Enhancing Patient Adherence to Newly-Prescribed Medicine for Chronic Diseases: A Comprehensive Review and Cost-Effective Approach to Implementing the New Medicine Service in Community Pharmacies in Poland

Background

Pharmacies are an essential part of the healthcare system, playing an important role in providing medicines and other pharmaceutical products to patients. The task of pharmacists is not only to provide patients with quality products, but also to provide adequately prepared information about medicines. Pharmacists help patients understand drug instructions by explaining complex dosage and usage rules. Such activities ensure that patients receive safe and effective therapy [1]. Pharmacists provide pharmaceutical care, defined as a process in which the pharmacist works with the patient and the treating physician, as well as other healthcare professionals and, when needed, monitor the patient’s individual therapy, suggesting strategies for adjusting therapy to achieve short- and long-term pharmacotherapy goals [2].

A core service offered by pharmacists in many countries is medication use review, a systematic assessment of patient medications to optimise the quality of medication use and thereby improve patient outcomes [3]. The aim is to identify potential medication-related problems and optimise the patient’s drug therapy. A medication adherence review may include the patient’s treatment schedule, patient compliance with medication regimens, and identification of any adverse effects or drug interactions [4]. Numerous studies have indicated significant benefits of medication use review, including improvement in symptoms, earlier therapeutic effects, improved medication adherence, and better quality of life [5,6].

One of the most important areas of medicines utilization review is the New Medicine Service (NMS). NMS aims to support patients, in particular educating and systematizing the patient’s knowledge about the disease when introducing a new medicine into pharmacotherapy. The New Medicine Service is offered to patients who have been prescribed a new medicine for the treatment of chronic diseases, which are diseases with a relatively long duration. The purpose of this service, in addition to providing patients with advice and guidance on the use of a new drug, is to increase patient compliance and therapy safety [1,7]. In some countries, NMS is also used as part of maternal and child health (MCH) care provided by pharmacists in community pharmacies (ie, in every pharmacy where the patient buys medicines) [8]. The NMS began in the UK on 1 October 2011 as a fourth additional Advanced Service of the Community Pharmacy Contractual Framework (CPCF), which was created to support people with long-term conditions and newly-prescribed medicines to help improve prescription adherence [9]. This article aims to review implementation of the NMS for community pharmacists in Poland and the provision of a cost-effective approach to improve patient adherence to newly-prescribed medicine for chronic diseases.

Justification for NMS Implementation – Prevalence of Chronic Diseases

Strengthening the health system to improve health outcomes is crucial in primary and secondary prevention. Chronic diseases are one of the most frequent causes of death around the world. According to a 2022 World Health Organization (WHO) report, non-communicable diseases (NCD) contribute to 74% of all deaths globally, accounting for many premature deaths in people aged 30–70 years [10]. Cardiovascular diseases account for most NCD deaths, followed by cancers, chronic respiratory diseases, and diabetes (including kidney disease deaths caused by diabetes), accounting for over 80% of all premature NCD deaths.

These data are also confirmed by Polish reports indicating that among the 10 most common causes of death in Poland are cardiovascular system diseases, atherosclerosis, diabetes, chronic obstructive pulmonary disease (COPD), and asthma [11]. This is particularly important in the context of the most frequently prescribed medicines, including nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and medication used for the treatment of chronic diseases (eg, arterial hypertension, diabetes, heart disease, asthma, COPD).

A Polish report on pharmaceutical care shows that this type of medication was used by patients for the first time 12.3 million times in 2019 [12]. Moreover, the largest group treated in primary healthcare for selected chronic diseases was patients aged 45–64 years old (36.5% adults). The most common reason for adult patients presenting to a primary care physician was elevated blood pressure, and arterial hypertension was also the most common new diagnosis. Thus, a dramatic increase in the number of patients requiring long-term and controlled treatment has been observed. During long-term treatment, the patient is often prescribed a new drug that they have not been administered before. Optimal adherence to appropriately prescribed medications is critical to the independent management of most chronic diseases. However, data reviews conducted across disease states and countries are consistent in estimating that 30–50% of newly-prescribed medications are inappropriately taken by patients or that these medications are ultimately not taken [13].

