Family Practice Vol. 21, No. 1, 46-50
© Oxford University Press 2004, all rights reserved.
Article |
What happened to the prescriptions?
A single, short, standardized telephone call may increase compliance
a Department of Primary Health Care, Göteborg University, b Gävle/Sandvikens Hospital, and c Research and Development Unit, Primary Health Care in southern Älvsborg county, Sweden
Correspondence to Bertil Hagström, Department of Primary Health Care, Göteborg University, PO Box 454, SE-405 30 Göteborg, Sweden; E-mail: bertil.hagstrom{at}telia.com
Received 12 December 2002; Revised 15 July 2003; Accepted 8 September 2003.
Hagström B, Mattsson B, Rost IM and Gunnarsson RK. What happened to the prescriptions? A single, short, standardized telephone call may increase compliance. Family Practice 2004; 21: 46–50.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background. Patients' compliance with prescribed prescriptions and doctors' advice is a prerequisite for successful treatment. Compliance is estimated to be
50% in the treatment of hypertension. Thus, it is important to find simple methods to increase compliance. Objectives. Our aim was to estimate the extent to which patients visit the pharmacy and redeem prescribed items after seeing a GP, and to assess if a phone call 1 week later improves compliance.
Methods. A total of 399 patients attending a primary health care centre receiving prescriptions were randomized to active intervention receiving a short standardized follow-up telephone call or to standard intervention receiving no telephone call. The doctors' prescriptions were later compared with the dispensed drugs at the pharmacies.
Results. A majority of the patients (90%) redeemed prescriptions. Women redeemed prescriptions to a greater extent than men, both in the control group (P = 0.023) and in the intervention group (P = 0.0003). A telephone call 1 week later increased the proportion of patients that redeemed their prescriptions (P = 0.023). Further analysis showed that only women were affected by the telephone call. Twenty percent of the prescriptions were drugs for cardiovascular diseases (CVDs). The proportion of dispensed drugs for CVD was only 66%, compared with 88% for all other drugs (P = 0.001).
Conclusion. A single, short, standardized telephone call increases women's compliance. Women also redeem prescriptions more often than men irrespective of a telephone call. The compliance and treatment of CVD are not acceptable, and seem to be lower for men than women.
Keywords. Cardiovascular diseases, controlled clinical trials, empowerment, gender, patient compliance, prescription drug.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patients' compliance with prescribed prescriptions and doctors' advice is a prerequisite for successful treatment. Patients' adherence to drug therapy is related to many factors. The seriousness of the disease is one issue, and compliance seems to be especially important when treating chronic disorders, i.e. cardiovascular diseases (CVDs).1 Compliance is estimated to be
50% in the treatment of hypertension.2,3 The reasons for non-compliance are various. The patient and the doctor might disagree about the value of pills and prescriptions. What the patient regards as ‘too many pills’, the doctor may well consider adequate. Factors influencing compliance are comprehensive.4
Various methods have been used to study compliance. Patient questionnaires and interviews have been applied, and counting pills and/or measuring blood or urine concentrations of drugs have been utilized. However, counting pills might be unreliable and measuring concentrations of drugs is expensive.3,5–7
The patient's willingness to redeem the prescribed drugs reflects one facet of compliance. A study of the patient's readiness to go to the pharmacy after seeing a doctor can be considered an intermediate form of compliance or primary compliance.8 If the prescriptions are redeemed, there are, however, no guarantees that the drugs are taken according to the doctor's advice.
Prescriptions not redeemed at the pharmacy reflect the population in the area and the drug studied.7 Cardiovascular drugs have a particularly low redemption rate.9 In an extensive Swedish study in 1991, 14% of prescribed items were unredeemed.9 In a local study in 1991 in Storvik, a village in the middle of Sweden, 25% of prescribed items were unredeemed.10 Redemption rates of prescribed items for long-term treatments vary in international studies between 50 and 80%.11,12 Almost all these studies deal with prescribed items, not with patients.
International figures are not easily accessible due to difficulties in ascertaining actual dispensing. Sweden, however, has a central system for dispensing medicines whereby prescriptions can only be redeemed at state-owned pharmacies. Villages and smaller towns usually have only one pharmacy, and all drugs will, as a rule, be dispensed from this pharmacy.
A few studies have focused on the effect of a follow-up telephone call on patients' compliance. Friedman assessed whether a totally automated, regularly scheduled, computer-controlled telephone call to patients at home without involved personnel could improve health behaviour. He found a significant improvement in adherence to medication regimens measured as significantly improved blood pressure control.13 However, the influence of a follow-up telephone call between people on patient compliance has not been evaluated.
