessing adherence to cardiovascular medications reported adherence rates of 50% and 66% in primary and secondary prevention, respectively (p = 0.012).6 This suggests that adherence is better in secondary prevention than in primary prevention and that being hospitalized may influence a patient’s medication adherence. However, studies describing changes in medication
adherence in the period preceding and following an acute event were not retrieved. Besides the hospitalization itself, 1
Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada 2 CSSS de l’Énergie, Shawinigan, Québec 3 Faculté de pharmacie, Université de Montréal 4 Centre de recherche de l’Hôpital du Sacré-Coeur de Montréal, Montréal, Québec 5 Centre Hospitalier Universitaire de Sherbrooke Corresponding Author: Marie-France Beauchesne, PharmD, Pharmacist, Centre Hospitalier Universitaire de Sherbrooke; Clinical Full Professor, Faculté de pharmacie, Université de Montréal. Email: [email protected]
Downloaded from aop.sagepub.com at SUNY STONY BROOK on November 14, 2014
1144
Annals of Pharmacotherapy 47(9)
many factors influence medication adherence, including patient interaction with health care professionals.7 More specifically, community pharmacists are uniquely positioned to interact frequently with patients and have easy access to medication refill information. A recent systematic review of studies addressing the impact of a community pharmacist’s interventions in cardiovascular diseases and diabetes management summarized 9 studies with medication adherence as the primary end point.8 Five of these studies had positive outcomes (ie, improvement in medication adherence was statistically significant) and included interventions such as patient education, regular follow-up, medication reminders or packaging, and physician notification.8 When focusing on the context of secondary prevention, a recent study assessed the impact of an intervention that included patient education, adherence aids, and expanded communication linkages between hospital-based and community pharmacists, physicians, and patients who were hospitalized for coronary artery disease (n = 143).9 There was better adherence in using prescription refills for β-blockers in the intervention group (71% vs 49%, p = 0.03), but the difference in self-reported adherence, the primary outcome, was not significant.9 Various interventions, often timeintensive, have been studied and the benefits appear inconsistent. Therefore, the most efficient intervention that can be provided by community pharmacists to improve medication adherence is unclear. To address the issue of medication adherence and its relationship to hospitalization, we conducted this pilot study, consisting of 4 steps. The main objective was to evaluate changes in medication adherence before and following hospitalization for an acute cardiovascular or respiratory event. A second objective was to explore patient perceptions toward medication adherence and the role of the pharmacist in the context of secondary prevention. To develop and eventually assess the impact of an intervention provided by community pharmacists for patients who were hospitalized for an acute cardiovascular or respiratory event, a third objective was to describe current community pharmacist interventions to improve medication adherence in the context of secondary prevention, as well as factors (barriers/facilitators) influencing them.
Methods Patient Study We conducted a pre/post hospitalization pilot study to evaluate the changes in medication adherence between the 12-month period preceding and the 12-month period following a hospitalization for acute exacerbation of COPD, acute coronary syndrome (ACS), or acute worsening of heart failure (HF). Patients who were hospitalized in a single tertiary care institution between October 27, 2010, and January 25,
2011, for one of these acute events were screened for their eligibility. Inclusion criteria were hospitalization for acute exacerbation of COPD, ACS, or acute worsening of HF and ability to speak either French or English. We excluded patients who were younger than 18 years, had cognitive or acute psychiatric problems, reported consuming more than 14 (male) or 9 (female) alcohol beverages per week, used elicit drugs, or were receiving palliative care. Data on the following patient baseline characteristics were collected: age, sex, comorbidities using the Charlson comorbidity index,10 family income, level of education, hospitalization in the previous year, smoking status, type of drug insurance, number of prescribed medications, number of doses per day, and whether a pillbox was prepared by the community pharmacist. Adherence was measured using data on prescription refills. This type of data was found to be valid and associated with other measures of medication adherence.11 To describe medication adherence, the proportion of days covered (PDC) values were calculated for selected cardiovascular medications in patients with ACS and HF (furosemide for individuals with HF only; β-blockers, angiotensin-converting enzyme [ACE] inhibitors/ angiotensin receptor blockers [ARBs], and statins for individuals with HF and ACS) and selected classes of respiratory medicines in patients with COPD (ie, long-acting inhaled anticholinergics and a combination of long-acting β2-agonists [LABAs] and inhaled corticosteroids [ICS]). These classes of medications were selected because they have been shown to reduce disease morbidity and/or mortality. Data on prescription refills were obtained through patients’ community pharmacies. Patients were encouraged to visit only 1 pharmacy during follow-up. If a change in pharmacy occurred, we attempted to retrieve information on prescription refills from other pharmacies. If the information on prescription refills was no longer available, followup was stopped. When a medication under study was discontinued or when there was a change in drug class, followup was also stopped. The PDC was calculated by dividing the total number of days the medication was supplied by the number of days in the follow-up period. The PDC was chosen over the medication possession ratio (MPR) because the maximum value for the PDC is set at 100% and avoids overestimation of adherence. This measure has been widely used to measure adherence based on prescription refills.12 First, the mean PDCs were calculated for all patients using 1 class of medication under study (eg, mean PDC for users of long-acting anticholinergics who were admitted for an acute exacerbation of COPD). We then combined the mean PDCs for all patients who had the same diagnosis (ie, COPD = long-acting inhaled anticholinergics, LABAs, and ICS; HF = furosemide, β-blockers, ACE inhibitors/ARBs, and statins; ACS = β-blockers, ACE inhibitors/ARBs, and statins). Lastly, we calculated the mean PDC for all medications under study for all patients. Mean PDCs are reported
Downloaded from aop.sagepub.com at SUNY STONY BROOK on November 14, 2014
1145
Beloin-Jubinville et al for the 12-month period before hospitalization and for the 0- to 3- (months 1, 2, and 3), 3- to 6- (months 4, 5, and 6), 6- to 12- (months 7, 8, 9, 10, 11, and 12), and 0-to 12-month periods following hospitalization. We used different time periods to determine whether adherence increased in the first months following hospitalization and decreased afterwards. Our hypothesis was that adherence would decrease after the first 3-month period following hospitalization. Paired t-tests were performed to compare changes in medication adherence before and after hospitalization (ie, for the different time periods under study). Adherence to cardiovascular medications was compared pre- and posthospitalization between patients who had their medication dispensed in a pillbox prepared by the community pharmacist and those who did not. Statistical analyses were completed using SAS software. We intended to recruit 73 subjects to have 80% power to detect a change of 10% (with a standard deviation of 15%) in the overall mean PDC pre- and posthospitalization (using a paired t-test and an α value of 5%). Patient interviews. Semistructured interviews were conducted, with a sample of the subjects recruited for an indepth exploration of 5 dimensions related to medication adherence and the pharmacist’s role: (1) perceptions about medication therapy, (2) perceptions about the community pharmacist’s role, (3) relationship with the community pharmacist, (4) medication adherence, and (5) the influence of hospitalization on medication adherence. Subjects were selected sequentially based on age (
