International Summit on Clinical Pharmacy & Dispensing

1. The Impact of pharmacist-led patient education on adherence to antibiotic therapy in primary care InternationalSummit on ClinicalPharmacy & Dispensing November 18-20, 2013 San Antonio, Texas, USA MSc. Pharm. Caglar MACIT Yeditepe University, School of Pharmacy Istanbul, Turkey

2. Introduction What is adherence? • The term compliance or adherence can be described as the extent of correlation between the patients’ obedience to the therapy and the advice of health providers. • Thus, it is relatedtothepatient’sdrug-takingattitude. *Barber N WA. Churchill’s Clinical Pharmacy Survival Guide. Edinburgh: Churchill Livingstone; 1999. *Segador J, et al. Int J Antimicrob Agents 2005;26, 56-61.

3. Adherence can be affected by certain factors; • Dose & frequency of drug • Duration of treatment • Pharmacological factors (eg; adverse effects) • Psychosocial factors (eg; patient dissatisfaction) • Medical errors (eg; lack of patient information) *Pechere JC, et al. Int J Antimicrob Agents 2007; 29: 245-53. *Claxton AJ, et al. Clin Ther 2001; 23:1296-310. *Jackson C, et al.Patient Educ Couns 2006; 61:212-8. *Niederman MS. Int J Antimicrob Agents 2005; 26 Suppl 3:170-5.

4. Antibiotics & Adherence • Antibiotics are efficient, potent, safe and life-saving agents used to facilitate the healing of bacterial infections.ɫ • Unnecessary and/or inappropriate use of these drugs is a common cause of development and spread of antibiotic resistance.ɫɫ ɫ Hawkings NJ, Butler CC, Wood F. Patient Educ Couns 2008; 73:146-52. ɫɫ http://www.acponline.org/patients_families/diseases_conditions/antibiotic_ resistance/.

5. Antibiotics & Adherence cont... • Clinical Pharmacy is a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and diseaseprevention.ɫ • Clinical pharmacists are active supporters of rational drug use; it has been shown that they provide patient care, and facilitate successful and effective medication use, including antibiotic treatment.ɫɫ ɫ The definition of clinical pharmacy. http://www.accp.com/docs/about/ClinicalPharmacyDefined.pdf (Accessed on 2013) (American Collage of Clinical Pharmacists) ɫɫ Hand K.. J Antimicrob Chemother 2007; 60 Suppl 1:73-6.

6. Aim of study • The aim of these studies were; to investigate whether pharmacist-led patient education about prescribed antibiotics has a positive impact on adherence. Istanbul Kars

7. Materials & Methods

8. Material & Methods cont...

9. Results Demographic results (Kars study) (Istanbul study) Figure 1a & 1b:Gender distribution of patients in Kars and Istanbul

10. (Kars study) (Istanbul study) Intermediate school Figure 2a & 2b: Educational status of participants in Kars and Istanbul

11. Figure 3: Age distribution of participants Table 1: Mean age of participants according to groups (Mean ± SD)

12. In which diseases are antibiotics prescribed mostly? (Kars study) (Istanbul study) Upper respiratory tract infections Eye infections Upper respiratory tract infections Lower respiratory tract infections Lower respiratory tract infections Skin infections Genitourinary infections Genitourinary infections Skin infections Gastrointestinal infections Dental infections Dental infections Gastrointestinal infections Figure 4a & 4b: Antibiotic prescriptions according to infection types

13. Adherence Results Table 2: Adherence rates of patients in Istanbul study Chi Square Test We can see that study group is more adherent than control group. Pharmacist-led-education provides some benefits. However, the difference in adherence is not significant.

14. Table 3: Adherence ratio of patients in Kars study AA: Administration Adherence; TA: Timing Adherence; ATA: Administration&Timing Adherence More patients in the study group used antibiotic until the last day of therapy (p < 0.05). Patients in thestudy group are more AT Adherent thanthecontrol group. As a result, subjectiverecovery rate is significantlyhigher.

15. Table 4: Correlation between Administration Adherence (AA) and examination period, number of pills in container and duration of therapy *Spearman’s rho correlation test Table 5: Effect of examination period, number of pills in container and duration of therapy to Administration & Timing Adherence (ATA) *Student T test ; Mann-Whitney U test ; SD: Standart Deviation According to these results: - number of pills Adherence - duration of therapy (Compliance)

16. Table 6: Effect of age on adherence in Istanbul study • *Chi Square test • In the study performed in Istanbul, patients older than 30 y old were observed to be more adherent than younger (18 - 30 y old) participants, especially in the study group. This differece in adherence between age groups is significant(p: 0,027).

