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Teaching Medication Adherence in US Colleges and Schools of Pharmacy

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To determine and describe the nature and extent of medication adherence education in US colleges and schools of pharmacy. A mixed-methods research study was conducted that included a national survey of pharmacy faculty members, a national survey of pharmacy students, and phone interviews of 3 faculty members and 6 preceptors. The majority of faculty members and students agreed that background concepts in medication adherence are well covered in pharmacy curricula. Approximately 40% to 65% of the students sampled were not familiar with several adherence interventions. The 6 preceptors who were interviewed felt they were not well-informed on adherence interventions, unclear on what students knew about adherence, and challenged to provide adherence-related activities for students during practice experiences because of practice time constraints. Intermediate and advanced concepts in medication adherence, such as conducting interventions, are not adequately covered in pharmacy curriculums; therefore stakeholders in pharmacy education must develop national standards and tools to ensure consistent and adequate medication adherence education.
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RESEARCH
Teaching Medication Adherence in US Colleges and Schools of Pharmacy
Nathaniel M. Rickles, PharmD, PhD,
a
Linda Garrelts MacLean, BPharm,
b
Karl Hess, PharmD,
c
Kevin C. Farmer, PhD,
d
Afton M. Yurkon, PharmD,
e
Carolyn C. Ha, PharmD,
e
Emmanuelle Schwartzman, PharmD,
c
Anandi V. Law, BPharm, PhD,
c
Paul A. Milani, PharmD Candidate,
b
Katie Trotta, PharmD Candidate,
a
Sara R. Labella, PharmD Candidate,
a
and Rebecca J. Designor, PharmD Candidate
a
a
Northeastern University School of Pharmacy, Boston, MA
b
College of Pharmacy, Washington State University, Spokane, WA
c
College of Pharmacy, Western University of Health Sciences, Pomona, CA
d
University of Oklahoma College of Pharmacy, Oklahoma City, OK
e
National Community Pharmacists Association, Alexandria,VA
Submitted November 28, 2011; accepted February 11, 2012; published June 18, 2012.
Objective. To determine and describe the nature and extent of medication adherence education in US
colleges and schools of pharmacy.
Methods. A mixed-methods research study was conducted that included a national survey of pharmacy
faculty members, a national survey of pharmacy students, and phone interviews of 3 faculty members
and 6 preceptors.
Results. The majority of faculty members and students agreed that background concepts in medication
adherence are well covered in pharmacy curricula. Approximately 40% to 65% of the students sampled
were not familiar with several adherence interventions. The 6 preceptors who were interviewed felt
they were not well-informed on adherence interventions, unclear on what students knew about adher-
ence, and challenged to provide adherence-related activities for students during practice experiences
because of practice time constraints.
Conclusions. Intermediate and advanced concepts in medication adherence, such as conducting in-
terventions, are not adequately covered in pharmacy curriculums; therefore stakeholders in pharmacy
education must develop national standards and tools to ensure consistent and adequate medication
adherence education.
Keywords: medication adherence, curriculum, medication
INTRODUCTION
The effectiveness of medications depends largely on
patients’ adherence to a prescribed medication regimen.
1
Althoughpatients’ medication-taking behaviorsvary, most
only adhere to their regimens approximately 50% of the
time, and half stop taking medication for a chronic illness
after 1 year.
2-5
When patients do not adhere to their regi-
mens, they are at increased risk for hospitalizations, emer-
gency department visits, worsening disease, and poorer
quality of life.
6-10
Medication non-adherence costs the
United States $290 billion per year in unwarranted health
care spending and results in an increased incidence of
preventable illness and death.
1,11
Medication non-adherence is a significant public
health concern and has received attention from various
stakeholders including the National Council on Patient
Information and Education (NCPIE), Agency for Health-
care Research and Quality, The New England Healthcare
Institute, the Pharmacy Quality Alliance (PQA), and the
National Consumers League. Multi-stakeholder involve-
ment in this issue brought about a national campaign in
2011, “Script Your Future,” to improve consumer aware-
ness of the importance and value of medication adherence
and to encourage and increase practitioner efforts to dis-
cuss adherence with their patients.
12
Additionally, US health
care reform policies such as coordinated care (eg, account-
able care organizations) and new payment models will rely
on the appropriate use of medications. Pharmacists will be
Corresponding Author: Nathaniel M. Rickles, PharmD,
PhD, Northeastern University School of Pharmacy, R218TF,
360 Huntington Avenue, Boston, MA 02115. Tel: 617-373-
7721. Fax: 617-373-7655. E-mail: n.rickles@neu.edu
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
1
required to implement adherence strategies and improve
outcomes in practice to receive outcomes-based health care
payment.
Over the last 50 years, we have learned much about
medication adherence, including epidemiologic factors,
predictors of medication non-adherence, and barriers and
interventions to improve medication adherence.
1
The ex-
tent to which academic medicine and pharmacy and edu-
cators in the allied health professions have transferred this
knowledge and experience to students is less clear. The
World Health Organization (WHO) recommends that
healthcare professionals be trained in adherence assess-
ment.
1
NCPIE, a coalition working to advance commu-
nication with patients about appropriate medication use,
convened a stakeholder panel of experts to address med-
ication non-adherence. The panel created a consensus on
10 national priorities with the greatest potential to im-
prove medication adherence.
13
NCPIE addresses the need
for multidisciplinary curriculum development on medi-
cation adherence, including pharmacy school curricula,
that focuses on increasing public awareness of the adher-
ence problem and implementing solutions. PQA, an or-
ganization that focuses on the improvement of medication
use across health care settings, has developed metrics to
evaluate the impact of pharmacy-level interventions on
patient medication adherence.
