|Year : 2018 | Volume
| Issue : 1 | Page : 18-22
Impact of one-dose package dispensing with patient counseling on medication adherence in geriatrics suffering from chronic disorders
Narayana Goruntla1, Vijaya Jyothi Mallela2, Devanna Nayakanti3
1 Department of Pharmaceutical Sciences, Jawaharlal Nehru Technological University Anantapur, Ananthapuramu, India
2 Department of Pharmaceutical Chemistry, Raghavendra Institute of Pharmaceutical Education and Research, Chiyyedu, Andhra Pradesh, India
3 Department of Chemistry, Jawaharlal Nehru Technological University Anantapur, Ananthapuramu, Andhra Pradesh, India
|Date of Web Publication||12-Jan-2018|
Research Scholar, Jawaharlal Nehru Technological University Anantapur, Ananthapuramu - 515 002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Medication nonadherence in elderly patients could result in a waste of medical expenses in a long-time span as well as deterioration of the patient's medical condition. Aim: The aim of this study is to evaluate the impact of one-dose package dispensing with patient counseling on medication adherence among elderly patients suffering from chronic disorders. Settings and Design: This is prospective, open-labeled, randomized trial carried out at dispensing pharmacy of the secondary care referral hospital, located in resource-limited settings of Anantapur District, Andhra Pradesh, India. Subjects and Methods: A total of 330 (aged ≥60 years) patients were randomly assigned to one of three study groups: Group A (n = 110), no change in dosing and packing; Group B (n = 110), one-dose package dispensing; Group C (n = 110), One-dose package dispensing with patient counseling. Medication adherence levels were measured using a pill count and visual analog scale (VAS) method at baseline and follow-up (after 1 month). Statistical Analysis: Descriptive statistics were used to represent the sociodemographic, clinical, and medication adherence profile of study participants. One-way ANOVA test is used to assess significant differences between three groups with a P < 0.05. Results and Discussion: Medication adherence levels measured by pill count and VAS method were significantly better in Group C (98.98 ± 1.34, 95.09 ± 5.02) one-dose package with patient counseling and Group B (92.93 ± 3.77, 90.09 ± 5.98) one-dose package dispensing than Group A (87.51 ± 6.23, 84.63 ± 6.86) conventional package (P = 0.0001, 0.004). Conclusion: Patients >60 years who are on multiple medications can benefit from one-dose package dispensing and appropriate counseling. This will improve medication adherence hence better outcomes.
Keywords: Geriatrics, medication adherence, one-dose package, pill count, visual analog scale
|How to cite this article:|
Goruntla N, Mallela VJ, Nayakanti D. Impact of one-dose package dispensing with patient counseling on medication adherence in geriatrics suffering from chronic disorders. CHRISMED J Health Res 2018;5:18-22
|How to cite this URL:|
Goruntla N, Mallela VJ, Nayakanti D. Impact of one-dose package dispensing with patient counseling on medication adherence in geriatrics suffering from chronic disorders. CHRISMED J Health Res [serial online] 2018 [cited 2019 Oct 23];5:18-22. Available from: http://www.cjhr.org/text.asp?2018/5/1/18/223129
| Introduction|| |
Medication adherence is well defined as the extent to which patient takes medication as prescribed by the health-care provider. According to reports given by the center for health transformation, annually 120,000 people die in America due to not taking medication, it states the significance of medication adherence in health care.
Geriatrics will suffer from multiple comorbidities, loss of memory, sleep disturbances, and increased risk of polypharmacy. This will increase the risk of medication nonadherence in geriatrics compared to young people. The number of drugs per patient in medical care for the elderly people was high in comparison with general medical care. The monitoring survey of Medicine and the Elderly in 2005 revealed that the increase in a number count of medication per patient will increase the risk of nonadherence.
