Effectiveness of Various Methods of Teaching Proper Inhaler Technique: The Importance of Pharmacist Counseling

This article delves into the role of a pharmacist in patient inhaler education.  There were four different interventions that were compared in this study. The purpose of the study was to determine the efficacy of direct patient education vs. video or print education.

  1. Patient reads a metered dose inhaler (MDI) package insert pamphlet.
  2. Patient watches a Centers for Disease Control and Prevention (CDC) video demonstrating MDI technique.
  3. Patient watches a YouTube video demonstrating MDI technique
  4. Pharmacist gives patient direct instruction of MDI technique (2 minutes long)

This study had a patient population of 72 and each was screened for demographic information, including literacy. All patients used inhalers. These patients were randomized to one of the four interventions and then evaluated by their ability to demonstrate proper inhaler technique using a placebo MDI. The effectiveness of each intervention was measured by the patient’s ability to complete each step of proper inhaler technique, and no partial credit was given. The result of the study showed that only 29.2% of the patients were able to do this correctly. There was also a statistically significant increase in correct inhaler technique in the group of patients given direct inhaler technique education.

This study showed that pharmacists can positively influence patent inhaler outcomes (in comparison to other methods) by giving direct patient education. This is important for the advancement of our profession because it shows that we can provide care outside of simply dispensing medications. Studies like this may provide a framework for allowing pharmacists to provide other services.

What other services do you see pharmacists being able to provide in the future?

View the article here:

Axtell S, Haines S, Fairclough J. Effectiveness of Various Methods of Teaching Proper Inhaler Technique: The Importance of Pharmacist Counseling. J Pharm Pract. 2016 Feb 23. pii: 0897190016628961.

Medication Nonadherence and Effectiveness of Preventive Pharmacological Therapy for Kidney Stones

In a recent study conducted by Dauw and colleagues, the effects of nonadherence were observed among patients with kidney stone disease. Adherence to primary treatment with thiazide diuretics, alkali citrate, and allopurinol among 8,890 patients was studied over a period of two years.

Adherence to kidney stone therapy within the first six months of initiating treatment was studied, with adherence defined as a proportion of days covered (PDC) at or above 80%. PDC is calculated as the number of days available or “covered” by a certain medication divided by the total number of days in the followup period, multiplied by 100. In addition, they assessed whther each patient had an emergency room visit, hospitalization, and/or surgery for kidney stone disease within two years of his/her initial prescription fill.

Of the patients in the study, 51.1% were adherent to their pharmacological kidney stone therapy. Adherence to therapy showed 27% lower odds of an emergency department visit, 41% lower odds of hospitalization, and 23% lower odds of a surgical procedure for kidney stones compared to nonadherent patients. This evidence clearly outlines the consequences of nonadherence to reventative treatment of kidney stone disease. In general, adherence rates among this patient population are very low. Realizing that improved medication adherence is associated with tangible benefits for patients with kidney stones, healthcare providers should be vigilant in their counseling of patients with kidney stone disease on the use of preventative pharmacological therapy.

Dauw CA, Yi Y, Bierlein MJ, et al. Medication Nonadherence and Effectiveness of Preventive Pharmacological Therapy for Kidney Stones. J Urol. 2016;195(3):648-652

Impact of attention-deficit hyperactivity disorder on school performance: what are the effects of medication?

ADHD is a disorder that can detrimentally affect a student’s performance in school and extracurricular activities. ADHD medications are highly regulated medications because they have a high abuse/theft rate because students who don’t have ADHD take them in attempts to approve their academic performance. This study looks at how much these medications actually improve quantifiable performance of students with ADHD. This study looked at academic performance (GPA, work completed) and academic skills (achievement and cognitive tests), and academic enablers (study skills, motivation) of school-age children to determine how much these stimulants improve students’ overall performance, synthesizing data from many long- and short-term studies. The results found that CNS stimulant use improved teacher perceptions of students’ classroom behavior the most, reducing disruptive behavior and increasing focus on classroom activities. It was also observed that use of stimulants increase students’ productivity, which could possibly lead to a long-term increase in GPA. The efficacy of these medications is mainly reduced by adherence, and can also be affected by the learning environment. Optimizing the effects of these medications is achieved by constant reassessment of efficacy and patient adherence.