14
Pharmacistsare accountable for patients’ medication-
taking behavior and future pharmacy graduates need to
be prepared to detect, monitor, and intervene to improve
patients’ medication adherence. There is a paucity of lit-
erature describing the extent to which pharmacy educa-
tors teach students about medication adherence. Only
22% of 50 pharmacy colleges and schools surveyed in-
dicated having assessment instruments to evaluate stu-
dents’ skills related to promoting medication adherence
to patients.
15
Only 18% had students work with patients
to schedule medication doses, tailor therapy, and estab-
lish cues to remind them to take their medicine; 12% had
educational content focused on determining patient moti-
vation to adhere to a medication regimen; and 8% taught
students interventions to improve patients’ medication
adherence.
The Accreditation Council for Pharmacy Education’s
(ACPE) standards for pharmacy colleges and schools dis-
cuss the importance of “optimal medication therapy out-
comes and patient safety,” but there is no direct mention of
medication adherence, how adherence affects patient
outcomes, or the severity of the problem.
16
The American
Association of Colleges of Pharmacy (AACP) Center for
the Advancement of Pharmaceutical Education developed
a 2004 recommendation that students should be able to as-
sess a patient’s previous adherence to medication, identify
social and behavioral issues associated with non-adherence,
and discover different methods within pharmacy to im-
prove adherence.
17
The National Association of Boards
of Pharmacy (NABP) is also committed to medication ad-
herence as it relates to their mission in “developing, imple-
menting, and enforcing uniform standards for the purpose
of protecting the public health.”
18
NABP specifically men-
tions adherence in the first of their 3 competency state-
ments that form the foundation of the North American
Pharmacist Licensure Examination (NAPLEX). Specifi-
cally, NABP states that the NAPLEX examinee should
be able to “identify, present, and address methods to
remedy medication non-adherence, misuse, or abuse.”
19
Given the importance of the topic to various phar-
macy and other stakeholders, the primary objective of this
study was to obtain a more detailed description of the na-
ture and extent of medication adherence education in US
colleges and schools of pharmacy.
METHODS
The study consisted of 3 parts: (1) a national Web-
based survey of faculty members at colleges and schools
of pharmacy, (2) a national Web-based survey of student
chapters of 2 national pharmacy organizations, Phi Delta
Chi (PDC) and the National Community Pharmacists
Association (NCPA), and (3) conference calls with a con-
venience sample of pharmacy preceptors and faculty
members.
In the first part of the project, researchers conducted
a national Web-based survey to pharmacy faculty mem-
bers on communication topics taught in US colleges and
schools of pharmacy. This cross-sectional survey instru-
ment was developed by the Western University of Health
Sciences (WesternU) team, based on the Kimberlin study.
15
The study purpose was to identify what communication
topics were covered by pharmacy colleges and schools
and how they were delivered and evaluated. There were
only 2 items that specifically related to medication adher-
ence. The first item asked respondents to indicate whether
adherence topics (defined as barriers to adherence and
encouraging patient participation in care) were taught as
a part of a required or elective course. The second item
asked faculty respondents to indicate how this adherence
content was delivered (lecture, multimedia, live actors/
modeling, practice, and/or case-based). An e-mail with
a link to the electronic survey instrument was sent to 269
deans, department chairs, and/or curriculum chairpersons
at US colleges and schools of pharmacy (e-mails were
sent to more than 1 person at some colleges and schools).
The survey was available for completion from December
2010 to March 2011. To achieve an excellent response
rate, 3 Web-based reminders to complete the survey
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
2
instrument were sent. The survey instrument was approved
by the university’s institutional review board (IRB).
The second and third parts of the study were led by
members of the National Community Pharmacists Asso-
ciation’s (NCPA) Advisory Council on Medication Ad-
herence. These researchers developed a 9-item Web-based
survey instrument to send to representatives at 71 student
chapters of Phi Delta Chi pharmacy fraternity and
90 student chapters of NCPA. The researchers targeted
2 student organizations to increase the odds of receiving
a response from each of the colleges and schools. Survey-
Monkey (SurveyMonkey, Palo Alto, CA) was used to
distribute the survey to PDC student chapters and Survey-
Gizmo (SurveyGizmo, Boulder, CO) was used to distribute
the survey to NCPA student chapters. Chapter representa-
tives were asked to have 1 third or fourth-year (P3 or P4)
student from their chapter to complete the survey instru-
ment, with preference to be given to P4 students because
questions about the third year were included in the survey
instrument. As an incentive, chapters that participated in
the survey were entered into a random drawing to win free
registration for their organization’s national meeting.
Because there was no prior research exploring spe-
cific adherence topics and how they were covered in cur-
ricula, all items were new and constructed for the study’s
goals to gain a better description of specific topics covered
in colleges and schools of pharmacy. Students were asked
to provide online consent to participate before completing
the survey instrument. There were 3 items asking respon-
dents to use a 4-point Likert-scale to indicate to what extent
a topic was taught: not taught, somewhat taught, moder-
ately taught, or extensively taught. Another item asked
respondents to indicate in which courses and years in the
pharmacy curriculum adherence topics were covered. Re-
spondents were also asked to describe how adherence
topics were presented in the curriculum (eg, lecture, video,
textbook/readings, guest speaker, role playing, written
patient cases, and other).
Students were queried about the extent to which they
engaged in adherence interventions during their introduc-
tory pharmacy practice experiences (IPPEs) and advanced
pharmacy practice experiences (APPEs). Specifically, stu-
dents indicated whether they had: (1) no opportunity to do
any adherence-related interventions, (2) identified patient
non-adherence but could not determine intervention, (3)
identified patient non-adherence and planned interven-
tion, and (4) intervened and followed up on a patient.
