A systemic approach to improve patients adherence to medications a Dutch initiative to create sustainable change Presentation for the Espacomp Congress 2009, Bangor, Wales. Marnix P.D. Westein, Phar. D., email: m.westein@winap.nl Royal Dutch Association for the Advancement of Pharmacy (KNMP) Tom Schoen, Senior Policy Advisor, The Federation of Patients and Consumer Organisations in the Netherlands (NPCF)
Overview of the presentation Facts and figures on medication adherence Survey comparing Dutch initiatives Changing our perspective A systemic approach Conclusion
Facts and Figures (1) Discontinuation percentage of chronic pharmacotherapy in the first year after start of the treatment (Netherlands 2002) Chronic Pharmacotherapy forever Report, Pharmo institute, 2002.
Facts and Figures (2) Adherence percentages found in Dutch Studies (2004) Factors related to adherence Report, NIVEL, 2004.
Internet survey of Dutch initiatives to improve adherence (2007) 41 initiatives were reported Examples: Monitoring drug prescriptions Distribution using a Medicationroll Communications checklists SMS reminder services Periodic Medication review Self management courses Patient Healthcare professional ICT Medicine
Internet survey of Dutch initiatives to improve adherence (2007) Comparing different actors different views on the problem different ways of measuring different solutions Results Unclear outcomes No widespread change
Changing our perspective on improving medication adherence Old perspective New perspective
Changing our perspective (2) Medication adherence is influenced by many variables which are highly interconnected many actors who act partly independent and act on multiple levels This generates outcomes which are difficult to measure and difficult to predict. In Health promotion research such a system is referred to as a complex or soft system.
A systemic approach is needed to create sustainable change Step 1: Investigate the problem Step 2: Develop a rich picture (of the actors, levels and their connections) Step 3: Extract main themes Step 4: Increase cooperation between actors Step 5: Develop and test potential solutions Step 6: Change practice D G Cramp, et al. Health Serv Man Res 2009; 22: 71-80 Naaldenberg J, et al. Glob Health Prom 2009; 16; 39
Step 2: develop a rich picture (NPCF, 2008) Umbrella Organizations Pharm., Phys. and nurses Insurance companies Government Patient organizations Health care environment Nurse Pharmacist Physician ICT Pharmaceutical Companies Research & education Patient Medicine Social environment
Step 3: extract main themes (NPCF, 2008) 1. Improve communication between patients and healthcare professionals 2. Improve cooperation and information sharing between healthcare professionals 3. Develop and prescribe medicines which are easily adapted to patients daily routines 4. Tailor patients support to suit individual needs Tijd voor een beter gebruik van medicijnen, Westein NPCF 2008.
Step 4: Increase cooperation between actors Start of a national taskforce with members from 13 national organizations (KNMP/NPCF 2009) Task: to share visions on improving adherence and debate structure, meaning and power relations To improve cooperation and information sharing To identify and solve practical issues Result 2009: an overview of members activities in 2009 and plans for 2010
Examples of activities 2009 Outlines for a National research program on effective use of medicine Development of multidisciplinary healthcare guidelines for chronic diseases (e.g. diabetes, COPD) Increased pharmacy drug prescription monitoring Increased use of medicationroll Introduction of a yearly medication review for elderly Introduction of prescribing nurses
Step 5: Develop and test potential solutions (2010 ) Quantify goals Set priorities Standardize tools for measurement Develop and pilot interventions Measure results Integrate ICT-tools Increase evidence based practice
Systemic approach: conclusion 2009 2007 Introduction to Pharmionics Vrijens & Urquhart, 2005 Journal of Antimicrobiol Chemotherapy
Initiatives on multiple levels MACRO Health policy MESO Center MICRO Patient-provider dyads PATIENT (De Geest et al., BRIGHT study protocol; McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q 1988;15(4):351-77.)