Excerpt

The prescription of medicines is a core element of the delivery of modern health care. Medicines are widely used not only to relieve symptoms and cure conditions but to prevent ill health in the future. Medical advances, combined with an ageing population, have resulted in many patients taking multiple medicines in complex regimes. There is an increasing number and diversity of healthcare professionals involving in prescribing, dispensing or reviewing medicines. Prescribing was once the preserve of the medical profession but prescribing rights are now available to other health professionals either as independent or supplementary prescribers.

Medicine-taking is a complex human behaviour and patients evaluate medicines, and the risks and benefits of medicines using the resources available to them. Unwanted and unused medicines reflect inadequate communication between professionals and patients - about health problems and how they might be treated, and about patients’ ongoing assessment and experience of treatments. This guideline will be of help to all healthcare professionals by providing guidance on how to involve patients in the decision to prescribe medicines and on how to support patients in their subsequent use of medicines. The recommendations include advice to healthcare professionals to ensure there are robust mechanisms to ensure communication between the many professionals who may be involved in each patient’s care.

Contents

• Preface
• Introduction
• Patient-Centered Care
• Key principles
• 1. Guidance
  • 1.1 Recommendations
  • 1.2 Aim of the guideline
  • 1.3 How the guideline is set out
  • 1.4 Scope
  • 1.5 Guideline Limitations
  • 1.6 Responsibility and support for guideline development
  • 1.7 Research recommendations
  • 1.8 Acknowledgements
  • 1.9 Glossary
• 2. Methods
  • 2.1 Introduction
  • 2.2 Developing key clinical questions (KCQs)
  • 2.3 Literature search strategy
  • 2.4 Identifying the evidence
  • 2.5 Critical appraisal of the evidence
  • 2.6 Health Economics methods
  • 2.7 Forming recommendations
  • 2.8 Areas without evidence and consensus methodology
  • 2.9 Update
  • 2.10 Consultation
  • 2.11 Relationships between the guideline and other national guidance
  • 2.12 Disclaimer
  • 2.13 Funding
• 3. Principles and concepts used in the development of the guideline
  • 3.1 Patients’ rights to be involved in decisions about medicines
  • 3.2 What is meant by involving patients in decisions about medicines?
  • 3.3 What are we trying to achieve in involving patients in decisions about medicines?
  • 3.4 Roles and responsibilities of patients and health care professionals
  • 3.5 Understanding the influences on medicine-taking by patients
  • 3.6 Terminology and structure of guideline
  • 3.7 Shared decision-making about medicines
• 4. Interventions to increase shared decision-making about medicines
  • 4.1 Recommendations
  • 4.2 Introduction
  • 4.3 Process of shared decision-making
  • 4.4 Methods
  • 4.5 Is it possible to increase patient involvement in decisions about medicines?
  • 4.6 How can practitioners elicit patients’ preferences for involvement in decisions about medicines?
  • 4.7 What tools are available to help elicit patients’ beliefs about medicines?
  • 4.8 What tools are available to help elicit patients’ information needs?
  • 4.9 How can information about medicines be provided for patients in order to enhance SDM in regard to medicines?
  • 4.10 What information about medicines should be provided for patients in order to enhance SDM in regards to medicine?
  • 4.11 Mental capacity narrative
  • 4.12 What information about shared decision-making and adherence should be recorded in patients’ notes?
  • 4.13 What tools are available to support the patient in reaching an informed decision? How effective are these tools?
  • 4.14 How can a practitioner elicit whether a patient agrees with the prescription recommended by the practitioner?
  • 4.15 What aspects of consultation style increase patient involvement in decision-making?
  • 4.16 Do interventions to increase patient involvement increase length of the consultation?
  • 4.17 Cost–effectiveness of interventions to increase shared decision-making
• 5. Patients’ experience of medicine-taking
  • 5.1 Recommendations
  • 5.2 Introduction
  • 5.3 What are the barriers and facilitators for individuals in medicine-taking
  • 5.4 Update of qualitative evidence synthesis - Pound 2005 synthesis
  • 5.5 Systematic reviews of barriers and facilitators for individuals in medicine-taking
• 6. Information for inpatients and practitioners when patients are transferred between services
  • 6.1 Recommendations
  • 6.2 Introduction
  • 6.3 What information regarding medicines should be provided for patients and practitioners when patients are discharged from secondary care?
• 7. Assessment of adherence
  • 7.1 Recommendations
  • 7.2 Introduction
  • 7.3 What are the advantages and disadvantages of self-report in assessing patient’s adherence?
• 8. Interventions to increase adherence to prescribed medicine
  • 8.1 Recommendations
  • 8.2 Introduction
  • 8.3 Methods
  • 8.4 Evidence to recommendations : difficulties in interpreting studies on interventions to improve adherence
  • 8.5 Does change in dosing regime affect adherence?
  • 8.6 Effect of prescription charges on adherence to prescribed medicine
  • 8.7 Does medicine packaging affect adherence?
  • 8.8 Does the use of multi-compartment medicine systems increase adherence to prescribed medicine?
  • 8.9 Does medicine formulation affect adherence?
  • 8.10 Do reminders (and what types of reminders, text messaging etc) increase adherence to prescribed medicine?
  • 8.11 Is there any evidence on interventions that aim to minimize side-effects in order to increase adherence?
  • 8.12 How does the way the information is presented (e.g. pictorial vs. written) affect adherence?
  • 8.13 Do specific forms of therapy (e.g. CBT) affect adherence?
  • 8.14 Would a contractual agreement between HCP and patient affect adherence?
  • 8.15 Does being involved in self-monitoring (e.g. of own blood pressure) increase adherence to prescribed medicine?
• 9. Reviewing medicines
  • 9.1 Recommendations
  • 9.2 Introduction
  • 9.3 Does medicine review increase shared decision–making or adherence?
• 10. Health economics and interventions to increase adherence
  • 10.1 Introduction
  • 10.2 Which Interventions are cost effective in increasing adherence/compliance?
  • 10.3 Update of the systematic review by Elliott (2005)
  • 10.4 Summary and Discussion
• 11 Bibliography
• Appendix A Medicines Adherence Final Scope
• Appendix B Key Clinical Questions and Searches
• Appendix C Clinical Evidence Extractions
• Appendix D Health Economic Extractions
• Appendix E Guideline Development Group Declarations of Interest

Suggested citation:

Nunes V, Neilson J, O’Flynn N, Calvert N, Kuntze S, Smithson H, Benson J, Blair J, Bowser A, Clyne W, Crome P, Haddad P, Hemingway S, Horne R, Johnson S, Kelly S, Packham B, Patel M, Steel J (2009). Clinical Guidelines and Evidence Review for Medicines Adherence: involving patients in decisions about prescribed medicines and supporting adherence. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners.