|Year : 2021 | Volume
| Issue : 2 | Page : 120-125
How do physicians and nurses assess and support patient medication adherence? An examination of a rural secondary care hospital in Delhi, India
Saurav Basu1, Ruchira Pangtey1, Bratati Banerjee1, Saurabh Kumar2
1 Department of Community Medicine, Maulana Azad Medical College, Delhi, India
2 Department of Office of the Medical Superintendent, Maharishi Valmiki Hospital, Delhi, India
|Date of Submission||18-Nov-2020|
|Date of Acceptance||14-Jan-2021|
|Date of Web Publication||29-Jun-2021|
Dr. Saurav Basu
Room No. 358, Department of Community Medicine, Maulana Azad Medical College, 2 BSZ Marg, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Suboptimal medication adherence contributes enormously to patient mortality, morbidity, and related health-care costs. Health-care providers (HCPs) have a pivotal role in supporting medication adherence in their patients through appropriate health communication. We assessed the perspectives and practices of medical doctors and nurses toward the assessment and support for patient medication adherence in Indian health settings.
Materials and Methods: We conducted a cross-sectional study at a secondary-care hospital in Delhi. Data were collected from medical doctors, interns, and nursing staff using a self-administered questionnaire on the following domains: Medication Adherence, frequency, methods and tools of assessment, high-risk patient identification and interventions applied to promote adherence.
Results: We recruited a total of 117 HCPs. The common modes of assessment of medication adherence used by the HCPs included a general question (78.6%), observing missed appointments (43.6%), and querying for forgetfulness (29.9%). However, none of the HCPs were aware of validated questionnaire (scales) for the assessment of medication adherence. Drug-related adverse effects as a cause of nonadherence were evaluated by 38.3% HCPs only.
Conclusions: The development of simple and validated methods for assessing medication adherence applicable in resource-constrained settings along with the curricular training of HCPs on patient adherence and related know-how needs urgent prioritization.
The following core competencies are addressed in this article: Practice-based learning and improvement, Systems-based practice, and Interpersonal and communication skills.
Keywords: Assessment, health-care providers, India, medication adherence
|How to cite this article:|
Basu S, Pangtey R, Banerjee B, Kumar S. How do physicians and nurses assess and support patient medication adherence? An examination of a rural secondary care hospital in Delhi, India. Int J Acad Med 2021;7:120-5
|How to cite this URL:|
Basu S, Pangtey R, Banerjee B, Kumar S. How do physicians and nurses assess and support patient medication adherence? An examination of a rural secondary care hospital in Delhi, India. Int J Acad Med [serial online] 2021 [cited 2021 Jul 24];7:120-5. Available from: https://www.ijam-web.org/text.asp?2021/7/2/120/319798
| Introduction|| |
Medication adherence is the extent to which the drug-taking behavior of the patients corroborates with that prescribed by the physician. Medication nonadherence substantially increases avoidable patient morbidity and mortality, worsens clinical outcomes and the preventable associated health-care costs., Among people with chronic noncommunicable diseases (NCDs), less than one in two achieve optimal adherence, with further reduction in the absence of regular drug possession arising from the lack of drug accessibility or affordability.,
It is well-established that health-care providers (HCPs), especially physicians and nurses, have a pivotal role in supporting medication intake behavior of patients through appropriate health communication for attaining optimal adherence and health outcomes., HCPs are responsible for assessing and identifying nonadherence and anticipate those at risk of nonadherence, communicate effectively to promote adherence and apply clinically tested interventions for adherence support., Furthermore, HCPs should be responsive toward assuring and assisting patients against the harm from any real or perceived drug side effects.
A large volume of research in developing countries in recent years has focused on the assessment of medication adherence in patients with NCDs and their determinants., However, there is a lack of studies that have evaluated medication adherence support behaviors among HCPs, especially among those operating in the public or the government sector.
We, therefore, conducted this study intending to assess the perspectives and practices of doctors and nurses toward the assessment and support for patient medication adherence in Indian health settings.
| Methods|| |
Study design and setting
A cross-sectional study was conducted at a secondary-care government hospital in a rural area of North-West Delhi during 2 months from September to October 2019. Medicines are dispensed free of cost to all the patients at the hospital pharmacy with refill requirements at 2–4 weeks on an outpatient basis.
Study population and selection criteria
The study was conducted among clinicians (consultants, resident doctors, and medical officers), interns, and the nursing staff employed at the hospital.
Frequency of assessment of medication adherence and the application of interventions to promote medication adherence in patients with acute and chronic health conditions.
