Improving Owner Compliance with Pet Medication Regimens
Karen M. Tobias, DVM, MS, DACVS, University of Tennessee
M. A. Salisbury, DVM, DACVO, Animal Eye Care, Sarasota, Florida
Karen McClung, Animal Eye Care, Sarasota, Florida
Margaret Swalec, MS
Successful treatment of medical conditions in veterinary patients typically requires pet owner adherence to and compliance with prescribed therapeutic regimens. Owner adherence is described as when the owner obtains the prescribed medications and initiates and continues administration as prescribed.1 Compliance is the consistency and accuracy with which the owner follows the prescribed regimen, including dose, frequency, duration, and timing of administration.1
Consequences of Lack of Adherence & Compliance
In human medicine, the average rate of patient adherence is ≈50%.2 In veterinary medicine, study results indicate that compliance and adherence are similarly low; in studies of dogs receiving short-term antimicrobial therapy, 56% to 59% of owners administered the incorrect number of doses per day, with most underdosing their pet.3,4 Adherence failure and lack of compliance can result in lack of patient improvement, disease progression, or even death of the patient. Lack of compliance can also have more subtle adverse effects; for example, incomplete treatment of infection can promote antimicrobial resistance.3 Withdrawal signs can occur with abrupt discontinuation of some drugs, and overdosing can result in toxicity or extra costs. Decisions regarding treatment efficacy can be adversely influenced by unidentified poor compliance, and lack of improvement can increase the frustration of the pet owner and/or veterinary staff.1,3
Factors that Affect Adherence & Compliance
Factors that affect adherence to and compliance with therapeutic regimens include cost and accessibility of medications, number of drugs administered, frequency and duration of drug administration, complexity of the treatment regimen, and abilities of those administering the drug (eg, able to administer eye drops to pets, able to administer oral medications to cats).2,3,5,6 Patient behavior and owner lifestyle (eg, long working hours or travel) can also preclude drug administration that is required more than once a day.
Some therapeutic regimens are inherently complex. For example, a 5-minute interval between eye drops is typically advised to prevent washout of the previous medication and, in some cases, to increase the combined effects of the drugs.7 A longer interval may be necessary between oral administration of some drugs (eg, oral sucralfate suspension administration is delayed for 2 hours after doxycycline administration) to decrease negative effects on bioavailability.8 Such necessary but complex instructions are likely to reduce pet owner compliance.
Simplifying dose regimens can help improve owner compliance.9 In a study of canine otitis externa, owner compliance with the therapeutic regimen increased from 21% to 79% when the topical medication was only administered once a day rather than twice a day and as a single volume rather than as multiple drops.10 Similar findings were noted in another study when antibiotics were prescribed for once- or twice-daily administration rather than every 8 hours.9
Clinicians can also improve pet owner compliance with complex therapeutic regimens by building a relationship with the owner, eliciting the owner’s perspective on treatment, demonstrating empathy, and investing the owner in the outcome by sharing information regarding the condition and treatment options and involving the owner in the decision-making process.1 Follow-up telephone calls and coaching from staff can also be helpful.11 Some owners may be hesitant to discuss technical difficulties with clinicians; however, if staff provide demonstrations and observe treatments, owners may be more confident in the treatment plan and therefore more compliant.1,2,5,12
Compliance can be verified by examining the amount of medication that remains during a follow-up visit.2,13 If residual medication counts are unexpectedly high or low, the staff should determine the cause and ways to assist the owner in improving compliance.
Tools for improving compliance include written instructions, videos, charts, checklists, calendars, and special packaging that explain, organize, and streamline treatments.1,2,5,12
In human medicine, division of daily or weekly doses into a multicompartment pill box can help increase patient compliance.2 However, such a technique is usually not possible with topical or oral liquid medications. In addition, removing medications from labeled containers may be risky if the medications appear similar, as in the case of omeprazole and cyclophosphamide capsules, acepromazine and chlorpheniramine tablets, and grapiprant and metronidazole caplets.
A safer method may be the use of a compartmentalized tray that can be labeled with times and medications (eg, name, color, number) and hold the medication containers (Figure 1). The owner can place the medications in a row at the beginning of the day and move each drug to the next row once administered; this allows the person administering a complex medication regimen to keep track of the drugs that have been administered. Additional labels can be added to indicate which medications should be stored in the refrigerator.
For complex medication regimens, a compartmentalized tray can be labeled with administration times and other information. In addition, medications and compartments can be color-coded to provide visual cues. In this example, each medication has its own column and each row represents a different treatment time. The owner moves the medication to the next labeled compartment in the column after it is administered and moves the medications back to the top row after the final dose of the day.
Examples of medication logs are available (see Suggested Reading). Clinicians and staff may be able to devise medication sheets that are more readily adaptable to the patient or type of treatment (Figures 2 and 3).
Checklists should be adjusted for each patient. Rows can be added for headings or special instructions (eg, rest periods between treatments); these headings can later be filled in with treatment times once the best scheduling options have been discussed with the owner. Medications should be entered on the checklist in the order of administration, and rows should be left empty as needed for additional instructions between treatments. Maintaining a document of pretyped instructions with blank spaces to add the dose, frequency, or other medication directions can be beneficial. The details of each medication should be entered after each instruction is added to the checklist to tailor the treatment to the patient. Including a box for additional instructions or information (eg, next appointment time or clinician signature line) at the bottom of the document can also be helpful. To improve visual recognition, color-coding each treatment and placing a sticker of similar color on the checklist may help the owner adhere to the schedule.
The medication checklist can be copied and printed for daily use; as a more environmentally sound practice, the checklist can be laminated or placed in a clear plastic document folder. The owner can use an erasable marker to check off each medication once administered.
For complicated medication regimens, a well-designed daily medication log can help improve owner compliance. In this example, each column represents a different administration time and each row a different treatment. Administration times are filled in at the top by the clinician or staff using times tailored to the patient’s condition and the owner’s lifestyle. Different checkbox shapes can be used to help owners distinguish different administration methods; in this example, squares represent eye drops and circles represent oral tablets. Owners can copy the instructions to make daily checklists, or the instructions can be sealed in plastic so that an erasable marker can be used to check off treatments.
Medication sheet in a tabular format. Shaded boxes indicate the medication was administered at that time.
Additional Safety Measures
If a medication must be refrigerated between each administration, medication management options should be discussed with the owner. Some owners may prefer to leave an empty container in the appropriate compartment as a reminder, whereas others may wish to retrieve the medication from the refrigerator immediately before administration and place it in the appropriate compartment. If several medications must be refrigerated, incorporating a separate compartmentalized organizer that fits on a refrigerator shelf may be helpful.
Successful resolution of some veterinary conditions may rely on complex treatment regimens. Owner compliance with these regimens can be improved by simplifying the dose schedule and providing clear, concise written instructions, charts, or checklists. Use of compartmentalized, labeled medication trays or color-coded medication containers and instructions can provide additional visual cues to help the owner deliver the treatments appropriately.