17. Discussion • In our study, two subjective methods (self-questionnaire and telephone interviews) and one objective method (pill count) were combined in order to measure adherence to antibiotic therapy. • The pill count method was performed by patients themselves so it was considered as partially objective. However, it should preferably be carried out by a health professional.

18. Among demographical characteristics, only age (participants > 30 are more adherent) affected the adherence of patients, and only in the Istanbul study (p: 0,027). • The length of time taken for the physician to examine the patient did not significantly affect adherence (p: 0,164 for AA and p: 0,798 for ATA). • It was observed that there was a negative correlation between number of doses prescribed, the duration of therapy and adherence in terms of ATA.

19. In Istanbul, • No statistically significant differences between study and control groups were observed in terms of adherence. • However, administration, timing and ATA rates were found higher in the study group. • Lack of significance may be due to the small numbers of patients in this study (n: 60). So, the study should be expanded to include more participants. • Finally, as in the studies (Claxton AJ et al. in 2001; Kardas P. in 2002 and 2003) gender, education, and working status did not affect adherence of patients; however, the age of patients in Istanbul did seem to affect adherence. *Claxton AJ.et al. Clin Ther 2001; 23:1296-310. ** Kardas P. J Antimicrob Chemother 2002;49:897-903. *** Kardas P. The Journal ofApplıed Research in Clinical and Experimental Therapeutics 2003. (Accessed at 2013: http://www.jarcet.com/articles/Vol3Iss2/Kardas.htm.)

20. Many studies that support our studies, demonstrate that structured education provided to patients by physicians and pharmacists can improve adherence to prescribed therapy. • Al-Eidan et al performed a study in 2002 on adherence of patients to Helicobacter pylori eradication therapy; adherence were measured in study and control groups, 92.1% and 23.7% respectively (p= 0,02). • In a study carried out by Kardas P. in 2002, effect of pharmacist-led education on adherence to antibiotic treatment in respiratory tract infections was shown.

21. Segador J et al. performed a study in 2005 on effect of patient education on adherence to antibiotic treatment in acute sore throat therapy and study group were observed more adherent. • Morgado MP et al. carried out a study on hypertension in 2011 and this study showed that improved adherence and blood pressure control were provided by pharmacist-led patient education. • In a study performed in midwest USA by Taitel M et al. in 2012, the positive impact of face-to-face patient education provided by the pharmacist on adherence to statins was demonstrated. • On the other hand, one study suggested that patients did not adhere to penicillin treatment even although they were informed and educated about their disease and aim of the treatment*. *Kardas P. The Journal ofApplıed Research in Clinical and Experimental Therapeutics 2003. (Accessed at 2013: http://www.jarcet.com/articles/Vol3Iss2/Kardas.htm.)

22. Recommendations arising from this research… • In order to increase adherence, • Antibiotics should be prescribed following culture and sensitivity testing. Thus, both adherence to antibiotic treatment and healing ratio of patients will increase. Also, development of resistance against antibiotics can be prevented. • Patients should be instructed to take their drugs with/without, before or after meals according to the pharmacokinetic properties of drug.

23. Patients should be educated not only about their usage, but also about possible side effects, the importance of adherence to therapy, the aim of therapy, and the duration of treatment. • Patients should be advised to set the alarm on their mobile phones or clocks to remind them to take their medications.

24. Conclusion • Pharmacistsmay be abletoplay an important role in providingpharmaceuticalcaretopatientsreceivingantibiotictreatmentviapatienteducation. • They can alsoprovide a counseling service totheirpatientsandhelptoensurepatientsusetheirmedicationsappropriatelythusenhancingrationaldruguse. • Further researches should be performed in order to compare adherence of patients to the antibiotic therapy and demonstrate the potential benefit and importance of the clinical pharmacist-led patient education in the provision of antibacterial therapy.

25. for their contribution Assist. Prof. Dr. Philip M. CLARK Assist. Prof. Dr. Latif OZBAY Res. & Teach. Assist. S. Beril KADIOGLU MSc. Pharm. Nefise Bilge ESEN MSc. Pharm. Serdar Sinan GUNES