Students could also choose “not applicable” if the oppor-
tunity to engage in adherence interventions was not avail-
able during their IPPEs and APPEs. Students were asked
4 brief background questions about the name of their
college or school of pharmacy, location, type of university
(public/private/other), type of pharmacy program (0-6,
2-4, undergraduate then PharmD degree, or accelerated
PharmD degree), and in what year of the program the
student was enrolled (P1-P4).
In the third part of the study, the NCPA Advisory
Council on Medication Adherence developed a list of
questions addressing the nature and extent of coverage of
adherence topics in the pharmacy curriculum to ask a con-
venience sample of 6 community pharmacy preceptors (4
from independent pharmacies and 2 from chain pharma-
cies) and 3 pharmacy faculty members with adherence
interests. The independent pharmacy preceptors were all
active members of NCPA and the 2 preceptors at chain
pharmacies were known to the authors through their pre-
ceptor service at their respective pharmacy schools.
These questions were administered during a sched-
uled conference call (2 group conference calls with pre-
ceptors and1 group conference call with faculty members)
conducted by a member of the research team. Consent to
participate in the study was obtained prior to the call. The
calls were recorded for purposes of transcription and re-
view of key themes. Preceptor questions were focused on
what activities students undertake during their practice ex-
periences in the areas of detecting, monitoring, and inter-
vening in medication non-adherence. Preceptors also were
asked to what extent they thought students were competent
to implement strategies to improve medication adherence.
Finally, preceptors were asked to indicate what changes
they would make in the pharmacy curriculum to better pre-
pare students to engage in detecting, monitoring, and inter-
vening in medication adherence of patients in community
pharmacy practice.
Prior to the telephone interview, the 3 faculty mem-
bers indicated that they did not have a thorough enough
knowledge of the entire curriculum to give an accurate
estimate of the extent to which adherence topics were
covered, where such topics were taught in the curriculum,
and how much time was spent on the different adherence
topics. Therefore, 2 survey questions asking for this in-
formation were deleted from the interviews with the fac-
ulty members. The 3 faculty members provided feedback
on whether various adherence topics should be required;
how prepared they felt students were to detect, monitor,
and intervene in medication non-adherence; and how com-
petent they thought students werein implementing various
intervention strategies. The 3 faculty members also iden-
tified possible opportunities to better prepare students to
engage in adherence-related activities.
All survey data were entered in SPSS 18.0 (SPSS Inc,
Chicago, IL) and analyzed using descriptive statistics
such as medians and frequencies where appropriate. In
a few cases, responses were received from both the Phi
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
3
Delta Chi and NCPA student chapters of a college or
school, and/or 2 or more responses were received from
the Phi Delta Chi and/or the NCPA student chapter of
a college or school. To ensure only 1 response from each
college or school of pharmacy was included in the data
analysis, we eliminated the second response if that re-
sponse was from an individual in their first or second year
as we believed that students in the third and fourth years of
the program had more knowledge of the entire curricu-
lum. If there were 2 responses from a third or fourth year
student at a college or school, we used the response of the
more senior student as that student was more likely to be
able to answer the APPE questions. In cases where we
received 2 or more responses from students in the same
year at a college or school, we combined the responses
and imputed the averaged score for the college or school.
The conference call tapes were transcribed using the Cogi
iPhone application (Cogi, Santa Barbara, CA). Student
researchers categorized the key themes identified from
the phone conversations. Both the student survey instru-
ments and the scripts used during the conference calls were
approved by multiple IRBs. (Copies of the survey instru-
ments and the questions asked during the phone inter-
views are available by request from the corresponding
author.)
RESULTS
One hundred ten survey responses were received
from 92 different colleges and schools of pharmacy (rep-
resentatives from 18 of the 92 colleges and schools com-
pleted the same survey instrument twice). A majority of
faculty respondents (n 599, 90%) indicated that curric-
ular content/education on medication adherence was re-
quired by their college or school of pharmacy, and 1
respondent indicated the school included it as an area of
focus within an elective course. Three respondents indi-
cated either that the question was not applicable to their
college or school, or that adherence was not covered in
their program. A large number of respondents indicated
that medication non-adherence was covered through lec-
ture (n 593), practice-based experiences (n 574), or case-
based problems (n 560).A smaller number of respondents
indicated that adherence was taught using multimedia
resources (n 529) or by live actors and/or modeling
(n 536).
The NCPA Advisory Council on Medication Adher-
ence received 37 of the 71 survey instruments sent to PDC
student chapters, and 58 of 90 survey instruments sent to
NCPA student chapters. One or more survey instruments
were received from 52 (43.7%) of the 119 accredited (full
or candidate status) colleges and schools of pharmacy.
20
Of the 52 colleges and schools represented, 56% (n 529)
were public and 44% (n 523) were private. The types of
pharmacy programs represented were: 0/6 PharmD pro-
grams (4), 2/4 PharmD programs (16), undergraduate de-
gree then PharmD programs (2), accelerated PharmD
programs (10), and other types of programs (2). Six
(12%) of the survey respondents were fourth-year stu-
dents, 28 (54%) were third-year students, 17 (33%)
were second-year students, and 1 (2%) was a first-year
student.
Approximately two-thirds (.70%) of the study sam-
ple was “moderately or extensively taught” background
topics on medication adherence, including models for un-
derstanding adherence; predictors, causes, and conse-
quences of medication non-adherence; and impact of
medication adherence on clinical outcomes (Table 1).
All of these background topics had a median score of
3 or higher on a 5-point scale, indicating the topics were
“moderately or extensively taught.” On the 6 topics re-
lating to adherence interventions, only 2 topics, motiva-
tional interviewing and educational interventions, had
median scores of 3, indicating the topic was moderately
taught. Over 50% of respondents indicated “not being
taught at all” or “only somewhat taught” about reminder
systems, coordinating refill dates, and technology-based
solutions. Student responses were split with regard to
behavioral cueing; half of the respondents were “not at
all taught” or “somewhat taught” and the other half of
respondents were “moderately or extremely taught” the
topic.