The aim of this study was 2-fold. First, we wanted to estimate the extent to which patients redeemed their prescriptions after seeing a GP, and secondly to assess if a follow-up phone call could improve patients' inclination to redeem prescriptions.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The study was carried out in 1996–1997 in Storvik, a village of 7000 inhabitants in central Sweden. It is characterized by farming and small industries. Storvik had only one primary health care centre (PHC) with five active GPs at the time of the study. The nearest hospital is situated 15 km from the village. Storvik has only one pharmacy located 500 m from the PHC. Other pharmacies are
15 km away from the village.
Selection of patients
During a 4-week period, all prescriptions to patients 18 years or older were written in duplicate and categorized according to the ATC list (Anatomical Therapeutic Chemical Classification). The copies were kept at the PHC. Usually drugs are prescribed mostly at appointments, but occasionally also after telephone requests. However, our study includes only prescriptions made at visits. We focused intensely on medicines for chronic diseases known to linked to low compliance, such as CVDs.
The pharmacies in Storvik and the surroundings were informed of the project. All dispensed and prescribed drugs were registered by the physicians at the PHC. Registration was from the date of prescription and for five consecutive weeks.
Randomization
The patients were randomized into two groups. Patients born in even years comprised the intervention (I) group, and those born in odd years, the control (C) group, i.e. a fixed allocation. The PHC GPs were informed of the study but not of the method of randomization.
Intervention
One week after the GP visit, a practice nurse at the PHC phoned all patients in the I group. Initially, patients were questioned concerning general well-being. The following questions were then asked: "Did you receive any prescription(s) at the GP visit? If yes, why?", and finally: "Have you redeemed your prescription?" No direct appeal to redeem the prescriptions was made. Five attempts at a telephone call were made, with calls lasting from 2 to 3 min.
Prescriptions were later compared with the dispensed drugs at the pharmacies. Due to ethical reasons, pharmacies refused to supply data on an individual level. Thus, single cases could not be studied and data were obtained only on group levels (I and C groups and ATC grouping). The patients were informed of the study and participation was voluntary.
Statistics
Analysis was by intention to treat. The proportion of persons in the I and C groups who redeemed one or more of their prescribed items were compared according to gender. When comparing differences between the two groups, chi-square test with Yates correction was used. When the numbers were small, Fishers exact test (two-tailed) was used.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
During the 4-week period, 489 patient visits were made to the PHC, and drugs were prescribed at 402 visits (Fig. 1). Three patients refused to participate.
|
Altogether, 399 patients were randomized to the I (n = 184) and C groups (n = 215). In the I group, 178 patients (97%) were reached by telephone. There were more women in both groups, but no differences could be seen in the groups (Table 1).
|
Redeeming prescriptions
In all, 643 drugs were prescribed, i.e. 1.6 items per patient. The majority (n = 252; 63%) received one prescription, 101 patients (25%) received two and 47 patients (12%) received three or more.
A majority of patients, 362 of 399 (90%), visited and redeemed one or more prescriptions within 5 weeks of the GP visit. Most patients (n = 345; 95%) utilized the Storvik pharmacy, while 17 patients (5%) used nearby pharmacies. Women redeemed prescriptions at a higher rate than men, in both the C and I group (P = 0.023 and P = 0.0003, respectively, Fishers exact test, two-tailed) (Table 1).
Intervening telephone call
Unlike follow-up phone calls to women, a telephone call did not affect the proportion of men redeeming prescriptions (P = 0.016 and P = NS respectively) (Table 1). For women, the number needed to treat is 14 (95% confidence interval 8–49), thus 14 telephone calls to women makes a non-redeemer a redeemer. In total, more patients in the I group visited pharmacies to redeem prescriptions compared with controls (P = 0.023) (Table 1).
Prescriptions for cardiovascular diseases
An analysis of the number of dispensed drugs, rather than the number of persons who visited the pharmacy, showed that men in the I group redeemed 80% (80/100) of their prescriptions and men in the C group redeemed 74% (111/150). Corresponding figures for women are 89% (177/199) and 87% (169/194).
Of the 643 drugs prescribed by the GPs, 20% belonged to the ATC-C group, i.e. drugs for CVD. The proportion of dispensed drugs in this group (ATC-C) was comparatively low, and only 66% (85/129) were redeemed as opposed to 88% (452/514) for all other drugs (P = 0.001).