Nonadherence will cause diminished therapeutic benefits for the patient, recurrent hospital and physician visits due to the decline of their medical condition, increased health-care spending, and even overtreatment of a condition. The rate of chronic disorders such as diabetes, hypertension, arthritis, and lung diseases will be very high in elderly people. Medication adherence is very important in chronic disorders in comparison with acute conditions. Evidence suggests that interventions which made to improve medication adherence will have the potential to reduce health spending, unwanted hospital or physician visits, morbidity, mortality, and it will improve health-care outcomes such as the quality of life.
There are various strategies to improve medication adherence such as simplifying regimen characteristics, imparting knowledge, modifying patient beliefs, patient communication, leaving the bias, and evaluating adherence. These effective and economical ways of improving medication adherence were found to simplifying regimen characteristics. It includes adjusting timing, frequency, dosage, matching to patient's activity of daily living, using adherence aids, such as alarms and one-dose package dispensing. One-dose package dispensing is one of the best strategies to improve medication adherence in the geriatric population.
One-dose package dispensing means giving out pleural medicines in a package where each dosage can be separated for the ease of identification and administration as per the prescription. One-dose packaging will avoid dosing errors, promotes patient safety, and improves medication adherence. One-dose packaging will help to prevent the chance of unintentional overdose of medications. This study aims to provide one-dose package dispensing with patient counseling in comparison with one-dose package dispensing alone and conventional dispensing system to improve medication adherence in a geriatric population suffering from chronic disorders in rural settings of Anantapur district. Evidence suggests that most of the studies in relation to adherence measurement and improvement are conducted in well-developed countries. In resource-limited settings as in South India, there is lack of formal education, low socioeconomic status, and poor access to primary health care. These factors make it important to evaluate the impact of counseling in improving medication adherence.
| Subjects and Methods|| |
This prospective, open-labeled randomized trial was carried out in dispensing pharmacy of secondary care referral hospital which is located in resource-limited settings of Anantapur District, Andhra Pradesh, India. The pharmacy department is a service arm of the hospital, which provides pharmaceutical services to the inpatient department, outpatient department, Intensive Care Unit (ICU), and neonatal ICU and pediatric ICU of the hospital. Pharmacy is functional 24 h a day with peak hours for outpatient's transactions is from 9.00 am–1.00 pm to 4.00 pm–7.30 pm daily on weekdays. This study was carried out for 1 year from October 2015 to September 2016. Due permission was sought from medical director and chief pharmacist of the pharmacy department. Ethical clearance was obtained from the Institutional Review Board before initiation of the study. Patients aged 60 years or more suffering from chronic disorders and taking treatment as an outpatient or ambulatory basis were included in the study. Patients on psychiatric medicines and alternative system were excluded from the study.
A total of 330 study participants who met study criteria were enrolled and randomly assigned to one of three study groups: Group A (n = 110), no change in dosing and packing (conventional package dispensing); Group B (n = 110), one-dose package dispensing; Group C (n = 110), one-dose package dispensing with patient counseling after obtaining informed consent. Patient demographic details including age, gender, educational status, socioeconomic status, current diagnosis, comorbidities, duration of disease, different categories of drugs used, and a total number of drugs used are collected from all study participants using a suitable predefined data collection form.
In Group A, all the prescription drugs were dispensed by the pharmacist in the conventional package and given instructions as per physician advice. In a conventional package, all drugs advised for the patient are kept in a single pack and dispensed.
In Group B, all prescription drugs are divided into single doses and dispensed in one-dose packages with instructions given by the physician. These packages are made with the papercard and contain divisions for morning, afternoon, and night. Each division had an indication to take before or after a meal. It makes identification and administration of medications as recommended by a physician easier.
In Group C, all prescription drugs are divided into single doses and dispensed in one-dose packages with appropriate patient counseling regarding the indication of prescribed medicines, dose, frequency, common side effects, possible drug-drug interactions, drug-food interactions, and the importance of medication adherence.