Table 2 shows the frequencies at which adherence
topics are covered. Lecture was a common mode of in-
struction for all medication adherence topics. Motivational
interviewing and educational intervention concepts were
largely taught through role playing, written patient cases,
videos, textbook readings, and guest speakers. Reminder
systems and coordinating refill dates were largely taught
through lecture, written patient cases, and role playing.
Almost a third of the sample had not been taught how to
coordinate refill dates. Behavioral cueing was largely pre-
sented via lecture, role playing and written patient cases.
Technology-based solutions were primarily presented in
lectures and about 29% of the sample indicated the topic
was not presented at their college or school of pharmacy.
Table 3 shows responses to open-ended questions
regarding which courses in the curriculum taught the ad-
herence topics. Background adherence topics and the im-
pact of medication adherence on clinical outcomes were
presented mostly in clinical and social and administrative
courses, with some content covered in pharmaceutical
science and other courses throughout the curriculum. Ex-
amples of courses in which background concepts on ad-
herence were taught are: Therapeutics/Pharmaceutical
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
4
Care, Health Care Systems, Psychosocial Aspects of
Health Care, Communications, and other courses on med-
ication safety and self-care therapeutics. During the first
year (P1), the majority of students were exposed to back-
ground topics on medication adherence in clinical and
social administrative courses. During the P2 and P3 years,
students were exposed to background topics on medica-
tion adherence mainly in their clinical courses.
Almost 50% of students indicated that during their
IPPEs, they had the opportunity to identify non-adherent
patients and plan an intervention. Some students (13.5%)
indicated that during their IPPEs they had the opportunity
to identify non-adherent patients but not to perform an
intervention. Other students (13.5%) reported they had
the opportunity to intervene and follow-up on patients.
Approximately 11.5% of the sample indicated they had
no opportunity to do adherence-related activities during
their IPPEs. The remainder of respondents indicated the
question was not applicable or their experience did not fit
in any of the categories. Using a coding scheme of 1 5no
opportunity, 2 5identified non-adherent patient but could
not determine intervention, 3 5identified non-adherent
patient and planned intervention, and 4 5intervened and
followed up with patient, the mean score on this item was
2.7 60.9.
Only about 12% of the respondents were in their
fourth year, thus, 50% of the sample indicated that the
question was not applicable to them or that they had no
opportunity to do adherence-related activities during their
APPEs. Fifty percent reported participating in some med-
ication adherence activities during APPEs. Of the 50%
who responded, more than half (27%) indicated they had
APPEs in which they had the opportunity to intervene and
follow-up with patients. Approximately 21% indicated
they could identify non-adherent patients; however, 11.5%
of these individuals indicated they had identified non-
adherent patients and planned an intervention, while the
remainder (9.6%) had not planned an intervention. Using
Table 1. Pharmacy Students’ Perspectives on Medication Adherence Topics Taught in the Doctor of Pharmacy Curriculum (N 552)
Adherence Topic
Not
Taught,
No. (%)
a
Somewhat
Taught,
No. (%)
a
Moderately
Taught,
No. (%)
Extensively
Taught,
No. (%)
a
Median
Score
b
Medication adherence education in general 0 10 (19.2) 16 (30.8) 24 (46.2) 3.0
Models for understanding medication adherence 1 (1.9) 12 (23.1) 18 (34.6) 19 (36.5) 3.0
Predictors of medication non-adherence 3 (5.8) 9 (17.3) 18 (34.6) 18 (34.6) 3.0
Causes of medication non-adherence 1 (1.9) 7 (13.5) 15 (28.8) 24 (36.2) 3.5
Consequences of medication non-adherence 0 8 (15.4) 10 (19.2) 28 (53.8) 4.
Impact of medication adherence on clinical outcomes 1 (1.9) 6 (11.5) 13 (25.0) 27 (51.9) 4.0
Motivational interviewing 4 (7.7) 9 (17.3) 16 (30.8) 17 (32.7) 3.0
Reminder systems 7 (13.5) 21 (40.4) 15 (28.8) 5 (9.6) 2.0
Coordinating refill dates 12 (23.1) 20 (38.5) 10 (19.2) 3 (5.8) 2.0
Behavioral cueing 3 (5.8) 19 (36.5) 13 (25.0) 10 (19.2) 2.5
Educational interventions 1 (1.9) 8 (15.4) 18 (34.6) 19 (36.5) 3.0
Technology-based solutions (texts/e-mail reminders) 16 (30.8) 18 (34.6) 10 (19.2) 3 (5.8) 2.0
a
Percentages may not add up to 100% because there were a few cases where multiple responses from a college or school were received; these
multiple responses were averaged to provide one response.
b
Based on the following scale: 1 5not taught, 2 5somewhat taught, 3 5moderately taught, 4 5extensively taught. These medians represent all
responses, including those averaged over multiple responses from a pharmacy college or school.
Table 2. Modes of Teaching Medication Adherence Concepts in the Pharmacy Curriculum (n 552)
a
Topic
Lecture,
No. (%)
Video,
No. (%)
Guest
Speaker,
No. (%)
Textbook
Readings,
No. (%)
Role
Playing,
No. (%)
Written
Patient Case,
No. (%)
Other,
No. (%)
Not
Presented,
No. (%)
Motivational interviewing 44 (84.6) 17 (32.7) 13 (25.0) 18 (34.6) 33 (63.5) 27 (51.9) 2 (3.9) 3 (5.8)
Reminder systems 31 (59.6) 6 (11.5) 10 (19.2) 10 (19.2) 13 (25.0) 14 (26.9) 5 (9.6) 8 (15.4)
Coordinating refill dates 32 (61.5) 2 (3.8) 10 (19.2) 7 (13.5) 13 (25.0) 13 (25.0) 3 (5.8) 17 (32.7)
Behavioral cueing 43 (82.7) 12 (23.1) 9 (17.3) 10 (19.2) 24 (46.2) 12 (23.1) 2 (3.9) 5 (9.6)
Educational intervention
(counseling, etc)
47 (90.4) 26 (50.0) 16 (30.8) 19 (36.5) 41 (78.8) 25 (48.1) 1 (1.9) 0
Technology-based solutions
(text/e-mail reminders)
27 (51.9) 2 (3.9) 8 (15.4) 8 (15.4) 9 (17.3) 9 (17.3) 9 (17.3) 15 (28.8)
a
Students could select multiple modes for each topic so percentages exceed 100% for each row and column.