I found this study really interesting because I know many people who have really struggled with academic performance because of ADHD, and how much being properly medicated helped their performances. As prescription of ADHD medications becomes increasing more prevalent, it is important as pharmacists to make sure that the people who actually need these types of medications are the one taking them, and that they are properly counseled in order to achieve maximum efficacy.

Baweja R, Mattison RE, Waxmonsky JG. Impact of attention-deficit hyperactivity disorder on school performance: what are the effects of medication? Paediatr Drugs. 2015; 17:459-477.


Self-Reported Medication Adherence Barriers Among Ambulatory Older Adults with Mild Cognitive Impairment

Medication nonadherence in elderly patients is a huge problem affecting more than half of patients visiting community pharmacies and is expected to lead to greater than $100 billion costs to patients and healthcare systems. Furthermore, nearly 20% of this elderly patient population, aged 65 and over, has a diagnosis of mild cognitive impairment (MCI). MCI is an early stage impairment which increases a person’s risk of developing dementia. Because a majority of the elderly population suffers from multiple medical comorbidities and requires many different medications, it is important to address their cognitive ability and how it can impact their capability to be adherent to their medications.

Many interventions have been implemented to assist older adults in being adherent to their medications, but only one intervention focused on helping patients diagnosed with an MCI has been identified and involved reminder phone calls at each dosing time throughout the day. This article focuses on a study that compared barriers to adherence faced by older adults with MCI and those without at outpatient or home-care programs. The identification of barriers was used to create new interventions that would aid in adherence among this population. Patients were surveyed using a 17-item questionnaire to determine barriers to adherence related to knowledge, cost, behavior, and physical ability. Of the 200 participants surveyed, 82.5% reported to having at least one barrier to medication adherence. There was found to not be a significant different to the average number of barriers per patient between the MCI and non-MCI group. 49% of the barriers were categorized as difficulty remembering the time or number to take for the medication.

Many self-reported barriers to medication adherence were identified, regardless of whether or not the patient had been diagnosed with a cognitive disability. Overall, the need for multi-component intervention for older adults is important to recognize and these intervention program must make targeting a barrier caused by memory their priority. These interventions must be tailored to each patient’s need and work to minimize and adherence barriers.

The information presented in this article is important to recognize as a pharmacist. As an accessible healthcare provider present at the time of dispensing, we can play a very influential role in promoting adherence to our patients. By learning to recognize common barriers or challenges that certain populations are facing, we can address these concerns or identify resources available that can improve the overall health of our patients. I think this article also presents a very interesting point in that the prevalence of barriers to adherence in older patients. Regardless of an MCI diagnosis or not, patients still reported to facing roughly the same number and type of challenges, highlighting the fact that regardless off health conditions, most patients are still plagued by challenges leading to nonadherence. Once we learn to recognize these problems and identify the cause, we can develop strategies to help these patients.


Pharmacotherapy. 2016;36:196-202.


Adherence is Overrated

When a patient walks into a pharmacy and says they are having trouble remembering to take a medication, there are problems that arise when determining the degree of nonadherence. First of all, patients will undoubtedly underestimate the amount of times the have missed their medication. In addition, if a patient is not stating any issues with adherence, pharmacists can only truly observe refill behavior to monitor adherence. Only the date the prescription is filled can be recorded, so often monitoring adherence can be difficult.

But here is why Dr. Crowe, PharmD, is stating that adherence is “overrated” – patients can be perfectly adherent, never missing a single dose and still experience ineffective drug therapy. Dr. Crowe feels that the focus of pharmacists should lie on making sure the drug therapy regimen is efficacious, no matter the adherence of the patient. Because pharmacists see patients several times in between visits with their physician, they can be the one to monitor symptoms and side effects in between the visits. Dr. Crowe states that this is important because “when patients hold up their end of the adherence bargain, they [should be] doing so with an effective medication.” He uses the example of multiple sclerosis (MS) and how pharmacists can not only monitor the symptoms, but the relapse frequency. If this frequency becomes too high, they can recommend a switch in therapy.

This is a great concept that I have never thought of before in the way that was described by the article. It makes sense that if patients are doing everything they should be, they should be getting the best possible benefits from their medication. As far as monitoring symptoms to check for medication efficacy, I immediately thought of antidepressant medications. Because they take several weeks to work, it would be helpful for the pharmacist to check in on the patient when they are refilling a prescription to see how their mood has improved. If there is no improvement after one or two refills, they can contact the physician to recommend a change in therapy. I hope that this mentality is one that every pharmacist uses or is introduced to during their career, in addition to monitoring adherence.


