Study: Daily calls boost medication compliance

PPS may make phone contacts more practical

Ensuring that home health patients take their medications regularly can be difficult, since patients can forget doses or fail to take them because of financial or other difficulties. This problem becomes especially acute when dealing with patients who have complex illnesses, in which the failure to take medicine on schedule can be more compromising.

Elderly patients living at home are considered to be at high risk for complications from poor medication compliance. Those complications, in turn, often necessitate a trip to the emergency room and rehospitalization.

A simple solution

A study of medication compliance has found a surprisingly simple remedy — just calling patients on a regular basis to see if they’ve taken their pills.¹

Terry Fulmer, PhD, RN, FAAN, professor of nursing at New York University in New York City, says that in a recent study, daily phone calls made a significant difference when compliance was measured later. "For those individuals who were called, their compliance was substantially higher."

And while the practice currently isn’t covered by Medicare, another participant in the study says that could change with the imminent arrival of the prospective payment system.

"Under the old fee-for-service payment system when the agency was paid for a visit but not for any other patient interaction, such phone calls were not reimbursable expenses," says Penny Hollander Feldman, PhD, director of the Center for Home Care Policy & Research at the Visiting Nurse Service of New York in New York City.

"Now that home health agencies will be paid a prospective payment starting in October, we are exploring ways of improving patient management that do not necessarily involve a visit," Feldman says. "We will be re-examining telephone support as one of a variety of effective patient interventions to augment visits."

The study, which was published last August in the Journal of Gerontological Nursing, looked at 50 frail, elderly patients who had a primary or secondary diagnosis of congestive heart failure and were taking multiple medications.

The patients were split into three groups:

• a control group receiving standard care;

• a second group that received additional daily telephone reminders about their medication;

• a third group that spoke to a nurse daily via a video telephone, which allowed the patient and nurse to see each other’s faces while they conversed.

"Our hypothesis was that a daily video interaction, a face-to-face interaction via the daily video telephone call, would be stronger in terms of improving compliance," Fulmer says. She says AT&T donated videophones for the study.

Monitored with MEMS caps

The phone and videophone calls were made daily, at a prearranged time of the patient’s choosing. Some patients, for example, would ask to be called at lunchtime, others in the afternoon after their nap. "[The patient] would say, Hi, Terry, how are you today?’ and I’d say, Hi, Mrs. So-and-so, did you take your medicine today?’ And she’d say yes or no."

No effort was made to directly observe the patient taking his or her pills or to time the call to coincide with the medication time. "They knew we would call and say, Did you take your pills?’" Fulmer says. "We did not say, It’s time for your pills.’"

The patients’ compliance was measured through the use of Medication Event Monitoring System (MEMS) caps, which electronically monitor the times that the bottles are opened. At the end of the study, Fulmer was able to retrieve the caps and study the compliance rates by computer.

The MEMS caps themselves are considered an intervention in medication compliance, since they remind the patients that their actions are being monitored, Fulmer says. Therefore, she waited two weeks after giving the patients the bottles, to give them time to get used to them, before beginning the calls. After six weeks of calls, there was another two-week monitoring period.

The difference in compliance among the three groups was striking:

• The control group showed a significant drop in compliance, from 81% at the beginning of the study to 57% 10 weeks later.

• The group receiving phone calls didn’t fall nearly as quickly, going from 76% at the beginning of the study to 74% at the end.

• The videophone patients did best of all, starting at 82% and ending at 84%.

Fulmer says the difference between the compliance rates in patients who received the phone calls and those who received the videophone calls was not considered significant for research purposes. "But we think that was because we did not have enough people in our sample. The trend was that the video telephone was very powerful."

In any case, the intervention of a daily call of some kind was linked to improved compliance in the two intervention groups, Fulmer says.

Computerized calls may have effects

Fulmer hypothesizes that a similar effect may be reached by using an electronic calling system that delivers a recorded message to patients. But she is unsure whether the loss of the live interaction between the nurse and patient would hurt results. "I think people want human contact," she says.

Fulmer believes many nurses already are conducting these types of reminder calls, despite the fact that they’re not currently a reimbursable service. "Nurses want to do it," she says. "They just know that it’s not in their scope of practice as it’s laid out financially right now."

(For more information on medication management, please see Homecare Quality Management, July 2000, pp. 80-84.)

Reference

1. Fulmer TT, Feldman PH, Kim TS, et al. An intervention study to enhance medication compliance in community-dwelling individuals. J Gerontol Nurs 1999; 25:6-14.

• Terry Fulmer, Professor, Division of Nursing, New York University, 429 Shimkin Hall, 50 W. 4th St., New York, NY 10012. Telephone: (212) 998-5375. Fax: (212) 995-4770.

• Penny Hollander Feldman, Director, Center for Home Care Policy & Research, Visiting Nurse Service of New York, 107 E. 70th St., New York, NY 10021. Telephone: (212) 794-6348; Fax: (212)794-6610. E-mail: pfeldman @vnsny.org. Web site: http://www.vnsny.org/research.