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
5
the same coding scheme, the APPE mean for this question
was 3.2 61.0.
Table 4 lists the general themes that arose during the
telephone conversations with the 3 preceptors. While
most points reflected concerns about students’ educational
experiences while on an APPE, some of the comments
reflected on the broader challenges faced by community
pharmacists to more fully and consistently care for their
patients. Preceptors indicated consistent medication mon-
itoring could yield opportunities to detect medication non-
adherence but this was not seen as a priority for students and
preceptors given the time constraints associated with
point-of-service care and other practice experience activ-
ities. Preceptors, in general, believed that students have
the skills to handle patient questions and follow-up on
medication non-adherence, but do not have enough time
to improve their skills given the short length of practice
experiences.
Table 3. Types of Courses in Which Medication Adherence Topics Were Covered in the Doctor of Pharmacy Curriculum
According to Pharmacy Students
Topic: Theories for Understanding Adherence
Type of course
P1 Year, n = 59,
No. (%)
a
P2 Year, n = 43,
No. (%)
a
P3 Year, n = 23,
No. (%)
a
Year not given,
n = 31, No. (%)
Total, n = 156,
No. (%)
Clinical 24 (41) 28 (65) 14 (61) 12 (39) 78 (50)
Social and administrative 26 (44) 10 (23) 6 (26) 11 (35) 53 (34)
Pharmaceutical sciences 4 (7) 1 (2) 1 (4) 4 (13) 10 (6)
Other 5 (8) 4 (9) 2 (9) 4 (13) 15 (10)
Topic: Predictors of Non-Adherence
P1 Year, n = 52,
No. (%)
P2 Year, n = 53,
No. (%)
P3 Year, n = 24,
No. (%)
Year not given,
n = 28, No. (%)
Total, n = 157,
No. (%)
Clinical 20 (38) 37 (70) 16 (67) 12 (43) 85 (54)
Social and administrative 27 (52) 8 (15) 5 (21) 9 (32) 49 (31)
Pharmaceutical science 2 (4) 5 (9) 1 (4) 3 (11) 11 (7)
Other 3 (6) 3 (6) 2 (8) 4 (14) 12 (8)
Topic: Causes of Non-Adherence
P1 Year, n = 57,
No. (%)
P2 Year, n = 53,
No. (%)
P3 Year, n = 29,
No. (%)
Year not given,
n = 33, No. (%)
Total, n = 172,
No. (%)
Clinical 24 (42) 38 (72) 22 (76) 19 (58) 103 (60)
Social and administrative 25 (44) 8 (15) 4 (14) 7 (21) 44 (26)
Pharmaceutical science 0 (0) 3 (6) 0 (0) 4 (12) 7 (4)
Other 8 (14) 4 (8) 3 (10) 3 (9) 18 (10)
Topic: Consequences of Non-Adherence
P1 Year, n = 48,
No. (%)
P2 Year, n = 61,
No. (%)
P3 Year, n = 40,
No. (%)
Year not given,
n = 35, No. (%)
Total, n = 184,
No. (%)
Clinical 24 (50) 45 (74) 30 (75) 17 (49) 116 (63)
Social and administrative 18 (38) 5 (8) 3 (8) 9 (26) 35 (19)
Pharmaceutical science 2 (4) 8 (13) 2 (5) 6 (17) 18 (10)
Other 4 (8) 3 (5) 5 (13) 3 (9) 15 (8)
Topic: Impact of Non-Adherence on Clinical Outcomes
P1 Year, n = 42,
No. (%)
P2 Year, n = 58,
No. (%)
P3 Year, n = 38,
No. (%)
Year not given,
n = 34, No. (%)
Total, n = 172,
No. (%)
Clinical 22 (52) 45 (78) 30 (79) 18 (53) 115 (67)
Social and administrative 16 (38) 5 (9) 3 (8) 6 (18) 30 (17)
Pharmaceutical science 1 (2) 6 (10) 2 (6) 4 (12) 13 (8)
Other 3 (7) 2 (3) 3 (8) 6 (18) 14 (8)
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
6
The preceptors felt they lacked knowledge about the
medication adherence curriculum taught to students in the
classroom such as key interventions and communication
approaches to improve adherence. They expressed a need
for greater communication with colleges and schools on
how to teach and assess medication adherence-related
skills and how to make learning in the classroom opti-
mally reflect the realities of practice. Preceptors felt their
lack of education and time to do adherence interventions
was not serving as a good model for students on how to
engage in adherence interventions. They suggested that
better computer technology and workflow designs could
assist pharmacists and students in more consistently and
proactively detecting, monitoring, and intervening on
medication non-adherence.
The 3 faculty members who were interviewed agreed
that background topics on medication adherence are impor-
tant and should be integrated throughout the PharmD pro-
gram, both in required and elective courses. This integration
could be achieved through the development of active-
learning techniques such as role-playing exercises. One
faculty member highlighted the value of pharmacy fac-
ulty members joining students on practice experiences
to facilitate and support medication adherence principles.
Faculty members also indicated the need for better bal-
ance in the curriculum on instructing students to think
about patients at both the individual and population levels.