Crowe, Michael. “Adherence is Overrated.” Pharmacy Today. 21.7 (1 July 2015). 63. Web. 17 February 2016.

Influence of the number of daily pills and doses on adherence to antiretroviral treatment: a 7-year study

A seven year retrospective study was conducted to draw a relationship between retroviral medication adherence, and the number of pills patients have to take.  The location was the University Hospital of Salamanca, Spain.  There were two levels of adherence established; greater than or equal to 95%, or less than 95%.  There were 264 patients who were studied.  The mean age was a little over 40 years old, and they had been a part of the antiretroviral treatment (ART) for 5.35 years.

One thing examined in this study is the shift from twice a day, and even three times a day medications to simply once a day medications.  The baseline number of patients who were taking their medications once a day was 10.  By the end of the study, there were 129 patients taking their medication once a day.  Those taking their medication three times a day went from 7 patients to 0 patients.   The average number of pills the patients had to take daily decreased from six to four throughout the study.

The study found that there was no correlation between adherence and the number of pills the patients had to take.  However, the study does clarify that the correlation could be non-existent for the specific setting/type of patients that were examined.  They found that it matters more to patients the frequency of the medications than the number of pills the patient has to take due to the disruption of the patients’ lives when having to take the pills at different times of the day.

Do you believe that there would be no correlation if the medication was treating a less serious diagnosis?  Have you ever found that having to take medications throughout the day interrupted your daily life?

J Clin Pharm Ther. 2016;41(1):34-39. 

Improving Patients Primary Medication Adherence

Pharmacists across the globe face a key issue in their ability to provide patients with the tools that enable them to adhere to medication regimens. Increasing adherence to prescribed treatment options will help to improve the overall health outcomes of the patients that pharmacist’s are serving.  For this reason, research into the causes for non-adherence and its resulting issues is and will continue to be an area of high importance. The interest that I have in improving medication adherence led me to the article entitled improving Patients Primary Medication Adherence.

This article is focused around a study completed in a French hospital during the months of November 2010 to June 2011. The study, which included patients over the age of 18 that were admitted into the ITD (Infectious and Topical Disease) and the general medicine unit, was developed to determine if incorporating clinical pharmacy activities into the discharge process would decrease the amount of post-discharge adverse effects.  To assess the results of this study, medication adherence was determined by contacting the patients’ community pharmacists 7 days after discharge.  The study did not find a correlation between the rate of re-admittance and/or visits to emergency rooms, but patients who received extra counseling during discharge were more likely to be adherent to newly prescribed medications.  For this reason, the study supported the idea that adherence can be increased by providing discharge counseling sessions to patients.

I feel like this is an important study for us to consider as pharmacists because managing patient adherence to medication regimens is the most important role we play in improving health outcomes.  By improving adherence, we have the ability to lower the risk for serious adverse drug events which can lead to hospitalization.  For this reason, I believe that pharmacists should implement all activities that are proven to increase adherence to maximize the results of treatment options.  This article has left me wondering how similar programs to increase medication adherence can be implemented in community pharmacy settings.

Leguelinel-Blache G, Dubois F, Bouvet S, et al. Improving patient’s primary medication adherence: the value of pharmaceutical counseling. Med. 2015;94(41)


Novel and Expanded Role for the Pharmacy Technician

A CMS Health Care Innovations Award – funded care transitions program known as SafeMed has the goal of reducing hospital readmissions and overall healthcare cost through the optimization of drug therapy. In particular they focus on adherence to drug therapy in addition to the efficiency of the drug regimens being undertaken by patients who are taking multiple chronic conditions – much like what we would expect in a patient who is eligible for MTM services.

Hospital readmissions are common in these patients who have an abrupt transition from extensive medical oversight to being unmonitored in their homes. Here, SafeMed decided to expand the role of their pharmacy technicians having them follow up with these patients by giving the patients phone calls after they return home from their hospital stays. These technicians were put through a training program with teachings provided by a pharmacist with expertise in MTM and through their basic understanding of MTM services they were appointed to a role of identification of some drug therapy problems. The idea here is not to have a technician assume the role of a pharmacist but rather be a less expensive extra set of eyes which could help draw attention to problems that could then be more promptly resolved by the pharmacist.