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
It seems as if a short telephone call to patients within 1 week after a GP visit increases patients' readiness to redeem prescriptions. This is more apparent in women than in men. Women also redeemed prescriptions more often than men regardless of a telephone call.
Methodological aspects
Six persons in the I group did not answer the call. Their presence in the I group marginally reduced the impact of the call, enhancing the redemption of prescriptions.
The purpose of the calls was to simulate telephone calls sometimes utilized clinically and to determine whether the short call affected redemption of prescriptions. The calls could be kept short and patients were generally positive about being contacted.
The vast majority of prescriptions were dispensed at the pharmacy in Storvik and only 5% were obtained at the three other pharmacies. It is unlikely that patients visited other pharmacies to any substantial degree.
One explanation for prescriptions not being redeemed was that there was no need for them to be filled. Patients may simply not have taken all their medicine. This form of ‘non-compliance’ probably influenced both groups equally.
Fixed allocation is usually considered an inferior method of randomization. However, in this study, doctors as well as patients were unaware of the allocation method. Thus allocation was considered acceptable.
The investigation was carried out in a rural environment and may not be valid in other environments.
Gender perspective
According to previous research, factors such as age, gender, marital status, education and social class do not influence the propensity to redeem prescriptions.14 However, our experience is that gender does affect this form of intermediate compliance. Why do men redeem their prescriptions to a lower extent than women? This gender difference might mirror the female preponderance in various facets of health care. In health care statistics, females exceed men as in- and out-patients. They also have a higher level of sick leave. It has been suggested that this reflects a greater capacity among women for caring and providing well-being. Being more compliant and redeeming prescribed drugs might manifest a caring attitude.
Cardiovascular disease
Compliance is important in the treatment of long-lasting diseases. In our study, the tendency to redeem prescriptions for drugs for CVD is low and, as previously described,14,15 appears to be lower for men.
Whether the disease has obvious symptoms or not might influence patient compliance.10 Many CVDs have mild or no symptoms. In our study, prescriptions related to CVD were redeemed less often.
To produce a substantial reduction of blood pressure in a population, Haynes claims that 80% compliance is necessary when treating hypertension.1 In our study, only 66% of CVD drugs were redeemed, while the actual intake presumably is lower. The compliance in treatment of hypertension and other CVDs is unacceptable.11
Empowerment
Compliance is not determined by the fact that patients obtain medicine. It is well known that a lot of medicines are redeemed but not taken.16 Still, it is important to know the extent to which prescriptions are filled.17,18
A short phone call seems to increase compliance. A telephone call indicates caring for patient problems and thus might enhance an inclination to comply.19–21 Showing concern for the patient may strengthen dialogue between care givers and patients, providing a more explicit role in treatment and thereby increasing empowerment.
On the other hand, non-compliance might be a conscious decision. It could be that drugs are deliberately ignored, instructions unclear, costs too high and conviction regarding the utility of drug therapy modest. If so, disobeying the doctor's order is a means of regaining control.4,22–26 The doctor needs this knowledge to understand such reactions.25 At the time of the study, the fee was at most 160 SEK (18
) for the most expensive item and at most 60 SEK (7) for the other items redeemed on the same occasion. The total cost for all drugs per year was limited to 1800 SEK (200) for each patient. Although cost is limited, it may still be high enough to cause non-compliance. The non-compliant patient is not easily recognizable. The best way to reveal non-compliance is simply to ask about compliance.27,28
Conclusions
In diseases where compliance is low and drug treatment of great importance, extra efforts, such as follow-up telephone calls, are of importance for increasing patient compliance. It is well known that a patient-centred attitude improves compliance.27 There is a need to explore patient attitudes toward prescribing and prescriptions to lead hopefully to a more relevant prescribing behaviour.28
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1 Haynes RB. Determinants of compliance: the disease and the mechanics treatment. In Haynes, RB, Taylor DW, Sackett DL (eds). J Fam Pract Compliance and Health Care. Baltimore: Johns Hopkins University Press; 1979.
2 Robbins J. Patient compliance. Prim Care 1980; 7: 703–711.[Web of Science][Medline]
3 Fallsberg M. Medication compliance in real life. Drug Inform J 1994; 28: 565–569.
4 Scherman M. Att vägra vara sjuk: en longitudinell studie av förhållningsätt till astma/allergi [Refusing to be ill: a longitudinal study of patients' relationships with their asthma/ allergy]. Thesis Göteborg: Acta Universitatis Gothoburgensis; 1994.