From their perspective, barriers to the development of
a national pharmacy curriculum on medication adherence
are resources and curriculum flexibility. Two solutions
that were suggested were to implement adherence con-
cepts and applications into a structured component of the
experiential program and to create more efficiency in how
adherence topics are interwoven in the curriculum.
DISCUSSION
This investigation used multiple data sources to as-
sess and describe the nature and extent of medication
adherence education and experiential training in US col-
leges and schools of pharmacy. This is the first known
study to attempt to understand the depth and breadth to
which pharmacy students are trained in understanding and
intervening on medication non-adherence. There were
several key findings. First, 90% of the respondents in the
national study indicated that adherence topics were
a required part of their college or school’s curriculum,
Table 4. Summary of Preceptor Comments From Telephone Interviews (N 56)
Detection of Medication Adherence
Non-adherence is usually uncovered during medication reviews (Medication Therapy Management, MTM) or when
investigating an adverse event, not during normal day–to-day or “point of service” activities.
Monitoring of Medication Adherence
Students may feel adherence is not a priority given other practice experience activities to “cram in.”
Technique of “reactive monitoring” is typically used (ie, checking who hasn’t picked up medications and finding out the reason).
Interventions on Medication Adherence
Students, in general, know how to answer questions and follow-up on non-adherence issues.
MTM allows students opportunity to intervene on non-adherence.
Role playing is a good way to challenge students on how to intervene (eg, laboratory simulations)
Gaps
Medication adherence should be taught earlier in curriculum.
Some preceptors lack knowledge on what motivational interviewing is and others having difficulty in being able to effectively
communicate.
Short length of practice experience interferes with students’ abilities to improve medication adherence skills.
Lack of tools/guidance from schools/colleges on how to teach/assess adherence-related skills.
Lack of knowledge about what is taught in the curriculum related to medication adherence.
Barriers
Lack of time for pharmacists to implement adherence techniques and serve as role models for students to do adherence activities.
Disconnect between what students learn about and what actually happens in practice.
“Preceptor behavior guides student behavior.”
Preceptors, not just students, need to be educated more on medication non-adherence.
Lack of communication between pharmacists and physicians affects adherence opportunities.
Improvements
Greater emphasis on the psychosocial needs of the patient.
Pharmacy environment should be proactive instead of reactive as it relates to adherence.
Improving work flow to allow more adherence activities to take place must be implemented.
Improved computer technologies/programs to detect medication non-adherence are needed.
A stronger pharmacist/patient relationship should yield better medication adherence.
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
7
Although this suggests that these institutions were cover-
ing the topic in some form, the survey instrument did
not explore what specific adherence topics were cov-
ered and how consistently they were taught throughout
the curriculum. However, the student surveys conducted
by the NCPA Advisory Council on Medication Adher-
ence as part of this study provided some answers to these
questions.
Our second key finding was that there is a gap in the
medication adherence instruction covered in colleges and
schools ofpharmacy. While a majority of students reported
that many adherence topics related to the nature and extent
of the problem (models for understanding adherence, pre-
dictors, causes, and consequences of medication non-
adherence, and impact of medication adherence on clinical
outcomes) were moderately or extensively taught in their
program, there was a large percentage of students who
reported either not being taught or being only somewhat
exposed to different adherence intervention strategies. This
suggeststhat the adherence instruction that the colleges and
schools of pharmacy in the WesternU survey reported cov-
ering is primarily background information on the medica-
tion adherence problem. Educational interventions and
motivational interviewing are the only intervention strat-
egies to which students reported having been moderately
or extensively exposed (ie, counseling patients on their
medications). This lack of intervention training may con-
tribute to why, on average, there was a mix of respondents
who had the opportunity to plan and follow-up on an
adherence intervention during their IPPEs and APPEs.
The gap noted in the education of pharmacy students
about conducting medication adherence interventions
demonstrates the need for colleges and schools of phar-
macy to develop national standards for medication adher-
ence education and a toolbox of curricular content to help
in the consistent and integrated implementation of those
standards. During the phone interviews, a faculty member
suggested that an adherence toolbox that would teach a set
of principles and encourage faculty members to apply the
principles in various courses using different instructional
modes should be developed. Faculty members and pre-
ceptors could use these tools to train both students and
practitioners on key adherencestrategies. WHO first stated
the urgent need for an adherence counseling toolkit that
is adaptable for different socioeconomic settings in 2003.
1
It is difficult to envision pharmacists as part of a multidis-
ciplinary solution to improve medication adherence that
is prepared for future industry requirements if they are not
adequately equipped with effective strategies to resolve
patient barriers to adherence.
The third and fourth key findings emerged during the
telephone interviews with community pharmacy precep-
tors and pharmacy faculty members. The third key finding
was that preceptors reported not feeling entirely well in-
formed about medication adherence interventions them-
selves, being inadequately informed on what students know
about medication adherence, and lacking the educational
tools to consistently facilitate adherence detection, mon-
itoring, and intervention. They expressed the need for
greater guidance from colleges and schools of pharmacy
on how to teach and assess adherence-related skills. One
faculty member expressed similar concerns and suggested
pharmacy faculty members needed to be more involved in
the experiential learning of students, such as coming to
experiential sites and showing applications of concepts
taught in the classroom.
Preceptors faced challenges in consistently facilitat-
ing adherence-related activities during practice experi-
ences, such as time constraints and other realities of daily
practice. Because of these limitations, they were concerned
that they were not modeling ideal adherence promotion
behaviors for students. If students do not see preceptors
consistently and effectively detecting, monitoring, and in-
tervening on medication non-adherence, they may per-
ceive these activities as not as critical as others and be
less inclined to engage in them. The findings from the
conversations with the preceptors provide additional ev-
idence that students appear to be inadequately and incon-
sistently exposed to intervention strategies for medication
non-adherence, both in the classroom and experiential
settings.
