AHA: Attention from Pharmacist Improves Compliance for Older Patients

CHICAGO, Nov. 14 -- Some relatively simple extra steps by the pharmacy may sharply escalate compliance by older patients, researchers reported here.

A comprehensive pharmacy care program improved 16-fold the number of patients who were at least 80% compliant, said Allen J. Taylor, M.D., of the Walter Reed Army Medical Center in Washington, and colleagues. Their study, presented at the American Heart Association meeting, was reported simultaneously online in the Journal of the American Medical Association.

The single center study included 200 patients ages 65 and older in the military healthcare system (mean age 78, 77.1% men). The pharmacy care program included individualized education by a pharmacist, custom-packed medications in blister packs, and two-month follow-ups with a pharmacist.

Pharmacists bundled patients' multiple medications into blister packs with morning, noon, and night dose cards, which were then sealed. The monthly cards were preprinted with the date.

In the first, six-month phase, when all patients received pharmacy care, adherence climbed from 61.2% at baseline ( 13.5%) to 96.9% ( 5.2%), which discussant Harlan M. Krumholz, M.D., of Yale, called "extraordinary."

Along with increased compliance, there were similar improvements in measured health outcomes. The researchers reported:

• Significantly lower blood pressure (129.9 16.0 mm Hg versus 133.2 14.9 at baseline, P=0.019).
• Significantly lower levels of low-density lipoprotein cholesterol (86.8 23.4 mg/dL versus 91.7 26.1 mg/dL at baseline).

In the second phase, patients were randomized to continue pharmacy care or to return to usual care. Medication adherence dropped back to baseline for the usual care group (69.1% 16.4%) but stayed at 95.5% ( 7.7%) out to 14 months for the intervention group.

The corresponding patient health outcomes were:

• Systolic blood pressure continued to significantly fall in the pharmacy care group (-9.6 mm Hg reduction, 95% confidence interval -10.7 to -3.1 mm Hg) compared to standard care (-1.0 mmHg reduction, 95% CI -5.9 to 3.9 mmHg, P=0.04), and
• LDL cholesterol plateaued at the phase I levels for both groups and there was no significant difference in between-group difference levels or reductions.

These results show that "there wasn't a durable effect of having been in the program for six months," Dr. Taylor said. "You need to both start in the program and continue to benefit."

He said that strategies to improve medication adherence are necessary because of the heavy burden of medications in the elderly (average nine chronic medications a day in the study) and decreased efficacy of medication when not taken.

"If we can pay for medications, we should find ways to leverage the medications patients take to get better health outcomes through improving adherence," Dr. Taylor said.

Most of the patients started the study with cardiovascular risk factors including drug-treated hypertension (91.5%) and drug-treated hyperlipidemia (80.6%). All were independently living rather than in assisted living or nursing home residents.

In a related JAMA editorial, Ross J. Simpson, Jr., M.D., Ph.D., of the University of North Carolina at Chapel Hill said there are many factors that contribute to poor treatment adherence in older adults. He listed advanced age, cognitive impairment, depression, beliefs regarding the importance of the medication, the disease being treated, adverse effects, polypharmacy, frequent dosing, and high costs.

However, because participants in the study did not have to pay for medications or care received from the military health care system, this may make the results less generalizable, the authors noted.

Dr. Simpson added, "Even in this setting in which medications are free and medical care is accessible and of excellent quality, medication adherence is poor."

He also noted some weaknesses of the study. "The intervention does not seem to be guided by a specific behavioral model," he wrote. "In addition, counseling seemed particularly intense and time consuming, and the individual components of the counseling cannot be separated out and their relative value assessed. Likewise, the benefits of the major components of the intervention cannot be disentangled."

"A more important concern is that the intervention is not simply a combination of pharmacist counseling and blister packs," he continued. "Because the usual-care group was the reference group, the two groups in the randomized trial phase of the study had different levels of observation and different frequency of visits to the health facility after randomization, and patients in the usual-care group had an intervention that they had been receiving for six months removed.".

"Patients in the intervention group were observed more often and with greater intensity than those in the usual care group, thereby introducing a potential observation bias that favored the intervention group, especially because adherence is a behavior and observing a behavior influences the behavior," he noted.

While the blister packs were inexpensive, the education and labor were time consuming for the pharmacists, Dr. Taylor said. "This is not a CVS or a Rite Aid sort of solution."

"A teamwork approach is best," he said. "Physicians select the best treatments and then I think that the clinical pharmacist is a key link we haven't leveraged in this problem."

Further study will be needed to make such programs applicable in the general population, he concluded.