More time would be needed to draw conclusions about the clinical outcomes surrounding this program. However, an increase in DTP pharmacist interventions did result from this method which intuitively should result in more effective outpatient treatment and less hospital readmissions resulting in less medical expenses, a parameter which is to be measured in follow up studying of this method. In addition, they aim to improve the education of these technicians which can provide a very useful arm for the pharmacists helping them spot the patients who could use their expertise most.


Bailey J. SafeMed: using pharmacy technicians in a novel role as community health workers to improve transitions of care.” J Am Pharm Assoc. 2016; 56(1): 73-81.

J Am Pharm Assoc. 2016; 56(1): 73-81

Unused Medication Disposal Patterns : Medicare Patient Survey

A recent study was conducted to examine what medications were most often left unused, how much is left unused, and how these medications were disposed, focusing mainly among Medicare beneficiaries. The study included a telephone survey conducted by a survey research center. This survey included 721 Medicare Advantage members who had Part D coverage as of December 31, 2013 and had completed the telephone survey in May 2014. There were 2994 reported medications. Out of these 2994 medications, 247 (8%) were reported being left unused by patients. Out of this 247 unused medication, 15% were for pain, 14% for hypertension, 11% for antibiotics, and 9% for psychiatric disorders. Some reasoning given by these patients included “dosage changed by doctor”, as well as over-prescribing and adverse effects. Surprisingly, only 11% of the unused medication were disposed of via drug take-back programs, whereas a majority (55%) were kept in a cabinet. The other methods included thrown in the trash (14%) and flushed down the toilet (9%). This study concluded that the lack of patient adherence alone can not be enough to explain the large percentage in unused medications. Community-level interventions must be in place to improve adherence as well as reduce improper disposal of unused medications.

I believe that this study is important because it puts data to the very important problem of improper disposal. I often have geriatric patients bringing their prescription vials to our presentations and visits. Some, if not most, of these vials turn out to be months or years old and are still filled with medication. It is also interesting to see what type of medications are often reported unused, such as antibiotic medication.


Maeng DD., Snyder RC., Medico CJ., et al Unused medications and disposal patterns at home: Findings from a Medicare patient survey and claims data J Am Pharm Assoc 2016;56:41–46

Studying the Effect of Text Messaging on Medication Adherence in Chronic Disease

A recent article reviewed the effectiveness of text messages as a tool for medication adherence for adult patients with chronic diseases. The reviewers recognized that although apps can be very helpful for those with smart phones, unfortunately many of those in the older population with chronic diseases do not have the most up-to-date technology. In the past, special pagers or devices with reminders were proposed to aid in adherence but due to low availability and an uncertain relation to routine care, they have been relatively ineffective as a reliable assistant.

As we have learned, adherence is clearly a very large issue, costing the United States almost $1 billion each year and $2000 for each patient in extra physician visits alone. Not only is cost a major factor, but the health of the patient is obviously a huge concern as well. Many patients with chronic disease states will become nonadherent to their therapy because they are not experiencing a noticeable difference in their health. Unfortunately this could cause their disease to worsen and require the need for additional medications.

The authors of the article conducted a literature search to find randomized clinical trials involving adults over the age of eighteen with a chronic disease that received a text message to promote adherence. Studies were excluded if their primary intervention was not a text message or if the study involved psychiatric, military, or institutionalized patients to avoid other possible controls on adherence. Sixteen randomized clinical trials were identified that included over 2,500 patients with a mean participant age of thirty-nine, a median intervention duration of 12 weeks, and including disease states of HIV, cardiovascular disease, asthma, allergic rhinitis, diabetes, and epilepsy. The type and frequency of text messages varied among the studies, with some texting at fixed time intervals and others sending only if the patient did not open their medication dispenser. Some messages included personalization with the medication name and dosage while others were generic.

It was concluded that text messages did in fact increase adherence and the study participants were moderately to highly satisfied with the assistance. The researchers did emphasize however that further studies with longer time periods and more objective measures of the outcome are necessary to come to significant conclusions.

What personalization of a text message do you think would be most effective, or should it change based on the patient’s beliefs, social activities, age, etc?

Reference: Thakkar J, Kurup R, Laba T, et al. Mobile telephone text messaging for medication adherence in chronic disease. Jama Intern Med. Published online February 1, 2016.