Given the significant impact of medication adher-
ence on the lives of patients and the severity of the med-
ication non-adherence problem, pharmacy education groups
must come together and ensure a common thread is woven
throughout curriculum and national curriculum standards.
The authors suggest that ACPE give strong consideration
to the addition of language and content in the PharmD
accreditation standards regarding adherence concepts and
tools as part of their curriculum and IPPE/APPE experi-
ences. Such language would facilitate a national effort
toward consistency in medication adherence knowledge
and behaviors that will better prepare students to address
non-adherence in practice.
There are a few limitations to this investigation. To
improve response rates among students in the project
conducted by the NCPA Advisory Committee, multiple
efforts were made to extend the deadline for survey in-
strument completion and an incentive for participation
was offered. Future research could determine if a larger
representation of students across more colleges and schools
of pharmacy would yield findings similar to those of the
present study. Also, the study involved a small conve-
nience sample of preceptors and faculty members. Because
American Journal of Pharmaceutical Education 2012; 76 (5) Article 79.
8
of these 2 limitations, we may not be able to generalize
our findings to other colleges and schools of pharmacy. A
future study involving more preceptors and faculty mem-
bers could be conducted to confirm our findings. We are
uncertain as to the accuracy of the student data because of
possible poor recall of content covered in past years. In
recalling past events (especially events that occurred over
several years), respondents may have underestimated or
overestimated the coverage of an adherence topic. We
also encouraged students to consult with students enrolled
in later years of the program in hopes that their input
would result in a more comprehensive response that more
accurately represented the respondent’s college or school
of pharmacy. While the current research asked students to
report the degree to which they were exposed to a topic,
a future study could assess what students actually know
about the background on medication adherence and in-
terventions to use with non-adherent patients. While the
brief survey instrument was field tested for face and con-
tent validity among a group of students prior to adminis-
tration, there is the possibility that survey items may not
have been clear, leading to some misinterpretation of
what was being requested.
CONCLUSIONS
While the pharmacy curriculum covers the concepts
of medication adherence to some extent, students are at
best only somewhat exposed to intervention strategies,
making application of key adherence strategies a signifi-
cant deficiency in pharmacy students’ educational expe-
rience. Our findings suggest that the following action
steps are necessary to embed adherence as a core compe-
tency in pharmacy school curriculum and ensure its ap-
plication in practice: integrating medication adherence
concepts and interventions throughout the curriculum
and experiential education, embedding medication adher-
ence education into national standards for pharmacy ed-
ucation, and developing a toolkit that is a national
resource for students and preceptors on adherence in-
tervention strategies. These steps are critical to prepare
future pharmacists to actively detect, monitor, and inter-
vene in cases of medication non-adherence.
ACKNOWLEDGMENTS
The authors would like to thank Professors Jon
Schommer, Dale Christensen, and Todd Brown, and sev-
eral community pharmacy preceptors for their helpful
comments during the data collection process.
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9
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The incidence and causes of drug-related hospital admissions and visits to an emergency department were evaluated. A retrospective chart review was conducted to identify drug-related visits and admissions for all patients who visited the emergency department of a 517-bed tertiary-care institution during a four-month period. Drug-related illnesses were classified as adverse drug reaction (ADR), overdose or abuse, noncompliance, drug interaction, or toxicity. Patient data included demographic characteristics, medication history, serum drug concentrations, length of hospital stay, and hospital admission charges. Of 10,184 patients who visited the emergency department, 293 (2.9%) had drug-related illnesses; 71 (24%) of these patients were admitted. The drug classes most commonly involved were drugs of abuse (23.2%), anticonvulsants (17.1%), antibiotics (12.6%), respiratory drugs (8.9%), and pain medications (8.9%). The most common category of drug-related illness was overdose or abuse (35%) followed by noncompliance (28%), ADR (28%), toxicity (8%), and drug interaction (1%). The average length of stay for patients who were admitted was 5.8 days, and the average cost of admission was $8888. Drug-related illnesses accounted for 2.9% of hospital admissions and visits for patients in the emergency department. The most commonly identified drug-related illnesses were overdose or abuse, noncompliance, and ADRs; the drug classes most commonly implicated were drugs of abuse, anticonvulsants, and antibiotics.
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The association of underutilization of drugs prescribed for the treatment of hypertension and acute-care hospital readmissions was evaluated. The data base consisted of computerized hospitalization records and computerized out-patient pharmacy records, checked by chart audit for validity. The number of days' supply of antihypertensive agents was estimated by dividing the quantity of drugs dispensed by the daily dose indicated by the prescription instructions. All patients had been admitted to an acute-care hospital during a 6-month period with the diagnosis of hypertension. Following discharge from the hospital, drug utilization and readmission status were determined for a minimum of 1 year. The drug compliance of a group of patients who were readmitted to the hospital was compared with the patients who were not readmitted. The readmitted group had a significantly higher ratio of days when they were without any antihypertensive agents relative to the length of time in the study. There were no statistically significant differences in demographic features or blood-pressure levels between the patient groups. These findings indicate that underutilization of antihypertensive drugs may be associated with hospitalization, which could be prevented if patients had complied with their medication schedules.
