National trial to test strategies to improve
medication compliance in a community
pharmacy setting
Researchers:
Dr Anne-Marie Feyer, PricewaterhouseCoopers
Professor SI (Charlie) Benrimoj, University of Sydney
Carrie Schulman, PricewaterhouseCoopers
Rebecca Jessop, PricewaterhouseCoopers
Deanna Pyper, PricewaterhouseCoopers
Brian Sabet, PricewaterhouseCoopers
Mary Mitchelhill, PricewaterhouseCoopers
EXECUTIVE SUMMARY
THE RESEARCH AND DEVELOPMENT PROGRAM IS FUNDED BY THE AUSTRALIAN GOVERNMENT DEPARTMENT OF HEALTH AND AGEING
AS PART OF THE FOURTH COMMUNITY PHARMACY AGREEMENT
EXECUTIVE SUMMARY
Acknowledgement
PricewaterhouseCoopers would like to thank the Department of Health and Ageing for funding this project
as part of the Fourth Community Pharmacy Agreement, which has been administered by the Pharmacy
Guild of Australia.
The researchers would like to make special thanks to the pharmacies, pharmacists and patients who
participated in this trial without whom this report would not have been possible.
Thanks are also warranted to both the project’s Pharmacy Reference Group and Advisory Groups who
helped finalise some of the trials design and participated in workshops and discussions with participating
pharmacies throughout the trial.
This report was produced with the financial assistance of the Australian Government Department of
Health and Ageing. The financial assistance provided must not be taken as endorsement of the contents
of this report.
The Pharmacy Guild of Australia manages the Fourth Community Pharmacy Agreement Research &
Development which supports research and development in the area of pharmacy practice. The funded
projects are undertaken by independent researchers and therefore, the views, hypotheses and
subsequent findings of the research are not necessarily those of the Pharmacy Guild.
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EXECUTIVE SUMMARY
1. Executive Summary
Background
Non-compliance with medication regimens is recognised in Australia and internationally as a pervasive underlying
cause of poorer health outcomes and increased health care costs. It is estimated that 50% or more of patients fail
to comply with their medication regimen.
The Pharmacy Guild of Australia (the Guild) engaged PricewaterhouseCoopers (PwC) in collaboration with the
University of Sydney, to carry out a study investigating and evaluating strategies to improve medication compliance
within the community pharmacy setting. This project was funded by the Australian Government Department of Health
and Ageing as part of the Fourth Community Pharmacy Agreement Research and Development program managed
by the Guild. The Final and Full Final Reports provide details on the methodology and results of this 18 month project,
as well as recommendations for national implementation.
The focus of this study was to develop, implement and evaluate a professional service in community pharmacies
that aimed to improve patient medication compliance. The study commenced in August 2008 and concluded in
April 2010. To provide an intervention period of six months, the trial was implemented over an eight-month period,
from April 2009 to December 2009.
The medication compliance service trialled in this study was underpinned by four theoretical principles which informed
the design, implementation and evaluation of the intervention. These were:
•
An evidence based approach
•
Practical adult learning theory
•
Organisational change
•
Behaviour change
Given the importance of behaviour change at both the patient and pharmacy level, the national trial was comprised
of two integrated but distinct interventions, as illustrated in Figure 1.
Figure 1: Patient and pharmacist interventions
IMPROVED COMPLIANCE
Patient intervention
Stage 1
Stage 2
Stage 3
Stage 4
Sign up
Explore
Collaborate
Follow through
Sign up for the
Trial
Explore
medication-taking
behaviour and
attitude
Collaborate and
commit
to next steps
Follow through
• Invite the patient to come up • Record the patient’s
Pharmacist Intervention
Pharmacy recruitment and
selection
Pharmacist training and
education
Ongoing support and
reinforcement
Delivery of patient
intervention
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EXECUTIVE SUMMARY
Key features of the study design
Both the pharmacy and patient interventions were based on the following key design features:
1. Pharmacy recruitment occurred via national expression of interest to community pharmacies in Australia for
whom the researcher had fax or email contacts. Pharmacies were randomly recruited to the study from those
expressing interest, to fill a sampling framework using SEIFA and PhARIA classification of pharmacies, to
obtain a sample which had reasonable national representation on these characteristics.
2. Education and support to community pharmacies were provided throughout the trial, using a variety of
communication modes: interactive workshops, site visits to the pharmacy by research teams, fax and
newsletter, reminders, teleconferences and a dedicated website.
3. Patients on long term medication regimens were recruited by pharmacies from their existing cohort of patients.
4. Compliance (also described in the literature as adherence and concordance) is the extent to which the patient’s
medication taking behaviour was consistent with the recommendations of the prescriber and was measured
using the dispensing history in the pharmacy records of patients on long term medication regimens. From the
literature, adherence with the prescribed regimen should be measured empirically. Adherence of >80% is
defined as being compliant. In this study, patients were screened for a MedsIndex score (based on dispensing
data) of less than 85 out of 100 for inclusion in the trial.
