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The Common Myths of Compliance

Dementia, complex drug regimens and forgetfulness all contribute to drug error with self-medicating patients. In hospitals, care homes and even in domiciliary care, limited time and resources, as well as a lack of training, vastly increase the risk of drug error and jeopardise patient welfare. Even in this age of vast information, an outdated understanding of MDS technology is standing in the way of vast savings and improvements in patient outcomes.With the cost of drug error estimated at between £2.7 and £4 billion, an understanding of countermeasures to the compliance problem is no longer an ‘optional extra’ for residential homes and soon-to-be GP consortia (1). Confusion still arises around MDS among the country’s senior pharmacy and medical professionals, and the myths surrounding it are so deeply ingrained, even GANFYD, the GP’s answer to Wikipedia, has got it wrong (2-4).

Life Before MDS

Since they were introduced in the UK in 1989, MDS have become a crucial tool in combating the numerous obstacles to compliance. Before MDS came onto the market, the way medication was administered in care homes (especially those run by the local authorities of the day) was archaic, dangerous and wholly inadequate.The introduction of MDS solved the problem and, in the process, totally transformed the relationship between community pharmacies and care homes, giving pharmacies an important new unique selling point and revenue stream. Some 20 years later, thanks to MDS, medication management is safer, more efficient and better organised than ever.The level of drug errors has fallen and the audit processes in place mean that error is more easily detected.

Growing Pains

The introduction of MDS was not without its difficulties; even two decades on, these ‘teething troubles’ continue to haunt it. Initially, some care professionals suggested that MDS was the beginning of the ‘de-skilling’ of nursing, as medication management systems were safe and easy to use by non-skilled staff. But the fundamental problem with MDS was the question of how it would be paid for.

When early MDS first appeared in 1989, Boots – the first movers in the market – offered to provide MDS systems free of charge.This set a precedent which later became the norm.Many pharmacies resented this situation back in 1989, specifically the expectation that this valuable, yet resourceintensive service, should come for free.

A difficult route to market and its associated costs have weighed heavily on MDS over the years and have deflected attention away from the remarkable progress this innovation has brought about in standards of healthcare. Clearly, MDS carries with it a lot of baggage and it is this baggage, rather than any actual issues, that even 20 years later still has a significant impact on the market and distracts us from the reason why MDS was created in the first place. So it is important to dispel some of the outdated but lingering assumptions about MDS.

Myth One: MDS Do Not Accommodate Liquids

The British Medical Journal recently made two announcements: that prescribers are four times more likely to give the wrong dose of medicine with liquid prescriptions compared with tablets; and that monitored dosage systems do not accommodate liquid medicines (2). Spot the incorrect statement. The latter is the most outdated, yet still extremely common, assumption in the world of MDS; that the system is only suited to solid dosage forms.

This myth dates back 20 years to a time when MDS was in its infancy. Quite simply, the technology to pack liquid medicines into a monitored dosage format was not available. Even now, there is only one MDS able to accommodate both liquids and tablets.

To date, the vast majority of MDS on the market have tried to get around the obstacle of accommodating liquids by including reminder cards that direct carers doing the drug rounds to any medications not packed within the MDS (liquids, oral medication, as well as topical medicines such as gels and creams). This extra step in the process opens up yet another opportunity for human error to set in, and defeats the objective of centralising all of a patient’s medications in one system.

Given that to date there is only one system that accommodates liquid and solid medication side by side, it is understandable that this particular myth is still accepted. However, the availability of a single anti-error solution that accommodates all dosage formats makes MDS technology accessible to a vast new audience that may have previously written it off. In truth, the problem of non-compliance is more prevalent in the elderly, and they are more likely to suffer from swallowing difficulties and require their medicines in a liquid format. Therefore, dispelling the untruths around liquids and MDS is vital to improving quality of care for older patients.

Myth Two: MDS Can Store a Maximum of Four Doses per Day

This common misconception portrays MDS as inflexible systems that are appropriate for a limited number of patients.With the average number of prescriptions dispensed annually to people over 60 having doubled in a decade, and elderly patients in care homes taking an average of eight prescribed medicines per day, a four-a-day system would be useful for only the minority of older patients (5,6).

It is true that the majority of MDS are limited to accommodating doses at mealtimes and before bed, which makes compliance almost impossible. However, a minority of systems allow virtually unlimited doses during the day, to take account of the importance of accurate timing and the complexity of many drug regimes, particularly for the elderly.

Containing sufficient doses for the patient is crucial to the efficacy of an MDS, and all systems are certainly not created equal in this respect. The most sophisticated systems incorporate software that can adapt to up to 11 dosage intervals throughout the day, and do not have to be limited to breakfast, lunch and dinner. This means each individual dose is labelled with the specific time the medicine should be administered, leaving the minimum room for error to creep in, whether the patient is self-medicating or in a care home environment.

Myth Three: Medication in MDS Has a Shorter Shelf-Life

A recent pharmaceutical journal article stated that temperature-, light- and moisture-sensitive drugs would perish in an MDS, but there are no scientific studies to suggest that medication deteriorates when housed in an MDS.The alternative to MDS – the cold seal blister packs, which are often poorly sealed – have been used for years;were there a problem with tablets deteriorating, it would certainly have been realised by now. So, given the system’s 20-year pedigree, as well as the absence of any evidence to the contrary, this particular MDS myth is entirely unfounded. For the normal life span of medication in care homes, MDS raises no deterioration issues at all.

