27 Apr 2022
Pharmacy-based interventions can unburden our healthcare system
Medication non-adherence occurs when a patient fails to take their medications according to the prescribed dosage, time, frequency, and direction. Non-adherence is difficult to measure as it is based on patient reporting.
Medication non-adherence for patients with chronic diseases is extremely common in the United States, affecting as many as 40 to 50% of patients prescribed medications to manage chronic conditions like diabetes or hypertension.
In 2017, it was estimated that medication nonadherence causes 125,000 unnecessary deaths and costs the national health care system $290 billion each year in the United States. Yet, most practising physicians are barely aware of the problem.
We are yet to estimate how much medication non-adherence costs the South African health care system and how many lives are lost per year.
A complex problem
Nonadherence to medication is a complex and multidimensional health care problem. The causes may be related to the patient, treatment, and/or health care provider.
Patient-related barriers to medication adherence can be:
The lack of knowledge and understanding about diseases and treatments
The perception and beliefs about disease management
Affective factors (depression, anxiety, shame, etc…)
Behavioural factors (e.g. missed appointments)
Factors related to treatment burden and an adverse drug event (treatment fatigue, side effects)
Socioeconomic and demographic factors (disease-related, transport, age, etc.)
The lack of support (e.g. social support)
It is crucial to detect nonadherence, determine the reason for it, and discuss possible solutions with the patient to tailor an intervention to their needs.
One example is a study from Denmark in which an interventional toolbox was developed, enabling pharmacy staff and general practitioners to tailor a counselling program for individual patients.
These tools were divided into five groups: (1) Evaluating medicines and drug-related problems; (2) Patient counselling and coaching; (3) Patient education and information; (4) Reminder technologies; and (5) Communication tools.
The results of a study done in Amsterdam also confirmed the importance of pharmacists helping nonadherent diabetic patients with their medication intake through a tailored, modular pharmacy-based intervention.
Burdened health care system
South Africa has the fourth-highest HIV prevalence rate in the world, with 19.10%. Nevertheless, because of the country's large population, this percentage amounts to approximately one-fifth of all HIV cases worldwide, more than any other country.
The country has the world’s largest ART program, with 68% of people with HIV receiving antiretroviral therapy (ART) in 2021 and 93% of those patients achieving viral load suppression.
The rollout of nurse-initiated and managed antiretroviral treatment (NIMART) was implemented in 2010 by the National Department of Health in South Africa to strengthen the nursing response to HIV and TB in the country.
Nurses working on the frontlines of the epidemic are trained to be able to provide support on counselling, prevention, diagnosis and treatment.
Nurse-Initiated Management of ART
Decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases.
According to the KZN department of health, since the introduction of NIMART in 2010, the number of patients on antiretroviral therapy in the province quadrupled from 168 610 in 2009 to 1 039 511 patients in 2015.
This province was the largest recorded ART cohort in the country at the time which totalled 3 318 384 patients spread over 9 provinces.
However, the importance of ensuring capacity building, training and mentoring of nurses to integrate HIV services to reduce workload and provide a comprehensive package of care to patients was noted.
Pharmacist-Initiated Management of ART
A U.S study developed a pharmacist-managed adherence clinic and designed a study to assess the impact of the adherence interventions by measuring the proportion of patients with 95% or greater adherence to ART before and after referral to the program.
HIV providers referred patients with adherence problems to a pharmacist-managed adherence clinic. Interventions included scheduled clinic visits with the HIV Clinical Pharmacist and monthly refill reminders from pharmacy staff members over 6 months.
In most studies, adherence is defined as taking 80% or more of the prescribed medication doses. In this study, the proportion of participants with 95% or greater adherence to their ART regimen increased from 7% at baseline to 32% post-intervention. A subanalysis of the study revealed an overall increase from a baseline adherence mean of 60% to 81% post-intervention.
SA Pharmacists available for impact
Pharmacists will soon be able to prescribe antiretroviral medication in South Africa. Just like nurses for NIMART, the pharmacist-initiated management of ART (PIMART) will allow significantly more South Africans to access antiretroviral therapy.
The first port of call for many people seeking health services in South Africa is a private pharmacy, according to professor Francois Venter at WITS. Venter believes that public ARV programmes have reached a plateau in recruiting patients and linking them to care.
Considering the burdened health care system of South Africa and the growing number of unemployed pharmacists in the country, it is clear that medication adherence & PIMART should be prioritised. Pharmacists' rising unemployment given the deficit is already a grave tragedy. But furthermore, unnecessary loss of lives and exorbitant costs to the health care system can be significantly reduced by pharmacy-based interventions.