The New Medicine Service – European Experiences

NMS is the most widely tested pharmaceutical service. Pilot programmes have been conducted in Italy, Norway, Finland, Ireland, Portugal, and Sweden, among others.

One of the countries where the impact of pharmaceutical interventions on medication adherence was assessed was Norway. In a study conducted in 67 pharmacies in Norway, the Morisky Medication Adherence Scale (MMAS-8) was used. The study involved patients who purchased a prescription cardiovascular drug for the first time [14]. After filling the prescription, patients had 2 consultations with a pharmacist several weeks apart, while patients in the control group did not receive this type of consultation. The study results indicated that after 7 weeks, treatment recommendations were followed by over 91% of patients in the study group and over 86% from the control group, which indicates the significant effectiveness of this type of activities. The UK’s NMS experience began in 2011 and has reached more than 90% of community pharmacies nationwide. The beneficiaries of the service are patients who have been diagnosed with a new chronic disease and are starting pharmacotherapy with a new drug (eg, therapy for asthma and COPD, type 2 diabetes, hypertension, or antiplatelet/thrombotic therapy). After obtaining the patient’s written informed consent, the pharmacist discusses the new medicine with the patient during an initial consultation. Following this, they schedule another consultation 7–14 days later for another prescription. The next appointment is about 2 weeks later. Consultations take place in the pharmacy or over the phone and are designed to identify and resolve potential medication problems [15].

In England, the actual number of NMS-eligible prescription medicines (Ministry of Health data) was assessed and whether it was affected by the distance between pharmacies and the primary care physicians’ offices. The study found that 0.25% of prescription items were eligible for the NMS, which differs significantly from the theoretical assumption of 0.5%. Importantly, there was no significant difference in the percentage of NMS eligibility between pharmacies located close to GP practices compared to those more distant [16].

In Belgium, the NMS was introduced in all pharmacies in 2013 for asthmatic patients who were beginning to use inhalers with corticosteroids. Although the service is not very widespread for this group of patients, Belgian pharmacies recommend extending the NMS to other groups of patients, with the necessary specification of cooperation between various healthcare professionals [17].

In Denmark, the NMS has been in place since 2015. It covers patients diagnosed with a new chronic disease and have started pharmacotherapy with a new medicine within the last 6 months. The service is provided by pharmacists and consists of 2 meetings in a pharmacy or over the phone, with the second meeting taking place in the pharmacy or on the phone 2–4 weeks after the first meeting [18]. Belgian consultations refer to a new medicine, supporting the patient’s treatment process by providing knowledge about the disease and its treatment to reduce the risk of non-adherence. Danish studies show that about 85% of the service beneficiaries are satisfied with pharmaceutical care services available in community pharmacies [19].

The problem of Improper Use of Medications

Misuse of prescribed medications is a global health problem and poses a significant challenge to entire healthcare systems [20]. The consequences of improper use of medications can be very serious. Medications taken incorrectly may not be effective or may cause adverse effects. Adverse drug reactions are any adverse and unintended effects of a medicine. Improper use of drugs includes taking the wrong dose, form, route of administration, interval between doses, and duration of use. Improperly used therapy can even cause the death of patients, and all drugs can cause adverse effects, although all patients experience them. Another very important problem is non-adherence to therapy. A low degree of adherence may result in treatment failure, which is challenging for the doctor and pharmacist participating in the treatment. Non-adherence is often a hidden problem, unrecognised by doctors and other specialists. Patients make treatment decisions based on information in the patient leaflet, problems with the form of the drug, lack of knowledge of how to use the therapy correctly, or based on the opinions of friends. The magnitude of this phenomenon is huge, and can affect up to 75% of patients [21]. It has been suggested that improving the effectiveness of adherence interventions can have a much greater impact on population health than any improvement in specific treatment methods [22,23].

