International Summit on Clinical Pharmacy & Dispensing

November 18-20, 2013 San Antonio, Texas, USA

The Impact of pharmacist-led patient education on adherence to

antibiotic therapy in primary care

MSc. Pharm. Caglar MACIT

Yeditepe University, School of PharmacyIstanbul, Turkey

Introduction

What is adherence?

The term compliance or adherence can be described as the extent of correlation between the patients’ obedience to the therapy and the advice of health providers.

Thus, it is related to the patient’s drug-taking attitude.

2*Barber N WA. Churchill’s Clinical Pharmacy Survival Guide. Edinburgh: Churchill Livingstone; 1999.*Segador J, et al. Int J Antimicrob Agents 2005;26, 56-61.

Adherence can be affected by certain factors;

Dose & frequency of drugDuration of treatmentPharmacological factors (eg; adverse effects)Psychosocial factors (eg; patient dissatisfaction)Medical errors (eg; lack of patient information)

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*Pechere JC, et al. Int J Antimicrob Agents 2007; 29: 245-53.*Claxton AJ, et al. Clin Ther 2001; 23:1296-310.*Jackson C, et al.Patient Educ Couns 2006; 61:212-8.*Niederman MS. Int J Antimicrob Agents 2005; 26 Suppl 3:170-5.

Antibiotics & Adherence

Antibiotics are efficient, potent, safe and life-saving agents used to facilitate the healing of bacterial infections.ɫ

Unnecessary and/or inappropriate use of these drugs is a common cause of development and spread of antibiotic resistance.ɫɫ

4ɫ Hawkings NJ, Butler CC, Wood F. Patient Educ Couns 2008; 73:146-52.ɫɫ http://www.acponline.org/patients_families/diseases_conditions/antibiotic_ resistance/.

Antibiotics & Adherence cont...

Clinical Pharmacy is a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention.ɫ

Clinical pharmacists are active supporters of rational drug use; it has been shown that they provide patient care, and facilitate successful and effective medication use, including antibiotic treatment.ɫɫ

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ɫ The definition of clinical pharmacy. http://www.accp.com/docs/about/ClinicalPharmacyDefined.pdf (Accessed on 2013) (American Collage of Clinical Pharmacists)ɫɫ Hand K.. J Antimicrob Chemother 2007; 60 Suppl 1:73-6.

Aim of studyThe aim of these studies were;

to investigate whether pharmacist-led patient education about prescribed antibiotics has a positive impact on adherence.

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Istanbul

Kars

Materials & MethodsISTANBUL (n: 60) KARS (n:199)

Inclusion criteria *Out-patients* ≥ 18 years old*Oral antibiotic use

Exclusion criteria *Possible drug interactions between the prescribed drugs*Possible allergic reactions to prescribed antibiotics* ≤ 18 years old

Study group n:31 n: 99

*Received both verbal and written education regarding dose and frequency, use & possible side effects. (Warning stickers were also used)*How does resistance develop? *Reccurence of disease and effectiveness of same antibiotic. *Why is it important to finish all antibiotic medications?

Control groupn: 29 n: 100

Educated about their medications verbally and in written instructions on dose and frequency (prescribed by physician) NO EXTRA INFORMATION

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Material & Methods cont...ISTANBUL (n: 60) KARS (n:199)

Data collection First questionnaire was applied when patients come to pharmacy(socio-demographic, diagnosis, details of antibiotics, take info from physician or not, need more info from pharmacist, having any allergy, and etc.)

Second survey was performed on telephone one day after the end of the treatment (amount of pills remaining in blisters or container, omitting the treatment or missing a dose, at what time patient takes drugs, feeling better or not , whether read medicine insert)

Data analysis *Self-administration Adherence pill count = pills taken by patient x 100*Timing Adherence pills prescribed by physician*ATA (Administration and Timing Adherence)*Statistical Analysis (SPSS v.17, Chicago,IL)

Limitations * Because these studies were performed in two pharmacies, study population remained limited.*One of the method used in studies was based on a self-reported surveys due to the phone call interviews. The reliability, especially objectivity, of the method depended on the truthfulness of the patients.

