Assessment of Medication Adherence in Rheumatoid Arthritis Patients

J.J. Appl. Sci. Vol. 10, No. 2 (2008) Assessment of Medication Adherence in Rheumatoid Arthritis Patients Kholoud Z. Qoul, Ikbal N. Thuheerat & Imad Al-Dogham Royal Medical Services, Amman, Jordan Received: 18/10/2007 Accepted: 5/6/2008 Qoul, Kholoud Z., Ikbal N. Thuheerat & Imad Al-Dogham (2008) Assessment of Medication Adherence in Rheumatoid Arthritis Patients. J.J. Appl. Sci: Natural Sciences Series 10 (2): 79-86. Abstract: The objective of this study is to assess medication adherence in rheumatoid arthritis patients, focusing on the reasons and barriers. The study was conducted at King Hussein Medical Center (Royal Rehabilitation Center) between February and June 2007. A specially designed questionnaire was delivered through direct interview provided by researchers to a total of 110 rheumatoid patients. These 110 patients met the following inclusion criteria: adult rheumatoid patients, taking at least one of the disease modifying anti-rheumatic drugs plus non-steroidal anti-inflammatory drugs, and their disease duration not less than one year. The study was approved by the ethical committee of the Royal Medical Services. Among the 110 patients included in the study, eighty-two (75.0%) were females and twenty-eight (25.0%) were males. Patients aged between 18-68 years with a mean of 45± (8.5). The median duration of the patients disease was seven years. Regarding the number of medications, 72.0% of the patients were on three or more medications, while 28.0% were taking less than three medications. Only 72 patients (65.0%) adhered to their medications whereas 38 patients (35.0%) did not adhere to their medications. Among the nonadherent patients, (72.0%) of them stopped taking their medications as soon as they improved, while (3.0%) of them stopped taking their medications once their condition got worse. For prescription refilling, the study showed that (49.0%) of the "non-adherent" patients refilled their prescription on time, compared to (51.0%) who were late on refilling their prescription. The study revealed that the top factors and reasons of non-adherence include side effects of medications, lack of belief in the benefit of treatment, and switching to different brand name, and medication load. (76.3%) of non-adherent patients indicated that their non-adherence was due to side effects of medications, (73.7%) was due to lack of belief in the benefit of treatment, (71.0%) was due to switching to different brand names, and (63.2%) was due to medication load. Key words: adherence, rheumatoid arthritis, medication, non-adherence. (2008). :(2) 10 :.86-79 :. ( ) 2007 - :.. 110 (%75) 82 45 68-18 %72. 7 %28. (%65) 72 (%35) 38. %72. %3 %49 %51. : % 73.7 % 76.3 %63.2 * Principal author's e-mail address: kzqoul@gmail.com %71.0. 79

Kholoud Qoul, Ikbal Thuheerat & Imad Al-dogham Introduction There are several definitions for adherence (or compliance) to a medication regimen. One definition states that it is "the extent to which patients take medications as prescribed by their health care providers".[1] Yet, another definition states that it is "the extent to which a person's medication taking behavior coincides with medical advice".[2] Adherence is advocated by health care providers because compliance suggests that the patient is passively following the doctor's order. Additionally, it suggests that the treatment plan is not based on a therapeutic alliance or contract established between the patient and the physician.[1] Several studies suggest that the ability of health workers to recognize nonadherence is poor, and that interventions to improve adherence have had mixed results.[1] Key elements to determine an individual's adherence to treatment include: threat of illness, positive outcome expectancy (perceived severity and susceptibility), barriers for using the treatment (e.g. expected disadvantage from treatment), and intent (intention to adhere to the treatment regimen).[3] Adherence to therapy is an individual patient behavior that is difficult to objectively measure, monitor, and improve. It is widely believed that nonadherence is a serious problem, with particularly high estimates of non-adherence for older adults and for individuals with chronic disease as rheumatoid arthritis (RA).[4] Rheumatoid arthritis (RA) is one of the most serious diseases with rates of morbidity and mortality equal to those caused by malignancy. They also exact a major personal and financial toll on the patient and their families through pain, disability, reduced self-esteem, and loss of income.[5] The aim of this study is to identify the underlying reasons for rheumatoid arthritis patients for being non-adherent to their medication. Such identification helps the physician to isolate patients who need intervention to improve adherence. Nonadherence is considered as a marker of a problem in the process of prescribing and the experience of using medication. Non-adherence may result in unnecessary health costs, investigations, changes in treatment, morbidity, and mortality.[4] The findings of the study could be used to improve the quality of patient care. A critical element in successful clinical treatment of a disorder is that patients take the medication that is prescribed to them.[6] Methods The study was conducted at King Hussein Medical Center (Royal Rehabilitation Center) between February and June 2007. A specially designed questionnaire (Appendix 1) was delivered through direct interview provided by researchers to a total of 110 rheumatoid patients. These 110 patients met the following inclusion criteria: adult rheumatoid patients, taking at least one of the disease modifying anti-rheumatic drugs (DMARDs) with non-steroidal anti-inflammatory drugs (NSAIDs). The interview questionnaire is divided into two parts. The first part collects general information about the patients (i.e., age, gender, educational level, etc.). The second part collects information regarding adherence practice by patients in addition to the responses of "non-adherent" patients to the reasons that cause their non-adherence. 80