Benefits of the New Medicine Service

Previous studies indicate that the NMS can significantly improve adherence to therapy, including the use of new prescribed treatment regimens. For example, a British study conducted in 46 pharmacies and involving 504 participants using medications for the treatment of asthma COPD, hypertension, and antiplatelet/antithrombotic therapy, indicates significantly higher adherence to therapeutic recommendations among those monitored by a pharmacist [23]. In this study group, patients received an NMS intervention involving 2 consultations (1 and 2 weeks after the prescription was filled, with a follow-up at week 26). The NMS significantly increased adherence by patients to their new medicine by 70.7% when compared with standard practice (60.5%) [23].

Further benefits associated with a pharmacy service helping patients to get a good start in taking their new medication for chronic disease were reported by a study conducted in Denmark [24]. Patients answered questionnaires using validated scales for adherence and concordance during a 15-min face-to-face interview and a 10-min telephone follow-up interview. Patients were satisfied with the NMS, reporting improved knowledge and increased safety with regard to a new medication used. While most patients were adherent, a potential risk of non-adherence was identified in nearly 50% of patients. Some patients had certain concerns about their new situation, which they considered more important than the issue of potential medication non-adherence [24].

A study using data from UK hospitals found that 79% of patients received at least 1 new drug after hospital discharge. New drugs can sometimes cause adverse effects or interactions with existing medications, potentially leading to a return to hospital [25], confirming the need for special care for patients taking a new drug.

Previous studies on the benefits of NMS have been focused on costs, including evaluation of cost-effectiveness of the service and pharmacist work. In England, for example, pharmacists provided telephone counselling to 500 patients who received a new medication for a chronic disease (eg, asthma, diabetes, cardiovascular diseases). At 4-week follow-up, non-adherence (9% vs 16%) and the number of patients reporting medicine-related problems (23% vs 34%) was significantly lower in the intervention group compared to the control, in addition to reduced mean total patient costs at 2-month follow-up (187.7 vs 282.8 GBP). These findings suggest the study intervention is effective, at least in the short term, with a reduced overall cost to the healthcare provider [26]. Increased patient medication adherence compared with normal practice and reduced overall cost following the NMS intervention have been demonstrated in another study [27].

Patient and Pharmacist Attitudes to the New Medicine Service

Opinions of patients, pharmacists, and doctors on what information is necessary to provide to patients receiving new drug prescriptions and who should provide it are integral aspects of NMS. Divergent expectations can lead to overlapping, ineffective efforts resulting in gaps in communication when patients receive a new drug. Therefore, collaborative efforts to ensure that patients receive full information about new drugs is essential to improve adherence and health-related outcomes [9].

Another study conducted in the UK indicates the opinions and experiences of pharmacists on the implementation of NMS to identify success factors and barriers to the implementation of this type of intervention [28]. The study also examined participants’ experiences with the introduction and provision of existing pharmacy services when compared with the implementation of NMS. In general, respondents assessed NMS positively, indicating the benefits of this service for both patients and pharmacists. Participants primarily appreciated the positive attitude of pharmacists, the self-accreditation procedure, and similarity to current practice. The barriers mainly included low interest and low awareness of primary care physicians about the services provided and their fees. Participants were concerned about the speed of implementation, and the absence of some materials needed prior to the start of the service [28]. Another potential benefit of the NMS is to improve medical drug therapy in older patients [29].

The implementation of the NMS has been explored in 23 community pharmacies across England, including interviews with 47 pharmacists and 11 general practitioners [30]. This study found that despite pharmacist’ positive views on the introduction of NMS, not all respondents were convinced that the service’s benefits would translate into a lower risk of medication-related problems. Primary care physicians were generally supportive of the initiative, but without significant knowledge of the service or its potential benefits [30]. This lays the groundwork for efforts to raise awareness of the service among patients and primary care physicians.

Similarly, the NMS introduced in Belgium indicates little knowledge and limited functioning of the service. A lack of commitment on the part of doctors, patients, and pharmacists was observed in the initial phase of the program. Importantly, many pharmacists did not even know the difference between NMS and existing pharmaceutical care, as studies from other countries have also shown. Doctors in Belgium considered the service as part of their own tasks and sometimes discouraged patients from using the service [31].

