Adherence to Medication
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Osterberg and Blaschke (Aug. 4 issue)1 discuss interventions that can be used to improve adherence to medication regimens. However, I am surprised that they do not include interventions by pharmacists among the recommendations in Table 3 of their article, which listed strategies for improving adherence.
The article does highlight pharmacist-led interventions for HIV infection as a promising area. The involvement of pharmacists has also been demonstrated to improve adherence or compliance in the management of hypertension,2 lowering of lipid levels,3 and the treatment of depression in patients.4 Furthermore, a set of billing codes, which are in compliance with the Health Insurance Portability and Accountability Act, for pharmacists to use in billing third-party payers when providing Medication Therapy Management Services (MTMS) has been recently approved in the United States. The Current Procedural Terminology Editorial Panel of the American Medical Association has approved three codes effective as of January 1, 2006.5 Pharmacists can use MTMS to communicate with patients and physicians in a concerted effort to improve adherence to medication.
Ronald J. Campbell, Jr., Pharm.D.
UPMC St. Margaret Hospital
Pittsburgh, PA 15215
camprj@upmc.edu
References
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-497.
Sookaneknun P, Richards RM, Sanguansermsri J, Teerasut C. Pharmacist involvement in primary care improves hypertensive patient clinical outcomes. Ann Pharmacother 2004;38:2023-2028.
Peterson GM, Fitzmaurice KD, Naunton M, Vial JH, Stewart K, Krum H. Impact of pharmacist-conducted home visits on the outcomes of lipid-lowering drug therapy. J Clin Pharm Ther 2004;29:23-30.
Adler DA, Bungay KM, Wilson IB, et al. The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients. Gen Hosp Psychiatry 2004;26:199-209.
American Society of Health-System Pharmacists. Professional service billing codes approved for pharmacists. (Accessed October 13, 2005, at http://www.ashp.org/news/ShowArticle.cfm?id=11615.)
To the Editor: The article by Osterberg and Blaschke is a nice review of how to increase adherence once a patient has a medication in his or her possession. What the article mentions but fails to address is how to deal with patients who do not adhere to the regimens because they cannot afford their medications. This is a problem especially for patients on multiple medication regimens. A mention of possible solutions to this ever-increasing cause of nonadherence would be useful.
Russell Krienke, M.D.
Austin Regional Clinic
Austin, TX 78704
rkrienke@arcmd.com
To the Editor: Many of the complexities associated with adherence to medication are laid out by Osterberg and Blaschke. However, the authors do not consider the role of sex in their discussion of both barriers to and interventions for appropriate drug use. For example, women are often poorer than men and, for cost reasons alone, may split pills or skip taking them — and then be judged as "lacking" in terms of adherence. In fact, all items on the authors' list of major predictors of poor adherence are relevant to sex differences. Consequently, interventions that assume a one-size-fits-all approach are likely to be too generalized and, thereby, potentially ineffective.1
Abby Lippman, Ph.D.
McGill University
Montreal, QC H3A1A2, Canada
References
Broyles LM, Colbert AM, Erlen JA. Medication practice and feminist thought: a theoretical and ethical response to adherence in HIV/AIDS. Bioethics 2005;19:362-378.
To the Editor: Osterberg and Blaschke provide a stimulating description of the importance of taking medication and the barriers that may impede adherence, thereby influencing clinical outcome. One barrier the authors highlight is inadequate communication between patient and provider, the remedy for which is at the heart of a recent philosophical move toward concordance — the process, as described by Marinker et al., of forming a therapeutic alliance to "optimise health gain from the best use of medicines, compatible with what the patient desires and is capable of achieving."1 In this setting, the prescription is replaced by a "concordat," which is broken only if communication fails. In the United Kingdom, this terminology is gradually replacing the terms "compliance" and "adherence,"2 which Osterberg and Blaschke agree are troublesome. We praise their suggestions for nonjudgmental inquiry about the consumption of medication, but further steps (especially training in communication)3,4 may be needed to facilitate full concordance and thus better streamline personal and health care system costs through optimal health. The article's epigraph should perhaps be reconsidered in terms of the patient's perspective: patients take drugs only if they agree that these agents are more beneficial than disruptive.
Gareth J. Treharne, Ph.D.
University of Birmingham
Birmingham B15 2TT, United Kingdom
g.j.treharne@bham.ac.uk
Antonia C. Lyons, Ph.D.
Massey University
Auckland, New Zealand
George D. Kitas, M.D., Ph.D.
Dudley Group of Hospitals NHS Trust
Dudley DY1 2HQ, United Kingdom
References
Marinker M, Blenkinsopp A, Bond C, et al. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain, 1997. (Accessed October 13, 2005, at http://www.medicines-partnership.org/about-us/history--context.)