J.J. Appl. Sci. Vol. 10, No. 2 (2008) Patients who answered "sometimes" when asked about their adherence were considered "non-adherent" patients by the researchers. The data was analyzed by utilizing descriptive statistics in terms of number and percentage of patients. The study was approved by the ethical committee of the Royal Medical Services. Results The total number of patients studied is 110 participants aged between 18-68 years (45±8.5). Among the participants, 82 (75.0%) are females, while 28 (25.0%) are males. The median duration of the patients disease is seven years. One quarter of the patients have the disease for less than 4 years, half of the patients have the disease for 4 to 10 years, and one quarter of the patients have the disease for more than 10 years. Table (1) shows that about 20% of the patients are illiterate, 30% elementary school education, 32.0% have a high school diploma, 10% have a community college diploma, and 8.0% have a university degree. Table 1: Patient characteristics Characteristics % Male Female Educational level: Illiterate Elementary education High school diploma Community college diploma University degree Number of medication taken by the sample patients: 3 <3 Adherence Non-adherence Missing their doses (non-adherent): Rarely Sometimes Refilling their medication prescription (non-adherent): Late On time Number of medication taken by the non-adherent patients: 3 <3 75.0 25.0 20 30.0 32.0 10.0 8.0 72 28 65 35 36 64 51 49 76 33 81

Kholoud Qoul, Ikbal Thuheerat & Imad Al-dogham Seventy-two percent of the patients were taking three or more medications, while 28.0% were taking less than three medications. The study shows that 72 patients 65.0% always adhere to their medications, 38 patients 35.0% do not adhere to their medications. Among the non-adherent patients, 72.0% stop taking their medications once they get improved, compared to 3.0% who may stop taking their medications once their condition get worse. Sixty-four percent of the non-adherent patients sometimes miss their medications, while 36.0% rarely miss their medication. For prescription refilling, the study reveals that 49.0% of the non-adherent" patients refill their prescription on time, while 51.0% were late on their prescription refilling. Table 2 shows the main reasons of non-adherence as indicated by non-adherent patients. 76.3% of the non-adherent patients indicate that one of the main reasons for non-adherence is the side effect of medications. Yet, another main reason indicated by 73.7% of the non-adherent patients is patients lack of belief in the benefit of treatment. 71.0% of the non-adherent patients indicated that switching to different brand names is a main reason for non-adherence. 63.2% of the nonadherent patients indicated that medication load 'polypharmacy' is a main cause for non-adherence. This is supported by the fact that two-thirds of the "nonadherent" patients take three or more medications (Figure 1). Table 2: Reasons for non-adherence to medication Reason n* Percentage** (%) 1. Side effect of medication. 29 76.3 2. Patient lack of belief in the benefit of treatment. 28 73.7 3. Switching to different brand names. 27 71.0 4. Medication load (polypharmacy). 24 63.2 5. Cost of medication. 20 52.6 6. Busy life style or forgotten. 20 52.6 7. Inability of patient to access pharmacy. 20 52.6 8. Inadequate follow up or discharge planning. 20 52.6 9. Patient lack of insight into the illness. 8 21.0 10. Poor provider-patient relationship. 6 15.8 *n: number of non-adherent patients who provided answers for their non-adherence ** Percentage = (n/38) X 100%, where 38 is the number of non-adherent patients 82