Challenges to NMS Implementation

The wide availability of the NMS requires more intense cooperation among all healthcare professionals, both in the design and implementation of services. Special training is needed, perhaps not only for pharmacists but also for physicians.

A systematic review of observational studies indicated barriers and facilitators of Medicine Use Reviews (MUR) and/or the NMS [32]. While pharmacists and patients rated MURs and the NMS positively, an apparent lack of communication between pharmacists and general practitioners was observed. Consultations were reported to be short (10–12 min), characterized by limited engagement with patients and their health problems. Further barriers included a lack of interest/awareness of family doctors, financial issues, and a lack of validated patient education materials. A lack of patient knowledge of NMS and unwillingness to cooperate with the pharmacist were also indicated [32].

Although medication use reviews aim to increase patients’ knowledge and understanding of their medications, the beneficial effects depend on the individual communication and interpersonal skills of the pharmacist, which is a source of variability in the conduct of medication use reviews. Community pharmacies offer a range of services, including education, counselling, and public health screening, which is often the patient’s first point of contact with health professionals in case of health problems. Thus, implementation of the MUR/NMS seems to be a reasonable approach in community pharmacies. Pharmacists should ask patients if they want to use these services, and document any assistance provided.

Numerous studies have shown that pharmacists are willing to extend their services to play a greater role in public health. The NMS has been also implemented in Poland [33,34], where this service was a part of the project “Closer to the Patient”. The findings demonstrated that the use of pharmaceutical intervention in the study group translated into improved adherence to medical instructions regarding correct pharmacotherapy [35]

Although NMS appears to be similar to MUR, it should be part of it in the treatment of chronic diseases. The effectiveness and safety of the services can be substantially increased through adequate training, standardized procedures, and close interprofessional collaboration between pharmacists, physicians, and other healthcare providers to deliver quality patient care.

Future Directions

For many years, the role of community pharmacies was limited to distribution, and pharmacists were relegated to selling medicines. However, the role of pharmacists in the health care system is constantly expanding. The COVID-19 pandemic has shown that pharmacists are open to patients, and often their advice replaced doctors’ advice on the selection of medicines because many health care facilities were unavailable at the time. In Poland, at that time, pharmacists were authorized to give vaccinations against COVID-19. Shortly thereafter, drug reviews for patients were introduced in pharmacies. As part of this service, the pharmacist reviews the medications and supplements taken by the patient, which helps detect polypharmacy or drug–drug interactions. Similarly, NMS will be of great importance. Due to the difficulty in understanding much information by patients during medical visits, but also due to the short duration of medical visits, it is necessary to further educate patients about the drugs used, especially those used for the first time, but with the prospect of long-term use.

In 2023, the document “Recommendations for the management of patients covered by the New Medicine Service under the pharmaceutical service” [36] was published in Poland, which provides a detailed description of the service under the NMS pharmaceutical service. The authors of the study proposed that the service should cover patients to whom a doctor has recommended a new drug as part of pharmacotherapy. The service will include 3 meetings during which pharmacists become familiar with the patient’s pharmacotherapy, explain how to properly use the drug, and dispel any doubts about possible adverse effects.

It is important that pharmacists providing this service have substantive preparation with necessary training, the program of which will be prepared by appropriate institutions, including the Centre of Postgraduate Medical Education of Warsaw.

Conclusions

This literature review clearly demonstrates that the NMS translates into improved medication adherence, improved patient involvement in the therapy and health status, and increased pharmacotherapy safety. With pharmacists’ expertise in detecting, resolving, and preventing medication errors and drug-related problems, they can contribute to significant improvement in the health of patients, including those prescribed a new medication. Numerous studies have shown that pharmacist services and clinical interventions reduce the risk of potential adverse drug effects and improve patient outcomes. In addition, most published studies show that pharmacists’ interventions are cost-effective and profitable. However, to implement expanded pharmacy services, it is necessary to conduct thorough training of pharmacists so that they can meet specific service delivery standards. It is also necessary to prepare validated patent education materials, such as pictograms or specialist leaflets, considering local and cultural conditions that were identified as barriers in the study.