Sample size and sampling
A universal sample of all the HCPs meeting the selection criteria and employed at the hospital were invited to participate in the study.
Data were collected using a self-administered questionnaire in the English language [Annexure 1]. The questionnaire included questions on. Frequency of assessment of patient medication adherence and association with disease type by the health-care provider (health-care worker). Methods employed for the assessment of medication adherence. Awareness of validated tools for medication adherence. Recognition of patients at higher risk of medication nonadherence. Interventions applied by the HCPs for supporting adherence in their patients. The questions were coded on 3- and 4-item Likert scales.
The paper-based questionnaires were distributed to all the eligible hospital staff after their clinic hours by an investigator. Those staff who requested for more time in answering the questionnaire were contacted at a later date as per their convenience. In most cases, the respondents returned filled questionnaires to the investigator within a 2-week period.
The data were analyzed with IBM SPSS Statistics for Windows, Version 25.0 (Armonk, NY: IBM Corp). Categorical data were reported as frequency and proportions, and continuous data as mean and standard deviation (SD). The group categories were stratified as per the personnel type (doctor/nurse) and as per the response categories. The Chi-square test was used to find out the association between the categorical variables. P < 0.05 was considered statistically significant.
| Results|| |
A total of 117 HCPs, including 48 (41%) medical physicians, 28 (24%) medical interns, and 41 (35%) nursing staff of a secondary care hospital, returned filled questionnaires with a net response rate of 85%. There were 62 (53%) male and 55 (47%) female participants and their mean SD age was 32.68 (9.1) years. The Cronbach's-alpha (reliability) of the study questionnaire was 0.694.
Assessment of adherence
The most common method for assessing adherence applied by the participants was through a general question “are you taking your medicine/s?” (78.6%). A total of 35 (29.9) HCPs reported regularly querying their patients whether they sometimes forgot taking their medication. Assessment of medication adherence by examining the frequency of missed appointments was practiced by 51 (43.6%) participants. However, none of the participants were aware of any validated medication adherence questionnaires.
The frequency of assessment of medication adherence was more likely on every patient visit in acute compared to chronic disease conditions [Table 1]. The participants were always more likely to suspect medication nonadherence in patients with suboptimal health outcomes (76.9%) and the elderly (52.1%) [Table 2]. The nursing personnel were significantly more likely to suspect nonadherence in patients with lower educational attainments (P = 0.04).
|Table 1: Frequency of assessment of medication adherence by health-care providers (n=117)|
Click here to view
|Table 2: Sociodemographic and clinical characteristics of patients suspected by health-care providers to have poor medication adherence in outpatient settings (n=117)|
Click here to view
The HCPs reported always practicing the following clinical strategies for improving patient medication adherence: Verbal repetition of the drug dosing to either the patient (65%) or their attendant (56.4%), explaining harmful consequences of nonadherence (55.6%), evaluation of drug-related adverse effects (38.5%), and the assessment of the inventory of prescribed medicines at the hospital store and identification of alternatives at periodic intervals (38.5%). Compared to the medical personnel, the nursing personnel reported significantly greater regularity in the application of adherence promoting behavioral interventions for their patients [Table 3].
|Table 3: Distribution of interventions applied by healthcare providers to improve medication adherence in vulnerable patients (n=117)|
Click here to view
| Discussion|| |
The present study found the modality of assessment of patient medication adherence by HCPs was mostly through nonvalidated methods. The use of an arbitrary and misconstrued universal 80% threshold as indicative of good adherence is a highly prevalent misconception among medical professionals. Furthermore, we found that HCPs may miss focusing on some of the vulnerable patient groups at increased risk of nonadherence like those belonging to lesser educational and lower socioeconomic status.
Evidence from previous studies suggests that globally, physicians are likely to substantially underestimate the prevalence of medication nonadherence in their patients., It is well-established that the accurate evaluation of medication adherence is problematic for medical practitioners worldwide, but particularly more so in the developing world where health systems often lack digital records for the secondary database analysis coupled with the reduced time available for effective doctor–patient consultation in overstretched public health facilities.
In this study, only 29% HCPs asked their patients if they sometimes forgot taking their medications, a question that is considered to have high specificity in the detection of nonadherence. There is growing recognition that physician education for improving their communication skills could enhance their performance toward increasing medication adherence in their patients., Consequently, the need for developing and validating simple and brief methods for reliably assessing medication adherence which could be utilized uniformly by all HCPs including community health workers is pertinent in the resource-constrained settings of the developing world.