J.J. Appl. Sci. Vol. 10, No. 2 (2008) 33% 67% <3 medication 3 medication Figure 1. Number of medications taken by non-adherent patients The study also reveals that other main reasons of non-adherence as indicated by non-adherent patients include: inadequate follow up or discharge planning, cost of medication, busy life style or forgotten, and inability to access pharmacy (as indicated by 52.6%), patients lack of insight of illness (as indicated by 21.0%), and poor provider-patient relationship (as indicated by 15.8%). Discussion This study shows that about two-thirds of participants adhere to their medications, compared to one-third who do not adhere to their medications. This result is consistent with the results of other studies, which show that the percentage of nonadherence ranges between 30.0% and 50.0% for patients on chronic medications.[7,8,9] Additionally, recent reports quote a range of drug adherence levels between 16.0% and 84.0%.[5,10,11] This study shows that 72.0% of non-adherent patients stop taking their medication once they get improved compared to 3.0% who stop their medication once their condition get worse. This result is almost as twice higher as another study that reports that 36.0% of studied patients' adhere to their medication frequency and dosage by either increasing or decreasing it.[12] Rate of refilling prescriptions is considered an accurate measure of overall adherence in closed pharmacy system (i.e., department of veterans' affairs heath care system) (1). Since this study is also conducted in a closed pharmacy system (Royal Rehabilitation Center), the argument of considering the rate of refilling prescriptions an accurate measure of overall adherence is valid for this study. The results of the study show that patients are almost evenly divided between those who refill their prescription on time and those who are late in refilling their prescription. Investigating medication beliefs is especially important in rheumatoid arthritis (RA) as it is a chronic disease. Patients are advised to take potentially toxic drugs, including non-steroidal anti-inflammatory drugs (NSAIDs) and disease modifying anti-rheumatic drugs (DMARDs).[6] A related study indicates that people with strong beliefs in the necessity of taking medication to maintain their health are found to be more adherent to treatment. On the other hand, patients with higher levels of concern about medication, commonly about the dangers of dependence and long-term side-effect, are more likely to be non-adherent.[13] It is found that 74.3% of rheumatoid arthritis patients have a positive belief in the necessity of their medication for maintaining health, and nearly 80.0% are concerned about potential long-term adverse effects of their medication.[6] This is consistent with the results of this study; 73.7% of non-adherent patients indicate 83

Kholoud Qoul, Ikbal Thuheerat & Imad Al-dogham that their lack of belief in the benefit is a reason of non-adherence to medication. Additionally, 76.3% of non-adherent patients indicated that the side effects of medication are one of the reasons for not adhering to their medications. Other studies indicated that health care systems and clinician barriers include insufficient access to physicians, lack of trust between clinician and patient, and in some cases, physician's negative attitude and inadequate knowledge about the disease and value of guideline-recommended care.[1,14] In contrast, this study shows that only 15.8% of the non-adherent patients indicated a poor providerpatient relationship for not adhering to their medications. Other studies showed that half of the patients forget to take their medication occasionally.[12] This study shows similar results with 52.6% of the non-adherent patients indicate that their busy life style and forgetfulness is a reason for not adhering to their medications. Other studies argue that forgetfulness in some cases represents the non-explicit denial of a disease and its social consequences.[15] In this study two-thirds of the non-adherent patients take equal to or more than three medications, while the remaining one-third takes less than three medications. Almost fifty three percent (52.6%) of the "non-adherent" patients indicate that the cost of medication is a reason for not adhering to their medications. This result is consistent with another study that indicates that the patients reported, financial problems, fear of side effects, difficulty navigating the public health system and perceived treatment as important barriers to adherence.[16] Additionally, another study named barriers to target for optimal adherence as: adverse effects, polypharmacy, frequency of doses (more than once daily), and high cost.[3] On other hand, Anita et al didn't find any correlation between concern about side effects and patients perception of the effectiveness of medication that translated into poor medication adherence.[12] Limitations of this study include the small sample size of patients and that the data are self-reported by patients. As a result, the analysis may be susceptible to misrepresentation and tend to result in overestimating the adherence. The humble sample size limits generalizing the findings of the study on all rheumatoid patients. Further investigation is required using larger sample size. Conclusion and Recommendation The percentage of medication adherence in rheumatoid arthritis patients is 65.0%. The most common reasons for non-adherence are side effects of medications, patients lack of belief in the benefit of treatment, and switching to different brand names. However, the least common reason is poor provider-patient relationship. The findings of the present study could be used to contribute in improving the quality of patient care. As such, more focus should be directed on reassuring patients about the safety of treatment. In particular, more emphasis should be directed to reduce patients' fears of long-term effects for taking medications, and to convince patients of the benefits of treatment. Direct counseling of patients by pharmacists may become promising because of pharmacists' specialized training and knowledge of medications and availability to patients. Methods that may be used to improve adherence include: patient education, improved dosing schedules, increase clinic opening hours, and improve communication between physicians, pharmacists, and patients. 84

