Analysis of medication adherence-related notes from a service-oriented community pharmacy

Abstract

Background: Medication nonadherence is a significant public health problem. Community pharmacists are positioned to intervene, however, the process is not well understood.

Objective: To classify and quantify the reasons for nonadherence documented by community pharmacists.

Methods: A retrospective content analysis of pharmacist notes related to nonadherence at a service oriented community pharmacy in the Midwest United States. Notes from the site's dispensing custom documentation software were obtained from September 1, 2014 through February 28, 2015 that were labeled "compliance", either prompted by proportion of days covered calculations or entered as a drug therapy problem. A code list was iterated for the notes based on the literature and by reading the notes and generating descriptive codes. A reliability analysis was calculated for two coders. Notes were coded, check-coded, and discrepancies were resolved using a consensus process. Frequencies were calculated for each code and representative text was selected.

Results: Pharmacists documented 3491 notes as part of their continuous medication monitoring process. Nineteen codes were developed. The reliability for the coders had a Cohen's Kappa of 0.749. The majority of notes (61.4%) documented the pharmacist evaluated the refill and had no concerns or would continue to follow. Also documented were specific reasons for out of range PDCs not indicative of a nonadherence problem. Only 2.2% of notes specifically documented a nonadherence problem, such as forgetfulness or cost.

Conclusion: While pharmacists encountered many false positive nonadherence alerts, following up with patients led to hundreds of discussions and clarifications about how patients use their medications at home. These results suggest a small minority of late refills are judged by pharmacists as indicative of an adherence problem, contrary to the prevailing literature. Pharmacists may benefit from modifying their approach to nonadherence interviewing and documentation as they seek to address nonadherence in practice.

Synopsis: This study descriptively coded community pharmacist notes related to medication nonadherence. Most notes were prompted by automatic calculations by the documentation software of the proportion of days covered. This prompted regular conversations about non-adherence issues and clarifications on how medications are being used at home. Documentation suggested most adherence problems were technical in nature rather than stemming from patient factors like medication beliefs. Pharmacists could be more intentional and descriptive when documenting nonadherence issues so that more targeted follow up can be made, including a greater investigation of medication beliefs.

Keywords: Adherence; Documentation; Pharmacist.