Adherence to polypharmacy - use of multidrug punch cards in primary care

Adherence is defined as ‘the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider’. Typical adherence rates to oral medication range from 50-76%. Non-adherence has been associated with increased morbidity, mortality and, healthcare costs. Manifold interventions have been investigated to enhance adherence, though the evidence remains scarce.
Multidrug punch cards constitute a special kind of dose-dispensing aids consisting of disposable frame cards with plastic compartments, sealed with a foil backing and typically providing 28 compartments for all oral solid medications of a patient according to a prescribed dosing regimen. Dose-dispensing aids aim at supporting medication self-management.
POEMS is an adhesive polymer film with printed electric circuitries and a RFID chip collecting real time data. Affixed on a multidrug punch card, POEMS records date, time and location of the medication removal of a whole therapy regimen and thus is able to electronically monitor adherence to polypharmacy.
The goal of this thesis was to investigate the effect of the multidrug punch card use on adherence and patient-relevant outcomes in primary care.
PROJECT A1 outlined the evidence of dose-dispensing aids in adherence-enhancing interventions and identified research gaps. Ten randomized controlled trials, nineteen controlled clinical trials, and one cohort study were included in the analysis. Overall, dose-dispensing aids had a positive but moderate effect. Poor methodological quality and insufficient information of intervention elements limited the evidence and the replicability. Evidence gaps concerned economic and humanistic outcomes, safety issues, long-term, disease-unspecific, and generalizable clinical outcomes, and clinical effects on multimorbid populations with polypharmacy.
In PROJECT B1, we explored the daily practice of community pharmacies in the nature and extent of adherence counseling. Adherence counseling was provided to only 99 (6.7%) patients and mainly by pharmacists. The pharmacists stated structural and procedural barriers to deliver adherence counseling.
In PROJECT B2, we mailed a survey to all 51 community pharmacies providing multidrug punch cards. Pharmacies reported to provide 1’869 patients with multidrug punch cards, in 14% of the cases primary care patients. The dose-dispensing service fitted well in the community pharmacies’ daily practice. Pharmacists estimated an adherence rate of 93% for their primary care patients using the multidrug punch card, and assumed them to be satisfied with the device.
We confirmed this view by a mixed methods study on acceptability, ease of use, preferences, and impact on adherence with primary care patients using multidrug punch cards in daily life in PROJECT B3. Additionally, we were able to describe the characteristics of these patients as age over 70 years; low education grade; being retired; living alone; preference for tidiness, rituals, and daily routines; inability or reluctance to leave home; and motivation to lead a healthy life. All 33 patients reported perfect adherence.
We developed a randomized controlled trial to investigate the effectiveness of electronic multidrug punch cards in connection with feedback on electronic dosing histories to improve adherence and patient-relevant outcomes in a primary care population. In PROJECT C1, we conducted a pilot study to assess and optimize the feasibility, efficiency, and quality of the study structures and procedures.
We recruited ten patients and only one patient accepted the use of multidrug punch cards. No patient was readmitted to hospital during the follow-up period. One major adjustment of drug therapy occurred in the intervention patient, but could not be explained with an adherence problem. According to POEMS data and self-reported adherence, he was perfectly adherent. The control patients showed maximal adherence rates as well. The results of the intervention patient were further explored in PROJECT C2. The evaluation of the pilot study showed that the study design was feasible, but lacked efficiency and quality.
Conclusions:
• Research gaps and poor methodological and reporting quality precluded a firm conclusion about the evidence of dose-dispensing aids.
• Several barriers hinder pharmacists to adequately deliver adherence counseling.
• Multidrug punch card service is well integrated in daily practice of Swiss community pharmacies but its provision for primary care patients is limited.
• A specific group of primary care patients reports to benefit from multidrug punch card use.
• A pilot study investigating the effectiveness of electronic multidrug punch cards in primary care patients failed because of poor efficiency and quality of the study structures and procedures. One intervention patient of this pilot study showed maintenance of perfect adherence and clinical stability.
Recommendations for practice:
• To overcome structural and procedural barriers for patient-centered counseling.
• To actively address medication self-management and non-adherence at patient contacts in the community pharmacy.
• To actively recommend multidrug punch cards to primary care patients with polypharmacy with regard to their capabilities, needs, and necessities.
• To tailor interventions for non-adherent patients.
Recommendations for research:
• To identify further patient groups who accept multidrug punch cards and benefit from their use.
• To develop guidelines for the delivery of tailored adherence support.
• To optimize the discovered inadequate points for a subsequent randomized controlled study on the effectiveness of multidrug punch cards.