Bissell P, May CR, Noyce PR. From compliance to concordance: barriers to accomplishing a re-framed model of health care interactions. Soc Sci Med 2004;58:851-862.
Thistlethwaite JE, Raynor DK, Knapp P. Medical students' attitudes towards concordance in medicine taking: exploring the impact of an educational intervention. Educ Health (Abingdon) 2003;16:307-317.
Expert Patient Programme. What is an expert patient? 2003. (Accessed October 13, 2005, at http://www.expertpatients.nhs.uk/what.shtml.)
The authors reply: We agree with Dr. Campbell that pharmacist-led interventions have proved successful in improving patient adherence to medications. However, these resources are not readily available to all providers. In the first paragraph under the section on interventions in our article, we did mention the benefits of interventions that involve pharmacists to improve adherence to medication, but we did not include this information in Table 3, which we limited to simple strategies that providers can use in general-practice settings. It is important that any intervention used to improve adherence, such as pharmacist-led interventions, include an evaluation of the cost and benefits of the approach.
We agree with Dr. Lippman's point that the role of sex should be considered in terms of the barriers and interventions related to medication-taking behavior and that more studies are needed in this area of medication adherence. We did not address the role of sex, since available data have not been consistent among all studies.1 We agree that adherence to antiretroviral medication is generally poorer in women than in men, as shown in studies on adherence to treatment regimens for HIV, and a recent study involving microelectronic monitors supports Dr. Lippman's argument about poorer adherence to medication among women with HIV.2
We addressed the need for physicians to be aware of the cost of medications, since expensive medications can be a barrier to adherence, but we did not explicitly include interventions that providers can use to overcome nonadherence that results from a patient's inability to afford the medication. The rising cost of prescription drugs, in addition to the increasing cost of insurance copayments, clearly contributes to poor adherence in many patients, but solutions to this problem were beyond the scope of our article.
We agree with Dr. Treharne and colleagues regarding the advantage of using the term "concordance" in describing the medication-taking behavior of a patient, since this implies an equal responsibility of patient and physician in the therapeutic relationship. We hope this term will become prevalent in the United States as well.
Lars Osterberg, M.D., M.P.H.
Veterans Affairs Palo Alto Health Care System
Palo Alto, CA 94304
larso@stanford.edu
Terrence Blaschke, M.D.
Stanford University Medical Center
Stanford, CA 94305
References
DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004;42:200-209.
Berg KM, Demas PA, Howard AA, Schoenbaum EE, Gourevitch MN, Arnsten JH. Gender differences in factors associated with adherence to antiretroviral therapy. J Gen Intern Med 2004;19:1111-1117.
The article does highlight pharmacist-led interventions for HIV infection as a promising area. The involvement of pharmacists has also been demonstrated to improve adherence or compliance in the management of hypertension,2 lowering of lipid levels,3 and the treatment of depression in patients.4 Furthermore, a set of billing codes, which are in compliance with the Health Insurance Portability and Accountability Act, for pharmacists to use in billing third-party payers when providing Medication Therapy Management Services (MTMS) has been recently approved in the United States. The Current Procedural Terminology Editorial Panel of the American Medical Association has approved three codes effective as of January 1, 2006.5 Pharmacists can use MTMS to communicate with patients and physicians in a concerted effort to improve adherence to medication.
Ronald J. Campbell, Jr., Pharm.D.
UPMC St. Margaret Hospital
Pittsburgh, PA 15215
camprj@upmc.edu
References
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-497.
Sookaneknun P, Richards RM, Sanguansermsri J, Teerasut C. Pharmacist involvement in primary care improves hypertensive patient clinical outcomes. Ann Pharmacother 2004;38:2023-2028.
Peterson GM, Fitzmaurice KD, Naunton M, Vial JH, Stewart K, Krum H. Impact of pharmacist-conducted home visits on the outcomes of lipid-lowering drug therapy. J Clin Pharm Ther 2004;29:23-30.
Adler DA, Bungay KM, Wilson IB, et al. The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients. Gen Hosp Psychiatry 2004;26:199-209.
American Society of Health-System Pharmacists. Professional service billing codes approved for pharmacists. (Accessed October 13, 2005, at http://www.ashp.org/news/ShowArticle.cfm?id=11615.)
To the Editor: The article by Osterberg and Blaschke is a nice review of how to increase adherence once a patient has a medication in his or her possession. What the article mentions but fails to address is how to deal with patients who do not adhere to the regimens because they cannot afford their medications. This is a problem especially for patients on multiple medication regimens. A mention of possible solutions to this ever-increasing cause of nonadherence would be useful.
Russell Krienke, M.D.