Baseline medication adherence for previous 1 month was measured in all groups using a pill count and visual analog scale (VAS) methods. In pill-count method, a number of pills consumed were calculated by the number of remaining pills with the patient, the percentage of medication adherence was calculated as the number of pills consumed in relation to the number of pills prescribed and dispensed. In VAS method, the patients were asked to mark their medication adherence rate for past 1 month on the scale. The scale comprises of grading from 0 to 10. In this, 0 indicates no adherence and 10 indicates 100% adherence to the medications.
After 1 month, a follow-up visit was conducted, again medication adherence was measured using a pill count and VAS method and compared between all groups to assess the effect of one-dose package dispensing and patient counseling over conventional dispensing method. Patients who are unable to come for a follow-up visit, medication adherence data was obtained through telephonic interview method.
Data generated from the responses of the participants interviewed were treated confidentially and were subjected to GraphPad Instat 3.0 software (San Diego, California, USA) for data analysis. Demographic characteristics of the participants are given in the form of descriptive statistics like frequency and proportion. One-way ANOVA was conducted to measure the difference between three groups before and after follow-up. The P < 0.05 was considered as statistically significant.
| Results|| |
A total of 330 patients were enrolled and divided into three groups. The mean age of Group A, B, and C are 68.58 ± 5.91, 69.59 ± 6.52, and 69.11 ± 6.48, respectively, most of the patients are between 60 and 70 years of age. All patients are uniformly distributed in three groups in respect of gender, educational status, marital status, diagnosis, categories of drugs used, and a number of drugs per prescription and medication adherence level as depicted in [Table 1].
|Table 1: Distribution of sociodemographic characteristics and medication adherence levels of study population (n=110)|
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Pill-count method was used to measure medication adherence level in three groups. Baseline medication adherence between Group A (87.35 ± 6.30), Group B (87.59 ± 6.98), and Group C (85.91 ± 7.03) was comparable (P = 0.139). After 1 month of assignment of one-dose package dispensing in Group B and one-dose package with patient counseling in Group C, medication adherence levels were measured, in Group A (87.51 ± 6.23), Group B (92.93 ± 3.77), and Group C (98.98 ± 1.34) (P = 0.0001) as shown in [Table 2].
|Table 2: Baseline and follow-up medication adherence levels in three groups by pill-count method|
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VAS method was also used parallel to pill-count method to measure medication adherence. Baseline average medication adherence levels between Group A (85.09 ± 6.46), Group B (86.09 ± 6.22), and Group C (84.27 ± 5.81) was comparable (P = 0.09). After 1 month of assignment of one-dose package in Group B and one-dose package with patient counseling in Group C, medication adherence level measured, in Group A (84.63 ± 6.86), Group B (90.09 ± 5.98), and Group C (95.09 ± 5.02) (P = 0.004) as shown in [Table 3].
|Table 3: Baseline and follow-up medication adherence levels in three groups by visual analog scale method|
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| Discussion|| |
Nowadays, pharmacist role has been extended from dispensing drugs to the management of drug therapy to achieve definite outcomes by providing pharmaceutical care services. One-dose package dispensing and patient counseling about the importance of drug therapy and significance of each drug will play a vital role in enlightening medication adherence to achieve definite clinical outcomes. Medication nonadherence is a major problem seen in geriatrics due to multi-drug combinations. Pharmacists can take measures to improve patient compliance by counseling them about adherence and the role of each drug.
At baseline, medication adherence levels which are calculated by pill count and VAS methods in Group A, Group B, and Group C are nearly similar. There was no statistical difference between these three groups with a P value of pill count (0.139) and VAS method (0.09).
From study findings after 1 month, it was observed that there was a significant improvement in medication adherence levels measured by pill-count method, in Group B (92.93%) using a unit dose package and Group C (98.98%) using unit dose package with counseling compared with Group A (87.51%) conventional package with a (P< 0.05). Improvement of medication adherence by one-dose package and counseling and patients felt the advantage to reduce the improper drug use as well. These findings are parallel with a study conducted by Nakai et al., in which medication adherence was measured by interview method.