Myth Four: MDS Only Applies to Oral Medicines

US studies show that non-compliance is as great a barrier to recovery in the context of topical medication as it is with oral medication. In the field of dermatology, it is observed that “poor compliance with treatment advice in chronic conditions represents a major challenge,” and that the rate of noncompliance may be as high as 40 per cent (7).Despite the fact that the immediate physiological consequences of not applying creams and lotions as prescribed is perceived as less threatening, it clearly contributes to the estimated £150 million of avoidable medicine waste in the UK (8).

In the past, MDS have focused primarily on oral medications, and only now are more advanced tools coming onto the market to help counteract topical drug error and provide a more comprehensive approach to the compliance conundrum.As well as accommodating larger quantities of liquids such as creams, gels and ointments in separate, safely-sealed containers, the more sophisticated systems have proprietary software that creates a MAR sheet specific to topical drugs, in the form of a body map.This literally maps out the areas where medication is to be applied to the patient, aiming to make the process as foolproof as it can be. So while topical MDS are a new development, expect to see them used more and more in the future as budget holders in healthcare look to plug the leaks in their steadily shrinking drug budgets.



Myth Five: One Size Must Fit All

The options available to help manage medicines have multiplied beyond belief in the last 20 years.The days of housing tablets in egg cups are long gone, and in their place is a variety of intelligent systems designed to take the thought and the risk out of the drug administering process.

Despite the speed of innovation in MDS, the diverse spectrum of options on the market ranges from the very simplistic (dosette boxes and blister packs) to the sophisticated.With so many preconceived (and often inaccurate) ideas about what MDS can (and can’t) do, many end users are still in the dark as to the features and benefits they can expect from a system. As more and more copycat products enter the market, to differentiate one from another, carers, pharmacists, doctors and individuals will be asking a range of questions (see Choosing the Right MDS, above).

What’s Next for MDS?

At the more advanced end of the innovation scale, telehealth is on the horizon. Soon, MDS will be compatible with SMS and email technologies to improve the flow of information about patients’ compliance (or otherwise) between relatives, carers, medical professionals, pharmacists and nurses.

But what will the fusion of MDS and telehealth look and feel like? Consider this example: 85 year-old Frank, who lives alone, pops open his MDS pod for the day.Through a microchip embedded in the seal, this automatically sends an email alert to his GP and logs the time in a database to be reviewed at his next MUR with Frank’s local pharmacist.Over the next few days, Frank starts missing doses, which triggers a rule pre-programmed into the system, and sets off another chain of events.A warning text is sent to Frank’s relative (much in the way of a personal alarm) and GP to prompt them to check on him and find out why he isn’t taking his medication as prescribed.

The move to telehealth will see pharmaceutical companies working alongside community pharmacies to manage patient compliance by individual drug type and therapeutic area. Pharmacies will be paid on a fee-for-service basis, improving their revenue-raising potential in the face of inevitable reductions in the NHS drugs budget. For the pharma industry, the benefits are clear; increased compliance equals a reduction in brand switching and greater brand loyalty among prescribers and patients.

Conclusion

As life spans grow and healthcare budgets shrink, there is no doubt that MDS will become the norm in social and domiciliary care going forward.Were it not for the many myths surrounding intelligent packaging,we may already be seeing the fruits of greater compliance on a wider scale.That said, the medical and caring profession and the patients in their care are reaping the rewards MDS has to offer, and as telehealth takes compliance to the next level,may the healthy innovation continue.

References
  1. . Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, NICE 2009, www.nice.org.uk/nicemedia/pdf/CG76CostStatement.pdf
  2. Athwal et al, Compliance aids: an elephant in the room, Pharmaceutical Journal, 22 January 2011
  3. Care home error rate of liquid medicine doses four times higher than pills, British Medical Journal, 8 February 2011
  4. GANFYD (Get A Note From Your Doctor), www.ganfyd.org
  5. Average Number Of Prescription Items Dispensed To Older People Nearly Doubles In A Decade, UK – Medical News, Today, increase in average annual prescriptions dispensed increased from 22.3 to 42.4 in ten years up to 1997
  6. Care Home use of Medicines Study (CHUMS), commissioned by DoH, October 2009
  7. Richards H, Fortune D and O’Sullivan T et al, Patients with psoriasis and their compliance with medication, J Am Acad Dermatol 41(4): pp581-583, 1999
  8. Evaluation of the scale, causes and costs of waste medicines, York Health Economics Consortium/ School of Pharmacy, University of London, November 2010


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Norman Niven is an expert in health and social care, with over 30 years of experience as a pharmacist and BUPA director. He is CEO of Protomed and inventor of leading liquid compatible monitored dosage system, Biodose. Norman sits on the board of the Healthcare Compliance Packaging Council (HCPC) and has a keen interest in the role of packaging innovation in improving healthcare outcomes and efficiency. With five patents pending for his flagship innovation, Biodose, Norman continues to design new systems and services to take advantage of pharmacists’ expertise within the healthcare supply chain. Email: nn@protomed.co.uk
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