5. This study focused on secondary non-compliance, where the script was filled but there was non-compliance to
the regimen, and targeting strategies to the patient. The reasons for secondary non-compliance (i.e.
prescription not refilled, not taken, intentional and non-intentional) were explored in conversation between the
pharmacist and patient. Data regarding the patient’s predictors and barriers to medication taking were collected
in a questionnaire completed at baseline and at the end of the trial.
6. ‘Motivational interviewing’ was used by the pharmacist as a method of collaborating and engaging with the
patient, in joint selection of an appropriate strategy or strategies to improve compliance. Strategies included
dose administration aids, medication profiling, home medicines review, patient education, reminders, referral to
GP, simplification of the medication regimen and patient diaries.
7. The pharmacist assessed the patient’s change readiness (the importance given to compliance and confidence
in being able to make a change) as well as the patient’s stage of change (pre-contemplation, contemplation,
preparation, action, relapse and maintenance).
8. The intervention was based on three cycles of exploring, collaborating and following through with data
collection and adjustment of the strategies, as appropriate, at each cycle.
Results and conclusion
In total, 132 pharmacies were recruited to the trial based on the study’s sampling framework (using SEIFA and
PhARIA classification), with 66 pharmacies successfully completing the trial. Participating pharmacies were able to
recruit 732 patients on long term medication regimens to the trial, with 612 (84%) returning for the three-month
pharmacy visit and 476 patients (65%) returning for the six-month follow-up visit. The key findings of the trial are
summarised below.
Improved medication compliance can be
achieved through a pharmacist-led intervention –
The key outcome of the trial was that medication
compliance significantly improved over the sixmonth trial, from 65.5 at baseline, to 77.2 at
three-months and 81.3 at six months (average
improvement of 16%). Considered in light of the
published literature, this level of improvement is
outstanding and supports the study’s hypothesis
that a significant improvement in compliance can
be achieved as a result of the pharmacist
intervention.
82
80
MedsIndex Score
•
78
76
74
72
70
68
66
64
Baseline
3 months
6 months
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EXECUTIVE SUMMARY
A medication compliance service should be based
on behaviour change principles – Principles of
behaviour change were fundamental to the
success of the trial, in engaging with busy
pharmacists to change their interaction with
patients, as well as understanding and changing
patient behaviour to improve patient outcomes in
compliance. At the pharmacy-level, results of
the trial showed an overall readiness and
motivation amongst pharmacists to implement
the compliance service. The results of the trial
also showed a significant improvement in
patients’ reported confidence in using the
compliance strategies, as well as stronger
beliefs about the importance of medication
compliance. According to behaviour change
literature, these results suggest an increased
readiness and motivation to change amongst
patients during the six-month trial.
1.9
2.0
2.1
2.2
Score
•
2.3
2.4
2.5
2.6
Confidence
2.7
Importance
2.8
2.9
Baseline
3 months
6 months
Time
•
Patient-centred interventions are important in promoting compliance – To achieve these results, over 1,300
strategies were delivered by pharmacists at baseline for the 732 patients in the trial (e.g. patient education and
reminders, readiness to change-focused discussions and shift in negative medicine beliefs) and a further 1,800
strategies over the remainder of the trial. Approximately half of the patients received a combination of strategies
highlighting the importance of patient-centred interventions on medication compliance.
•
A pharmacist-led compliance service may benefit all patients on long term medications – The compliance
service trialled in this study was found to be effective, independent of pharmacy or patient characteristics. This result
shows a generalised effect of the intervention and suggests that a pharmacist compliance service may be effective
for all patients with difficulties complying with long term medication regimens.
•
A professional compliance service requires trained and engaged pharmacists – The positive results of the trial
relied on motivated community pharmacists who were appropriately trained and supported to deliver the
compliance service. The results suggest that where initial engagement with the pharmacists was not optimal,
engagement with the patients appeared to be adversely affected. Successful engagement of pharmacists in this
trial was a key success factor contributing to the significant improvements in compliance.
•
A pharmacist-led compliance service can be well accepted by patients and pharmacists – Overall, both patients
and pharmacists reported very positive experiences in the trial, with 99% of patients indicating that they were
satisfied or very satisfied with the compliance service and 98% reported that working with their pharmacist was a
good way of helping them manage their medication.
•
An effective compliance service can be developed and implemented in the community pharmacy setting –
Results of the analysis showed that the average total cost associated with improving medication compliance over the
six-month trial, by an average of 16% per patient, was $275.61. This level of improvement in medication compliance
has been shown to result in substantial health benefits to patients and economic benefits to health services.
Overall, this trial was successful in the design and implementation of a cognitive professional service in the
community pharmacy setting, which resulted in a dramatic improvement in patient medication compliance. National
implementation of a program based on the design and implementation approach used in this trial could result in
significantly improved compliance for patients on long-term medication regimens, improvements in health outcomes
and reduced costs to the health system.
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