Pharmacy records reveal patient med adherence
Study concludes that patients inflate self-reports
Patients will say they’re taking their medications regularly, but if their viral loads are rising and CD4 cell counts are falling, it’s a good idea to double-check their self-reports. A study of 100 HIV patients receiving care through the Denver Public Health system demonstrated that nonadherence is relatively common.1
"Not all that surprisingly, there wasn’t a great correlation between self-reported adherence and pharmacy adherence," says William J. Burman, MD, attending physician in the Infectious Disease Clinic of Denver Public Health. "If you take pharmacy adherence to be a more accurate measure, then patients more often overestimated their adherence than they underestimated it," Burman says. "And clinicians can’t predict which patients will have adherence."
Investigators at Denver Public Health did an earlier study of patient adherence to a pneumocystis prophylaxis. That study found that nonadherence was common and not well-predicted by clinicians, Burman says. "Clinicians need, if at all possible, objective data to diagnose problems with adherence," he says.
The most objective data come from the pharmacy. But if a clinician doesn’t know where patients are filling prescriptions, then it’s possible to obtain a more accurate self-report by asking patients more specific questions. "Don’t ask, Do you take your medications correctly?’" Burman says. "What’s more helpful is a very focused questionnaire about the past three days, because generally the accuracy of self-reported data is greater if you ask very specific questions."
At Denver Public Health — a large urban public health system — pharmacy adherence is fairly easy to monitor. The health system serves mainly low-income and indigent patients who fill their prescriptions at one pharmacy. It’s easy to identify which patients have been filling their prescriptions and which haven’t.
"When we’re faced with a patient with rising viral loads, the first question we ask is, What have they been doing with their old drugs,’ and quite often that answer is very revealing," Burman says. "Our attitude is that if there were problems with adherence with the old regimen, unless you do something about that, there will be more problems with adherence in the salvage regimen," he adds.
The study found that of 81 patients on therapy, 56, or 73%, were adherent by a 3-day recall, and 48 or 59% were adherent according to pharmacy data. Self-reported nonadherence risk factors were alcohol abuse, life stress, and Hispanic ethnicity. Pharmacy nonadherence risk factors were African-American or Hispanic race/ethnicity and a history of injection drug use. Patients in the study reported that the most common reasons for missing doses were being busy (48%), forgetfulness (42%), "don’t feel like taking medication" (32%), and side effects (22%).1
Denver Public Health investigators surveyed patients on what obstacles and solutions were related to their adherence. "We took a lot of the patients’ suggestions," Burman says. For example, Denver Public Health clinicians dispense medications whenever possible and give pillboxes to all patients who want them. Also, Denver Public Health has an outreach team that pays weekly visits to patients who ask for help with adherence, he says.
"One of the lessons from the research was that life stress was really correlated with adherence," Burman says. "The message to clinicians is that we must deal with major problems before starting patients on antiretrovirals, and these problems include depression, substance abuse, social issues, and housing issues."
Burman also suggests that physicians be prepared to refer some patients to psychiatric care. "We consider that to be part and parcel of primary medical care."
Reference
1. Burman WJ, Sharkey L, Sampson J, et al. Adherence with antiretroviral therapy: A comparison of self-reported adherence with pharmacy records. Abstract #358 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
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