Austin Regional Clinic
Austin, TX 78704
rkrienke@arcmd.com
To the Editor: Many of the complexities associated with adherence to medication are laid out by Osterberg and Blaschke. However, the authors do not consider the role of sex in their discussion of both barriers to and interventions for appropriate drug use. For example, women are often poorer than men and, for cost reasons alone, may split pills or skip taking them — and then be judged as "lacking" in terms of adherence. In fact, all items on the authors' list of major predictors of poor adherence are relevant to sex differences. Consequently, interventions that assume a one-size-fits-all approach are likely to be too generalized and, thereby, potentially ineffective.1
Abby Lippman, Ph.D.
McGill University
Montreal, QC H3A1A2, Canada
References
Broyles LM, Colbert AM, Erlen JA. Medication practice and feminist thought: a theoretical and ethical response to adherence in HIV/AIDS. Bioethics 2005;19:362-378.
To the Editor: Osterberg and Blaschke provide a stimulating description of the importance of taking medication and the barriers that may impede adherence, thereby influencing clinical outcome. One barrier the authors highlight is inadequate communication between patient and provider, the remedy for which is at the heart of a recent philosophical move toward concordance — the process, as described by Marinker et al., of forming a therapeutic alliance to "optimise health gain from the best use of medicines, compatible with what the patient desires and is capable of achieving."1 In this setting, the prescription is replaced by a "concordat," which is broken only if communication fails. In the United Kingdom, this terminology is gradually replacing the terms "compliance" and "adherence,"2 which Osterberg and Blaschke agree are troublesome. We praise their suggestions for nonjudgmental inquiry about the consumption of medication, but further steps (especially training in communication)3,4 may be needed to facilitate full concordance and thus better streamline personal and health care system costs through optimal health. The article's epigraph should perhaps be reconsidered in terms of the patient's perspective: patients take drugs only if they agree that these agents are more beneficial than disruptive.
Gareth J. Treharne, Ph.D.
University of Birmingham
Birmingham B15 2TT, United Kingdom
g.j.treharne@bham.ac.uk
Antonia C. Lyons, Ph.D.
Massey University
Auckland, New Zealand
George D. Kitas, M.D., Ph.D.
Dudley Group of Hospitals NHS Trust
Dudley DY1 2HQ, United Kingdom
References
Marinker M, Blenkinsopp A, Bond C, et al. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain, 1997. (Accessed October 13, 2005, at http://www.medicines-partnership.org/about-us/history--context.)
Bissell P, May CR, Noyce PR. From compliance to concordance: barriers to accomplishing a re-framed model of health care interactions. Soc Sci Med 2004;58:851-862.
Thistlethwaite JE, Raynor DK, Knapp P. Medical students' attitudes towards concordance in medicine taking: exploring the impact of an educational intervention. Educ Health (Abingdon) 2003;16:307-317.
Expert Patient Programme. What is an expert patient? 2003. (Accessed October 13, 2005, at http://www.expertpatients.nhs.uk/what.shtml.)
The authors reply: We agree with Dr. Campbell that pharmacist-led interventions have proved successful in improving patient adherence to medications. However, these resources are not readily available to all providers. In the first paragraph under the section on interventions in our article, we did mention the benefits of interventions that involve pharmacists to improve adherence to medication, but we did not include this information in Table 3, which we limited to simple strategies that providers can use in general-practice settings. It is important that any intervention used to improve adherence, such as pharmacist-led interventions, include an evaluation of the cost and benefits of the approach.
We agree with Dr. Lippman's point that the role of sex should be considered in terms of the barriers and interventions related to medication-taking behavior and that more studies are needed in this area of medication adherence. We did not address the role of sex, since available data have not been consistent among all studies.1 We agree that adherence to antiretroviral medication is generally poorer in women than in men, as shown in studies on adherence to treatment regimens for HIV, and a recent study involving microelectronic monitors supports Dr. Lippman's argument about poorer adherence to medication among women with HIV.2
We addressed the need for physicians to be aware of the cost of medications, since expensive medications can be a barrier to adherence, but we did not explicitly include interventions that providers can use to overcome nonadherence that results from a patient's inability to afford the medication. The rising cost of prescription drugs, in addition to the increasing cost of insurance copayments, clearly contributes to poor adherence in many patients, but solutions to this problem were beyond the scope of our article.
We agree with Dr. Treharne and colleagues regarding the advantage of using the term "concordance" in describing the medication-taking behavior of a patient, since this implies an equal responsibility of patient and physician in the therapeutic relationship. We hope this term will become prevalent in the United States as well.
Lars Osterberg, M.D., M.P.H.
Veterans Affairs Palo Alto Health Care System
Palo Alto, CA 94304
larso@stanford.edu
Terrence Blaschke, M.D.
Stanford University Medical Center
Stanford, CA 94305
References
DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004;42:200-209.
Berg KM, Demas PA, Howard AA, Schoenbaum EE, Gourevitch MN, Arnsten JH. Gender differences in factors associated with adherence to antiretroviral therapy. J Gen Intern Med 2004;19:1111-1117.