In the follow-up visit, medication adherence levels measured by VAS method are also significant in Group C (95.09 ± 5.02) and Group B (90.09 ± 5.98) in comparison with Group A (84.63 ± 6.86) (P = 0.004). These results are almost similar to findings of a study conducted by Schneider et al.
The one-dose package dispensing and counseling about medications are good for patient health, particularly in the geriatric population. We could not comment on any economic value of dispensing the one-dose package by pharmacist such as compensation rate because we did not evaluate the economic value of this activity. However, we suggest that there should be some incentive for this pharmacist activity with the appropriate value for improving the medication adherence, which was shown in this study as well as the result of many kinds of the literature of one-dose package dispensing and patient counseling by a pharmacist. More research activities on pharmacist role in patient care should be conducted to have better health outcomes with proper drug use.
Strengths and weaknesses
Medication nonadherence is the most complex problem seen in medication management of geriatrics; this study will provide insights for improving medication adherence levels in geriatric population by adapting one-dose package dispensing in medication management policies. The major drawback of this study was measuring the adherence levels by the number of pills remaining or by respondents rating in VAS, so these methods may not give accurate adherence levels toward medications. There is a need still existing in the development of novel techniques to improve and to measure medication adherence levels which will improve the clinical outcomes.
| Conclusion|| |
Although one-dose package dispensing by the pharmacist as a progressive impact on medication adherence levels, still some gaps exist. These gaps can be filled educating patients about medication adherence and their usage which observed in this study. Patients 60 years or more, on multiple medications, will benefit from appropriate counseling about their medication by a pharmacist. This will have a positive impact on medication adherence level to achieve better health outcomes compared to conventional package dispensing system.
The authors would like to thank all participants in this study. We also thank Dr. Sudheer Kumar, Director, RDT Hospital, Anantapur, for his support to organize educational program in the study site. All the authors are wholeheartedly thankful to the people who are directly or indirectly responsible for the completion of the work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Osterberg L, Blaschke T. Adherence to medication. N
Engl J Med 2005;353:487-97.
Nakai K, Yamamoto N, Kamei M, Fujita M. The effect of one-dose package on medication adherence for the elderly care in Japan. Pharm Pract (Granada) 2009;7:59-62.
Angela FY, Thirumoorthy T, Kwan YH. Medication adherence in elderly. J Clin Gerontol Geriatr 2016;7:64-7.
Murray MD, Kroenke K. Polypharmacy and medication adherence: Small steps on a long road. J Gen Intern Med 2001;16:137-9.
Toh MR, Teo V, Kwan YH, Raaj S, Tan SY, Tan JZ, et al.
Association between number of doses per day, number of medications and patient's non-compliance, and frequency of readmissions in a multi-ethnic Asian population. Prev Med Rep 2014;1:43-7.
Jimmy B, Jose J. Patient medication adherence: Measures in daily practice. Oman Med J 2011;26:155-9.
Atreja A, Bellam N, Levy SR. Strategies to enhance patient adherence: Making it simple. MedGenMed 2005;7:4.
Kalichman SC, Amaral CM, Swetzes C, Jones M, Macy R, Kalichman MO, et al
. A simple single-item rating scale to measure medication adherence: Further evidence for convergent validity. J Int Assoc Physicians AIDS Care (Chic) 2009;8:367-74.
Murray MD, Birt JA, Manatunga AK, Darnell JC. Medication compliance in elderly outpatients using twice-daily dosing and unit-of-use packaging. Ann Pharmacother 1993;27:616-21.
Schneider PJ, Murphy JE, Pedersen CA. Impact of medication packaging on adherence and treatment outcomes in older ambulatory patients. J Am Pharm Assoc (2003) 2008;48:58-63.
[Table 1], [Table 2], [Table 3]