Could better communication improve adherence to medicines after patients leave hospital?

Could better communication improve adherence to medicines after patients leave hospital?

A new model of working with patients to help them follow recommended medicines could improve outcomes and reduce re-hospitalisation 

 

Growing numbers of older people in Europe are living with non-communicable diseases (NCDs), with some managing more than one long-term illness. Most of these conditions – such as diabetes, cardiovascular disease, cancer, chronic respiratory diseases and mental health disorders – require medication.

Patients who are prescribed several medications can struggle to follow complex drug regimens. By some estimates, adherence to medicines in older adults being treated for several NCDs can be as low as 50%[1],[2].

Returning home after a spell in hospital is often a challenge for patients and caregivers: new or changed medication regimes add complexity to older people’s routines at a time when they are recovering from illness or adapting to new limitations.

Patients usually receive a summary of any medicines and lifestyle changes recommended by clinicians on the day of discharge and, from there, are in the care of their general practitioner. However, it may be some time before their next contact with a healthcare professional.

‘Hospital discharge is a crucial moment for patients,’ says Dr Caterina Trevisan, a geriatrician and PhD candidate at the University of Padua’s Department of Medicine. ‘In people aged 70 years and older, it has been shown that just 48 hours after hospitalisation, 56% had a discrepancy between their discharge instructions and their actual home medication.’[3]

Caterina leads a new research project that will evaluate a multidisciplinary intervention designed to improve adherence in older patients discharged from hospital. The study will be conducted by a team which includes researchers from the Geriatric Unit of the University of Padua and the Neuroscience Institute of Italy’s National Research Council. They will use hospital records to study whether this multidisciplinary intervention, by improving patients’ adherence, could reduce the risk of  falls, re-hospitalisation and other key health indicators in the first 60 days after the patient returns home.

The study is part of a broader programme called Project chAnGE, supported by Upjohn, a Pfizer division, launched under the European Innovation Partnership Action on Health Ageing (EIP on AHA). Project chAnGE aims to identify gaps in Europe in relation to healthy ageing in people with non-communicable diseases, and support the necessary changes in clinical practice.

Communication: a two-way street

Confusion over medicine regimens can be due to patients or caregivers not fully understanding information provided by clinicians, or healthcare professionals not able to explain medicines and their importance effectively.

‘When it comes to changing behaviours and following recommended medicines, the three main challenges are knowledge, skills and motivation[4],’ explains Caterina. ‘Our new study will address all three.’

While previous research has looked at interventions based on changing a single aspect of how patients are supported after hospital discharge, the new project takes a more holistic view. Trials have shown that single-domain interventions involving pharmacists[5], providing patients with coaching, and offering telephone support can improve adherence[6],[7], but have little impact on their general health status. The Padua-based team has designed an approach that involves several clinicians and provides access to additional support at key moments after patients return home.

A holistic approach

A total of 360 hospitalised patients with NCDs will be recruited and randomly divided into two groups of 180. The first group will follow the usual approach of explaining their medication when they are discharged; the second will take part in the new approach. They will receive educational training from a multidisciplinary team which includes a physician, a hospital pharmacist, a dietician and an occupational therapist. The team will be provided with training from a communication expert to help them to provide patients with clear information.

‘Together, the physician and pharmacist will increase patients’ knowledge of their medicines,’ Caterina said. ‘The dietician will play an important role in motivating the patient to follow any lifestyle changes, while the occupational therapist can give suggestions to improve their functional recovery at home.’

The patients will then be contacted at home by phone 24-48 hours after leaving hospital. This will be an opportunity to see whether they can recall the information shared when they were discharged and to reinforce their motivation to follow the prescribed regimen. For patients and carers, it is a chance to ask questions or clear up any doubts they may have about the timing or dosing of their medication.

After that, they will be invited to contact the hospital physician for up to seven days if they have any further queries. ‘This gives patients and informal caregivers – who play an increasingly important role in managing vulnerable, older patients at home – additional support in case they may have any kind of doubt or concern,’ says Caterina.

Evaluating outcomes

Data on emergency department visits, rehospitalisation and vital statistics from hospital records, along with information about medication adherence and falls collected via telephone interviews, will help the researchers to determine whether the extra coaching and support translates into improved outcomes. If it does, the study could pave the way for changes in clinical practice that improve outcomes for patients and make health systems more efficient by reducing the number of avoidable hospitalisations.

‘I think the real strength of this intervention is that it is very easy to implement: it is low cost and requires minimal technological hardware or expertise,’ says Caterina. ‘We think that if it proves to be a success in the geriatric department, we can motivate other departments to take the same approach.’

[1] Sabatè E. Adherence to long-term therapies: evidence for action. [Internet]. Geneva; 2003. Available from: https://www.who.int/chp/knowledge/publications/adherence_report/en/

[2] Hughes CM. Medication Non-Adherence in the Elderly. Drugs Aging [Internet]. 2004 [cited 2019 Apr 18];21(12):793–811. Available from: http://link.springer.com/10.2165/00002512-200421120-00004

[3] Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of Health Literacy to Intentional and Unintentional Non-Adherence of Hospital Discharge Medications. J Gen Intern Med [Internet]. 2012 Feb 5 [cited 2019 Apr 18];27(2):173–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21971600

[4] Marengoni A, Monaco A, Costa E, Cherubini A, Prados-Torres A, Muth C, et al. Strategies to Improve Medication Adherence in Older Persons: Consensus Statement from the Senior Italia Federanziani Advisory Board. Drugs Aging [Internet]. 2016 Sep 21 [cited 2019 Apr 18];33(9):629–37. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27444182

[5] Marcum ZA, Hanlon JT, Murray MD. Improving Medication Adherence and Health Outcomes in Older Adults: An Evidence-Based Review of Randomized Controlled Trials. Drugs Aging [Internet]. 2017 Mar 10 [cited 2019 Apr 18];34(3):191–201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28074410

[6] Daley DJ, Deane KHO, Gray RJ, Clark AB, Pfeil M, Sabanathan K, et al. Adherence therapy improves medication adherence and quality of life in people with Parkinson’s disease: a randomised controlled trial. Int J Clin Pract [Internet]. 2014 Aug [cited 2019 Apr 18];68(8):963–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24750544

[7] Goeman D, Jenkins C, Crane M, Paul E, Douglass J. Educational intervention for older people with asthma: A randomised controlled trial. Patient Educ Couns [Internet]. 2013 Dec [cited 2019 Apr 18];93(3):586–95. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0738399113003212