J.J. Appl. Sci. Vol. 10, No. 2 (2008) References [1] Osterberg, L. & Blaschke, T. (2005) Adherence to medication. N Engl J Med 353, 487-497. [2] Brus, H. L. M., M. A. F. J. Van De Laar., E. Taal., J. J. Rasker & O. Wiegman (1998) Effect of patient education on compliance with basic treatment regimens and health in recent onset active rheumatoid arthritis, Annals of the Rheumatic Diseases 57, 146-151. [3] Simpson, R. J. (2006) Challenges for Improving Medication Adherence. JAMA 296 (21), 2614-2616. [4] Park, D. C., Hertzog, C., Leventhal, H., Morrell, R. W., Leventhal, E., Birchmore, D., Martin, M., & Bennett, J. (1999) Medication Adherence in Rheumatoid Arthritis Patients Older is Wiser. JAGS 47 (2), 172-183. [5] Hill, J., Bird, H., & Johnson, S. (2001) Effect of Patient education on adherence to drug treatment for rheumatoid arthritis: a randomized controlled trial. Annals of the Rheumatic Diseases 60, 869-875. [6] Neame, R., & Hammond, A. (2005) Belief about medications: a questionnaire survey of people with rheumatoid arthritis. Rheumatology 44, 762-767. [7] Meichenbaum, D., & Turk, D. C. (1987) Facilitating treatment adherence: a practitioner's handbook. New York: Plenum Press. [8] Sackett, D. L. & Snow, J. C. (1979) The magnitude of compliance and noncompliance care. Baltimore, London: The John Hopkins University Press; 11-22. [9] Barber, N., Parsons, J., Clifford, S., Darracott, R., and Horne, R. (2004) Patients' problems with new medication for chronic conditions. Qual saf Health Care 13, 172-175. [10] Belcon, M. C., Haynes R. B., and Tugwell, P. (1984) A critical review of compliance studies in rheumatoid arthritis. Arthritis Rheum 27, 1227-1233. [11] Bradly, L. A. (1989) Adherence with treatment regimens among adult rheumatoid arthritis patients: current status and future directions. Arthritis Care Res 2, S33-39. [12] Lim Anita, Y. N., Ellis, C., Brooksby, A., & Gaffney, K. (2007) Patient satisfaction with Rheumatology Practitioner Clinics: Can We Achieve Concordance by meeting Patients' Information Needs and Encouraging Participatory Decision Making? Ann Acad Med Singapore 36, 110-114. [13] Horne, R. & Weinman, J. (1999) Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 47, 555-67. [14] Petrilla, A. A., Benner, J. S., Battleman, D. S., Tierce, J. C. & Hazard, E. H. (2005) Evidence-based interventions to improve patient compliance with antihypertensive and lipid-lowering medication, Int J Clin Pract 59, 1441-1451. [15] Christensen, A. J. (2004) Patient Adherence to Medical Treatment Regimens Bridging the Gap between Behavioral Science and Biomedicine. Yale University Press, USA. [16] Chambers, S. A., Rahman, A., & Isenberg, D. A. (2007) Treatment adherence and clinical outcome in systemic lupus erythematosus. Rheumatology 46, 895-898. 85

Kholoud Qoul, Ikbal Thuheerat & Imad Al-dogham Name: Age: Occupation: Income (JD): Diagnosis: RA Appendix Patient-Medication Adherence Questionnaire Patient ID: Sex: Education Level: Disability: Cognitive deficits: Other medical illness: HTN DM Others No. of medications: < 3 > 3 Part I No. Question Always Sometimes Rarely 1. Do you adhere to your medications? 2. 3. Do you stop taking your medicine once you improve? Do you stop taking your medicines once you get worse? 4. Do you miss your clinic appointments? 5. How often do you miss taking a dose of medicine? 6. What is your rate of prescription refilling: On time Late ---- No. Part II Choose one reason or more for non-adherence to your medication? 1. Side effect of medication. 2. Inadequate follow up or discharge planning. 3. Patients lack of belief in the benefit of treatment. 4. Patient lack of insight into the illness. 5. Poor provider-patient relationship. 6. Cost of medication. 7. Busy life style or forgotten. 8. Medication load (polypharmacy). 9. Inability of patient to access pharmacy. 10. Switching to different brand names. 11. Non-availability of medication. 12. Other reasons 13. If you choose option (12) specify the reason(s). 86