Collaboration between family physicians and community pharmacists to enhance adherence to chronic medications

DISCUSSION

Nonadherence to medications for chronic medical conditions is common and is associated with increased use of health care, costs, and increased morbidity.1–11 Our results suggest that most family physicians in Saskatchewan recognize that nonadherence is a problem, with more than 80% reporting that they regularly assess adherence in their patients. This self-reported number seems high, and the exact nature of how adherence is assessed was not determined. Physicians believed that cost and medication side effects were the reasons most commonly responsible for nonadherence. Interestingly, few respondents identified barriers to adherence that were under physician control, such as complexity of medication regimen, lack of education of patients by physicians, and lack of reinforcement by physicians.

While more than half of respondents believed that the 2 health care professionals should equally share the responsibility of supporting patients with medication adherence, community pharmacists currently appear to be rarely used for this purpose. Most physicians thought that some level of collaboration with community pharmacists would be appropriate but differed in their opinions about the types of activities that would be appropriate to promote adherence. Generally, physicians reported that pharmacists could affect adherence in 2 main ways: by identifying and notifying physicians about patient nonadherence, and by emphasizing medication benefits over side effects. Monitoring prescription refill records is a relatively effective and inexpensive method for tracking adherence,13 and physicians who are notified about nonadherence in their patients might be more likely to have a patient-centred discussion about adherence at their next clinic visit. In contrast, fewer physicians were willing to include patient diagnosis and clinical indication or potential barriers to adherence on the written prescription to help pharmacists support adherence. Comments by those physicians not supportive of this activity revealed 3 common concerns: the time required; lack of financial reimbursement; and patient confidentiality and violation of the Saskatchewan Health Information Privacy Act. The third concern (patient confidentiality) is interesting, as it suggests that some physicians do not view community pharmacists as members of their patients’ “circle of care.”

There is some indication that clinical practice location and length of time in practice have an effect on family physicians’ communication and willingness to share clinical information with community pharmacists in order to promote medication adherence. More frequent communication related to medication adherence in rural areas might be owing to the smaller communities providing more opportunities for closer contact, recognition of expertise, and shared care between health care professionals. A recent study looking at the integration of pharmacists into family practice teams in Ontario21 affirmed this rationale: initial concerns of physicians related to pharmacists’ scope of practice and medicolegal implications of shared care resolved once physicians became familiar with the pharmacists’ skills and roles in patient care. The greater willingness of physicians in practice for less than 10 years to share information with pharmacists perhaps reflects a greater recent emphasis on interdisciplinary care during medical training in Canada.

In Saskatchewan, 55% of family physicians work in urban centres, 17% in regional communities, and 28% in rural areas.22 Thus, the distribution of our respondents closely reflected provincial physician demographics. Furthermore, the study had a response rate of 39.4%, which is higher than the response rate in the 2007 National Physician Survey—in which 31.64% of family physicians or general practitioners responded nationally and 29.25% responded from Saskatchewan.23

The responses of the Saskatchewan family physicians raise some interesting questions, which will require further study. First, how do physicians assess for medication adherence? Are the methods used sensitive enough to detect most patients with chronic medication nonadherence? Most physicians indicated a willingness to collaborate with community pharmacists to enhance medication adherence in their patients, but how can this be achieved with minimal effect on the workload and finances of these 2 health care professionals? A pilot project to implement some of the collaborative strategies looked at in this study is now warranted. In addition, further research looking at the opinions of patients and pharmacists in Canada on medication adherence might provide valuable insight that would be useful for enhancing adherence and chronic disease management.