5 Vaur L, Vaisse B, Genes NF et al. Use of electronic pillboxes to assess risk of poor treatment compliance. Am J Hypertens 1999; 12: 374–380.[CrossRef][Web of Science][Medline]
6 Choo P, Rand C, Inui T et al. Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy. Med Care 1999; 37: 846–857.[CrossRef][Web of Science][Medline]
7 Sharkness C, Snow D. The patients view of hypertension and compliance. Am J Prev Med 1992; 3: 141–146.
8 Rashid A. Do patients cash prescriptions? Br Med J 1982; 284: 24–26.
9 Nilsson L, Johansson H, Wennberg M. Large differences between prescribed and dispensed medicines could indicate undertreatment. Drug Inform J 1995; 29: 1243–1246.
10 Hagström B, Odlander C. Recepten som apoteket aldrig såg [The prescriptions that the pharmacy did not see]. AllmänMedicin 1995; 16: 29.
11 Bailey JE, Lee MD, Somes GW, Graham RL. Risk factors for antihypertensive medication refill failure by patients under Medicaid managed care. Clin Ther 1996; 18: 1252–1262.[CrossRef][Web of Science][Medline]
12 Christensen DB, Williams B, Goldberg HI, Martin DP, Engelberg R, Logerfo J. Assessing compliance to antihypertensive medications using computer-based pharmacy records. Med Care 1997; 35: 1164–1170.[CrossRef][Web of Science][Medline]
13 Friedman R. Automated telephone conversation to assess health behavior interventions. J Med Syst 1998; 22: 95–102.[CrossRef][Medline]
14 Conrad P. The meaning of medication; another look at compliance. Soc Sci Med 1985; 20: 29–37.[CrossRef][Web of Science][Medline]
15 Jula A, Salminen JK, Saarijarvi S. Alexithymia: a facet of essential hypertension. Hypertension 1999; 33: 1057–1061.
16 Oparil S, Calhoun D. Managing the patient with hard-to-control hypertension. Am Fam Physician 1998; 57: 1007–1014, 1019–1020.
17 Morris S, Schulz RM. Patient compliance—an overview. J Clin Pharm Ther 1992; 17: 283–295.[Web of Science][Medline]
18 Haynes B, McKibbon A, Kanani R. Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet 1996; 348: 383–386.[CrossRef][Web of Science][Medline]
19 Stewart M. What is a successful doctor–patient interview? A study of interactions and outcomes. Soc Sci Med 1984; 19: 167–175.[CrossRef][Web of Science][Medline]
20 Stewart M, Brown JB, Donner A et al. The impact of patient-centered care on outcomes. J Fam Pract 2000; 49: 796–804.[Web of Science][Medline]
21 Virji A, Britten N. A study of the relationship between patients' attitudes and the doctors' prescribing. Fam Pract 1991; 8: 314–319.
22 Kjellgren K, Ahlner J, Caljö R. Taking antihypertensive medication—controlling or cooperating with patients. Int J Cardiol 1995; 47: 257–268.[CrossRef][Web of Science][Medline]
23 Donovan J. Patient decision making. Int J Technol Asses Health Care 1995; 11: 443–445.
24 Conrad P. The meaning of medication: another look at compliance. Soc Sci Med 1985; 20: 29–37.[CrossRef][Web of Science][Medline]
25 Trostle J. Medical compliance as an ideology. Soc Sci Med 1988; 27: 1299–1308.[CrossRef][Web of Science][Medline]
26 Lassen L. Patient compliance in general practice. Scand J Prim Health Care 1989; 7: 179–180.[Medline]
27 Stephenson B, Rowe B, Haynes B, Macharia W, Loen G. Is this patient taking the treatment as prescribed? J Am Med Assoc 1993; 269: 2779–2781.
28 Hunt L, Jordan B, Irwin S, Browner CH. Compliance and the patient's perspective: controlling symptoms in every day life. Cult Med Psychiatry 1989; 13: 315–334.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M. V. Seeman Schizophrenia: Women Bear a Disproportionate Toll of Antipsychotic Side Effects Journal of the American Psychiatric Nurses Association, January 1, 2010; 16(1): 21 - 29. [Abstract] [PDF]
|
|
|
|
 |
|
 B. M. Roede, P. Bresser, J. M. Prins, F. Schellevis, T. J. M. Verheij, and P. J. E. Bindels Reduced risk of next exacerbation and mortality associated with antibiotic use in COPD Eur. Respir. J., February 1, 2009; 33(2): 282 - 288. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||