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ResultsDemographic results

(Kars study) (Istanbul study)

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Figure 1a & 1b:Gender distribution of patients in Kars and Istanbul

(Kars study) (Istanbul study)

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Intermediate sc

hool

Intermediate sc

hool

Figure 2a & 2b: Educational status of participants in Kars and Istanbul

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Mean age ± SD

Study group Control group

Istanbul 37.77 ± 16.52 34.96 ± 16.10

Kars 32.28 ± 11.74 36.39 ± 13.73

Figure 3: Age distribution of participants

Table 1: Mean age of participants according to groups (Mean ± SD)

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Eye infections

Upper respiratory tract infections

Lower respiratory tract infections

Genitourinary infections

Skin infections

Dental infections

Gastrointestinal infections

In which diseases are antibiotics prescribed mostly?

(Kars study) (Istanbul study)

Figure 4a & 4b: Antibiotic prescriptions according to infection types

Upper respiratory tract infections

Lower respiratory tract infectionsSkin infections

Genitourinary infectionsGastrointestinalinfectionsDental infections

Adherence Results

Chi Square Test

We can see that study group is more adherent than control group. Pharmacist-led-education provides some benefits. However, the difference in adherence is not significant.

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Adherence Study group (n=29)

Control group(n=31)

p values

Did you quit antibiotic treatment deliberately after feeling better? (AA) Yes No

3 (10,4%)26 (89,6%)

9 (29,1%)22 (70,9%)

0,438

At what time and how many pills did you take per day? (TA) Correct (time and dose) Wrong (time and dose)

25 (86,2%) 4 (13,8%)

19 (61,2%)12 (38,8%)

0,185

Did you get better following antibiotic therapy? (ATA) Yes No

20 (68,9%) 9 (31,1%)

16 (51,6%)15 (48,4%)

0,460

Table 2: Adherence rates of patients in Istanbul study

AA: Administration Adherence; TA: Timing Adherence; ATA: Administration&Timing Adherence

More patients in the study group used antibiotic until the last day of therapy (p < 0.05).Patients in the study group are more AT Adherent than the control group. As a result,

subjective recovery rate is significantly higher.

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Adherence Study group (n=99)

Control group(n=100)

p values

Did you quit antibiotic treatment deliberately after feeling better? (AA) Yes No

15 (33,3%)84 (54,5%)

30 (66,7%)70 (45,5%)

0,012*

At what time and how many pills did you take per day? (TA) Correct (time and dose) Wrong (time and dose)

69 (51,5%)30 (46,2%)

65 (48,5%)35 (53,8%)

0,480

Did you get better following antibiotic therapy? (ATA) Yes No

92 (52,6%)7 (29,2%)

83 (47,4%)17 (70,8%)

0,032*

Table 3: Adherence ratio of patients in Kars study

Correlation with Administration Adherence R p values

Examination period- Administration adherence % 0,182 0,164

Number of pills in container- Administration adherence % -0,257 0,048*

Duration of therapy- Administration adherence % -0,260 0,045*

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*Spearman’s rho correlation test

ATA Not ATA p values

Examination period (Mean ± SD) 14,30 ± 9,63 13,70 ± 8,14 0,798

No of pills in container (Mean ± SD) 8,87 ± 4,32 12,33 ± 4,35 0,003*

Duration of therapy (Mean ± SD) 5,69 ± 2,20 7,07 ± 2,23 0,007*

*Student T test ; Mann-Whitney U test ; SD: Standart Deviation

According to these results: - number of pills Adherence - duration of therapy (Compliance)

Table 4: Correlation between Administration Adherence (AA) and examination period, number of pills in container and duration of therapy

Table 5: Effect of examination period, number of pills in container and duration oftherapy to Administration & Timing Adherence (ATA)

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*Chi Square test

In the study performed in Istanbul, patients older than 30 y old were observed to be more adherent than younger (18 - 30 y old) participants, especially in the study group. This differece in adherence between age groups is significant (p: 0,027).