Improving medication adherence is considered one of the single-biggest interventions that could substantially improve health outcomes and reduce related costs in patient populations. Medication adherence implies a collaborative agreement between the physician and the patient for the disease management through specific pharmacological measures. Furthermore, despite the lack of prior systemic inquiry, there is some evidence that patients medication adherence varies among providers and is significantly influenced by the patient-provider relationship and their connectedness.,, In the present study, the most common strategy applied by HCPs for the promotion of adherence emphasized repetition of the treatment prescribed by them which can be particularly useful in patients with low health literacy or lower self-efficacy. However, nearly two in three HCPs did not routinely assess the occurrence of treatment-related adverse effects in their patients. HCPs also did not regularly assess drug-stock position in the hospital pharmacy before prescribing treatment, which in the event of a drug stock-out can potentially contribute to nonadherence or the failure of drug persistence. These lacunae indicate the pressing need for greater sensitization of HCPs toward this important public health problem.
First, we did not assess medication adherence in patients and attempt to corroborate it with the assessment made by the HCPs. Second, HCPs could have over-reported their focus on assessment and the promotion of medication adherence in their patients, due to the social desirability bias. Third, our study lacked participation from the hospital pharmacy staff who have crucial roles in assessing and intervening for improving medication adherence in patients. Fourth, the study was conducted in a single site with a significantly higher proportion of early-career physicians, which limits its generalizability.
| Conclusions|| |
Suboptimal assessment of medication adherence by doctors and nurses was observed in a secondary care hospital in a resource-constrained setting, indicative of the need for curricular training of HCPs on patient adherence and related know-how with urgent prioritization.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The study was approved by the Ethics Committee, Maharishi Valmiki Hospital, Pooth Khurd, Delhi and the approval number was No. F.1 (7-v)/1/MVH/2013/2668 dated 30.05.2019. The authors have utilized the STROBE statement which was applicable as per the EQUATOR (https://www.equator-network.org) reporting guidelines. All the participants were recruited after obtaining their written and informed consent. Confidentiality was maintained during all stages of the study.
| References|| |
Sabatâe E. Adherence to long-term therapies: Evidence for action. 1st
ed. Geneva: World Health Organization; 2003.
Egede LE, Gebregziabher M, Echols C, Lynch CP. Longitudinal effects of medication nonadherence on glycemic control. Ann Pharmacother 2014;48:562-70.
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-97.
Sankar UV, Lipska K, Mini GK, Sarma PS, Thankappan KR. The adherence to medications in diabetic patients in rural Kerala, India. Asia Pac J Public Health 2015;27:NP513-23.
Náfrádi L, Nakamoto K, Schulz PJ. Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence. PLoS One 2017;12:e0186458.
Kleinsinger F. The Unmet Challenge of Medication Nonadherence. Perm J 2018;22:18-33.
Basu S, Garg S, Sharma N, Singh MM. Enhancing medication adherence through improved patient-provider communication: The 6A's of intervention. J Assoc Physicians India 2019;67:69-71.
Akeroyd JM, Chan WJ, Kamal AK, Palaniappan L, Virani SS. Adherence to cardiovascular medications in the South Asian population: A systematic review of current evidence and future directions. World J Cardiol 2015;7:938-47.
Gellad WF, Thorpe CT, Steiner JF, Voils CI. The myths of medication adherence. Pharmacoepidemiol Drug Saf 2017;26:1437-41.
Siddiqui A, Siddiqui AS, Jawaid M, Zaman KA. Physician's perception versus patient's actual incidence of drug non-adherence in chronic illnesses. Cureus 2017;9:e1893.
Meddings J, Kerr EA, Heisler M, Hofer TP. Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: Still no better than a coin toss. BMC Health Serv Res 2012;12:270.
Basu S, Garg S, Sharma N, Singh MM. Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings. Ci Ji Yi Xue Za Zhi 2019;31:73-80.
Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatment: Clinical applications. JAMA 2002;288:2880-3.
Sherman BW, Sekili A, Prakash ST, Rausch CA. Physician-specific variation in medication adherence among diabetes patients. Am J Manag Care 2011;17:729-36.
Blandford L, Dans PE, Ober JD, Wheelock C. Analyzing variations in medication compliance related to individual drug, drug class, and prescribing physician. J Manag Care Pharm 1999;5:47-51
Atlas SJ, Grant RW, Ferris TG, Chang Y, Barry MJ. Patient-physician connectedness and quality of primary care. Ann Intern Med 2009;150:325-35.
Boskovic J, Mestrovic A, Leppée M, Bago M, Sostar Z, Naletilic D. Pharmacist competences and impact of pharmacist intervention on medication adherence: An observational study. Psychiatr Danub 2016;28:420-7.
[Table 1], [Table 2], [Table 3]