Article
A survey of drug-related admissions of patients aged 50 years and older was conducted at the Health Sciences Centre, Winnipeg to determine the interrelationship of risk factors, and isolate the effect of age. All nonelective medical admissions were prospectively assessed to determine the role of drug therapy as a contributory factor. Of the 863 eligible admissions, 162 exhibited at least one drug-related adverse patient event (DRAPE) at the time of hospitalization. This accounted for 19% of the admissions (23% of 718 admissions that involved prescription drugs). Although adverse drug reactions were responsible for many DRAPEs (48%), intentional noncompliance (27%), treatment failure (19%), alcohol (14%), and medication error (10%) were also frequent contributing causes. Drugs commonly implicated in DRAPEs were systemic steroids, digoxin, nonsteroidal anti-inflammatory agents, alpha-methyldopa, calcium channel blockers, beta-blockers, theophylline, furosemide, sympathomimetics, thiazides, and benzodiazepines. The risk of a DRAPE was related to the number of diseases prior to admission (r = 0.81; P less than .026) and the number of drugs used (r = 0.77; P less than .001). Age was not correlated with the risk of a DRAPE. Females had significantly more adverse drug reactions, although sex was not a predictor for overall DRAPE risk.
Article
PIP Focusing on the issue of adolescent compliance with medical regimens, the discussion defines compliance; reports on the incidence of noncompliance; discussed direct and indirect methods of measuring compliance; considers noncompliance as a diagnostic issue; reviews theoretical approaches to compliance research -- individualistic models, the health-belief model, and the provider-patient relationship; and examines adolescent compliance with oral contraceptives (OCs) and improving adolescent compliance with therapeutic regimens. Compliance has been defined as the extent to which an individual's behavior -- in terms of taking medications, following diets, or executing lifestyle changes -- coincides with medical or health advice. It has been reported that there is more noncompliance associated with longterm prescriptions than with those of shorter durations. The most common approach to the study of nonconforming health behavior has been to identify individual factors that are associated with various forms of noncompliance. Study finding suggest that despite the characteristics of the patient, the behavior of the health care provider can largely determine whether the adult patient will comply or not with medical advice. Further study will determine if adolescents behave similarly. Confirming previous reports, the findings suggest that the nature of the interaction between the health care provider and the patient, combined with the adolescent's sexual behavior and social psychological status, may influence how compliant she will be with her regimen. More ongoing research that will allow physicians to identify adolescents at risk of noncompliance so that appropriate intervention strategies may be employed is needed in this area. Strategies to increase the likelihood that adolescent patients will follow prescribed treatment regimens include: reminding the patient about the importance of compliance at each and every visit; improving the physician-patient relationship; and rewarding and reinforcing compliance.
Article
Although clinical trials have demonstrated the benefits of lipid-lowering therapy, little is known about how these drugs are prescribed or used in the general population. To estimate predictors of persistence with therapy for lipid-lowering drug regimens in typical populations of patients in the United States and Canada. A cohort study defining all prescriptions filled for lipid-lowering drugs during 1 year, as well as patients' demographic and clinical characteristics. New Jersey's Medicaid and Pharmacy Assistance for the Aged and Disabled programs and Quebec's provincial medical care program. All continuously enrolled patients older than 65 years who filled 1 or more prescriptions for lipid-lowering drugs (N = 5611 in the US programs, and N = 1676 drawn from a 10% sample in Quebec). Proportion of days during the study year for which patients had filled prescriptions for lipid-lowering drugs; predictors of good vs poor persistence with therapy. In both populations, patients failed to fill prescriptions for lipid-lowering drugs for about 40% of the study year. Persistence rates with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors were significantly higher than those seen with cholestyramine (64.3% vs 36.6% of days with drug available, respectively). Patients with hypertension, diabetes, or coronary artery disease had significantly higher rates of persistence with lipid-lowering regimens. In New Jersey, multivariable analysis indicated that the poorest patients (those enrolled in Medicaid) had lower rates of drug use than less indigent patients (those enrolled in Pharmacy Assistance for the Aged and Disabled) after adjusting for possible confounders, despite virtually complete drug coverage in both programs. When rates of use were measured in the US population for the 5 years following the study year, only 52% of surviving patients who were initially prescribed lipid-lowering drugs were still filling prescriptions for this drug class. In all populations studied, patients who were prescribed lipid-lowering drug regimens remained without filled prescriptions for over a third of the study year on average. Rates of persistence varied substantially with choice of agent prescribed, comorbidity, and socioeconomic status, despite universal coverage of prescription drug costs. After 5 years, about half of the surviving original cohort in the United States had stopped using lipid-lowering therapy altogether.
Article
Knowledge of long-term persistence with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy is limited because previous studies have observed patients for short periods of time, in closely monitored clinical trials, or in other unrepresentative settings. To describe the patterns and predictors of long-term persistence with statin therapy in an elderly US population. Retrospective cohort study including 34 501 enrollees in the New Jersey Medicaid and Pharmaceutical Assistance to the Aged and Disabled programs who were 65 years of age and older, initiated statin treatment between 1990 and 1998, and who were followed up until death, disenrollment, or December 31, 1999. Proportion of days covered (PDC) by a statin in each quarter during the first year of therapy and every 6 months thereafter; predictors of suboptimal persistence during each interval (PDC <80%) were identified using generalized linear models for repeated measures. The mean PDC was 79% in the first 3 months of treatment, 56% in the second quarter, and 42% after 120 months. Only 1 patient in 4 maintained a PDC of at least 80% after 5 years. The proportion of patients with a PDC less than 80% increased in a log-linear manner, comprising 40%, 61%, and 68% of the cohort after 3, 12, and 120 months, respectively. Independent predictors of poor long-term persistence included nonwhite race, lower income, older age, less cardiovascular morbidity at initiation of therapy, depression, dementia, and occurrence of coronary heart disease events after starting treatment. Patients who initiated therapy between 1996-1998 were 21% to 25% more likely to have a PDC of at least 80% than those who started in 1990. Persistence with statin therapy in older patients declines substantially over time, with the greatest drop occurring in the first 6 months of treatment. Despite slightly better persistence among patients who began treatment in recent years, long-term use remains low. Interventions are needed early in treatment and among high-risk groups, including those who experience coronary heart disease events after initiating treatment.