Age Fully adherent Not fully adherent p value

18 – 30 (n: 32) 15 (41,7%) 17 (70,8%) 0,027*

31 ≤ (n: 28) 21 (58,3%) 7 (29,2%)

Table 6: Effect of age on adherence in Istanbul study

In our study, two subjective methods (self-questionnaire and telephone interviews) and one objective method (pill count) were combined in order to measure adherence to antibiotic therapy.

The pill count method was performed by patients themselves so it was considered as partially objective. However, it should preferably be carried out by a health professional.

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Discussion

Among demographical characteristics, only age (participants > 30 are more adherent) affected the adherence of patients, and only in the Istanbul study (p: 0,027).

The length of time taken for the physician to examine the patient did not significantly affect adherence (p: 0,164 for AA and p: 0,798 for ATA).

It was observed that there was a negative correlation between number of doses prescribed, the duration of therapy and adherence in terms of ATA.

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In Istanbul,

No statistically significant differences between study and control groups were observed in terms of adherence.

However, administration, timing and ATA rates were found higher in the study group.

Lack of significance may be due to the small numbers of patients in this study (n: 60). So, the study should be expanded to include more participants.

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Finally, as in the studies (Claxton AJ et al. in 2001; Kardas P. in 2002 and 2003) gender, education, and working status did not affect adherence of patients; however, the age of patients in Istanbul did seem to affect adherence.

*Claxton AJ.et al. Clin Ther 2001; 23:1296-310.** Kardas P. J Antimicrob Chemother 2002;49:897-903.*** Kardas P. The Journal of Applıed Research in Clinical and Experimental Therapeutics 2003. (Accessed at 2013: http://www.jarcet.com/articles/Vol3Iss2/Kardas.htm.)

Many studies that support our studies, demonstrate that structured education provided to patients by physicians and pharmacists can improve adherence to prescribed therapy.

Al-Eidan et al performed a study in 2002 on adherence of patients to Helicobacter pylori eradication therapy; adherence were measured in study and control groups, 92.1% and 23.7% respectively (p= 0,02).

In a study carried out by Kardas P. in 2002, effect of pharmacist-led education on adherence to antibiotic treatment in respiratory tract infections was shown.

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Segador J et al. performed a study in 2005 on effect of patient education on adherence to antibiotic treatment in acute sore throat therapy and study group were observed more adherent.

Morgado MP et al. carried out a study on hypertension in 2011 and this study showed that improved adherence and blood pressure control were provided by pharmacist-led patient education.

In a study performed in midwest USA by Taitel M et al. in 2012, the positive impact of face-to-face patient education provided by the pharmacist on adherence to statins was demonstrated.

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On the other hand, one study suggested that patients did not adhere to penicillin treatment even although they were informed and educated about their disease and aim of the treatment*.

*Kardas P. The Journal of Applıed Research in Clinical and Experimental Therapeutics 2003. (Accessed at 2013: http://www.jarcet.com/articles/Vol3Iss2/Kardas.htm.)

Recommendations arising from this research…

In order to increase adherence,

Antibiotics should be prescribed following culture and sensitivity testing. Thus, both adherence to antibiotic treatment and healing ratio of patients will increase. Also, development of resistance against antibioticscan be prevented.

Patients should be instructed to take their drugs with/without, before or after meals according to the pharmacokinetic properties of drug.

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Patients should be educated not only about their usage, but also about possible side effects, the importance of adherence to therapy, the aim of therapy, and the duration of treatment.

Patients should be advised to set the alarm on their mobile phones or clocks to remind them to take their medications.

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Conclusion Pharmacists may be able to play an important role in providing

pharmaceutical care to patients receiving antibiotic treatment via patient education.

They can also provide a counseling service to their patients and help to ensure patients use their medications appropriately thus enhancing rational drug use.

Further researches should be performed in order to compare adherence of patients to the antibiotic therapy and demonstrate the potential benefit and importance of the clinical pharmacist-led patient education in the provision of antibacterial therapy.

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for their contributionAssist. Prof. Dr. Philip M. CLARK

Assist. Prof. Dr. Latif OZBAY

Res. & Teach. Assist. S. Beril KADIOGLU

MSc. Pharm. Nefise Bilge ESEN

MSc. Pharm. Serdar Sinan GUNES 25

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