Quality Standards for Diabetes Care Toolkit

Introduction

Medication management

The notion of agreement sounds simple but has a number of facets. These include: the acknowledgement and engagement of the patient as an active participant in treatment decision-making; individuals’ views on taking medication and the factors that influence adherence; and their satisfaction with their treatment – all of which may impact on medication use. Agreeing to start, review and stop medication is related to patient education (see Standard 1) in that people need to understand their condition/s, the way in which medication helps, and the importance of taking it appropriately and regularly.
The Best Practice Advocacy Centre’s (2012a) article about people with type 2 and poor glycaemic control notes that an individual’s belief about the need for anti-diabetic medication can be influenced by factors such as fear, fatalism about the disease and family or whānau’s negative experiences with treatment. It continues to say that ‘a shared decision-making approach to management allows patients and health professionals to form an agreement on diabetes care that may also correct previous clinical assumptions, eg, concerning treatment adherence, health literacy or motivation. To do this well, primary care teams need to have a good understanding of the patient’s background, beliefs and priorities’ (p 41).
A 2008 policy brief to the World Health Organization (Coulter et al) discusses the importance of patient involvement in treatment decision-making. They state in the summary: ‘One of the most common sources of patient dissatisfaction is not feeling properly informed about (and involved in) their treatment. Shared decision-making, where patients are involved as active partners with the clinician in treatment decisions, can be recommended as an effective way to tackle this problem. Clinicians and patients work together as active partners to clarify acceptable medical options and choose appropriate treatments. While not all patients want to play an active role in choosing a treatment – because of age-related and cultural differences – most want clinicians to inform them and take their preferences into account. Well-designed training courses can improve the communication skills of doctors, nurses and pharmacists. As patients become more involved, their knowledge improves, their anxiety lessens and they feel more satisfied. Patient coaching and question prompts help to empower patients to take a more active role in consultations. These prompts improve knowledge and recall and help patients feel more involved and in control of their care. Evidence-based patient decision aids facilitate the process of making informed decisions about disease management and treatment. Decision aids can improve a patient’s knowledge and their level of involvement in treatment decisions. They also give patients a more accurate perception of risk and encourage appropriate use of elective procedures’.
Parchman et al (2010) studied participatory decision-making in primary care and found positive associations with medication adherence, which in turn was associated with improved HbA1c and cholesterol.
Another factor that may influence agreement between parties is the satisfaction people feel with the treatment they are receiving. Anderson et al (2009) developed the Diabetes Medication Satisfaction Tool as assessment of treatment satisfaction was seen to be important for the building of a therapeutic relationship between patient and provider and for tailoring of regimen. The 16item tool ‘performed well in assessing treatment experiences: ease and convenience, lifestyle burdens, wellbeing, and medical control’ and can be found at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2606829/pdf/51.pdf.
National Institute for Health and Care Excellence (NICE) (2009) defines adherence as ‘the extent to which the patient’s action matches the agreed recommendations’ which presumes that the prescriber and patient are in agreement on the prescriber’s suggestions. Poor medication adherence is common. According to the Agency for Healthcare Research and Quality’s (2012), evidence report on medication adherence, studies have consistently shown that between 20% and 30% of prescriptions are never filled and that around half of chronic condition medications are not taken as prescribed. However, non-adherence should not be considered solely a patient problem but as a breakdown in the delivery system either because the patient did not fully accept the prescription when it was provided or did not receive the support required to follow through. The NICE Guidelines (2009) state the following in their introduction: ‘Addressing non-adherence is not about getting patients to take more medicines per se. Rather, it starts with an exploration of patients’ perspectives of medicines and the reasons why they may not want or are unable to use them. Health care professionals have a duty to help patients make informed decisions about treatment and use appropriately prescribed medicines to best effect. There are many causes of non adherence but they fall into two overlapping categories: intentional and unintentional. Unintentional non adherence occurs when the patient wants to follow the agreed treatment but is prevented from doing so by barriers that are beyond their control. Examples include poor recall or difficulties in understanding the instructions, problems with using the treatment, inability to pay for the treatment, or simply forgetting to take it. Intentional non adherence occurs when the patient decides not to follow the treatment recommendations. This is best understood in terms of the beliefs and preferences that influence the person’s perceptions of the treatment and their motivation to start and continue with it. It follows that to understand adherence to treatment we need to consider the perceptual factors (for example, beliefs and preferences) that influence motivation to start and continue with treatment, as well as the practical factors that influence patients’ ability to adhere to the agreed treatment’.
The World Health Organization published a report on adherence (2003) which can be found at: www.who.int/chp/knowledge/publications/adherence_report/en/. A summary can be found at: www.who.int/chp/knowledge/publications/adherence_introduction.pdf.
Key messages are as follows: