adherence Flashcards
(19 cards)
adherence:
“The extent to which a person’s behaviour - taking medication, following a diet, and/or executing lifestyle changes - corresponds with agreed recommendations from a health care provider”
(WHO, 2003, Adherence to Long-Term Therapies, p3)
→ Adherence = —
* Examples: filling prescriptions, keeping medical appointments…
Professional non-adherence
– Not just for patients!
* Prescribing antibiotics for viruses
* Not adhering to professional guidelines
* Concentrating on procedures which pay most
* Not recording patient information e.g. —
behaviour
smoking status
defining adherance:
Changes in terminology:
Compliance:
* The extent to which the patient’s behaviour coincides with the —
* Patient = — role; solely responsible for—
Adherence:
* Negotiation between patient and HCP
* Not solely — responsibility
(Concordance?)
* The degree to which the patient and the HCP agree about the nature of the
condition and the need for treatment
clinical prescription
passice
execution
patient responsibility
Taxonomy of Adherence: ABC Project (Vrijens et al., 2012)
– Medication specific: “The process by which patients take their medication as — ”
– However, useful to think more broadly about different adherence behaviours
3 essential elements:
A. — : When the — dose is taken
B. — : The — to which the dose taken corresponds to the — dose, from — til the — dose
C. — : The length of time between — and —
– Discontinuation marks the end of therapy –> possible period of —
prescribed
initiation
first
implementation
extent
prescribed dose
initiation
last dose
persistence
initiation and discontinuation
non persistence
measurement of adherence:
* Ideally, measures of adherence should be:
✓ — (overall consistency of a measure)
✓ — (the extent to which a measure assesses what it is intended to
assess)
✓ Give — results
✓ Usable over — periods of time
✓ Acceptable to — and –
✓ — and —
✓ — and –
✓ Applicable to a wide variety of —
reliable
valid
immediate
prolonged
patients and unobstrutive
non invasive and safe
practice and cheap
treatments
measurement of adherence:
1- Subjective methods
* Patient —
* Patient — cards
* Health care provider —
2- Objective methods
* Measuring — in body fluids
* Tablet —
* — observation
* Electronic — (MEMS)
* Prescription-redemption –
* therapeutic —
for both methods:
No single method is sufficiently — and —
* A — method approach that combines — and — measures is best
self report
diary cards
estimates
drug concentration
counts
direct observation
monitors
records
outcomes
reliable and valid
multi
self report and objective
How should adherence be reported?
* Categorical or Dichotomous:
– What constitutes “good adherence”?
* —- ? i.e. 100% of treatment
* —- ? e.g. 80%
* Pragmatic: The point — which the desired preventative or
desired therapeutic result is unlikely to be achieved?
* Continuous outcome:
– —- e.g. adherent to 83.2 % or 94.7% of
regimen
* was it carried out — ?
all or nothing
cut off
below ( basically minimum level needed to achieve a therapeutic goal )
implementation
correctly
Measurement of adherence
* EMERGE– guidelines for reporting studies of medication adherence
* Developed using the — for medication adherence
* Consists of 21 items organised in 2 sections
– 4 items reflecting the — of medication adherence
– 17 items specific to medication adherence —
taxonomy
conceptualisation
reporting
prevalence of nonadherance:
Reported rates of non-adherence vary widely: 4% - 92%
– Different definitions and measures across studies
– Varies by condition/population/type of adherence behaviours
* Acute illness/short-term meds c.20%
* Chronic illness/long-term meds c.50%
* Diet; Exercise regimens c.65%+
* Outpatient medical appts. C.25%
– ↑ — and — , ↓ adherence
Adherence to different treatments varies, even for the same patient
Example: Cystic Fibrosis
– Paediatric adherence
* Nutrition – 16-20%
* Physiotherapy – 47%
* Oral medication – 40-95% (self-report)
– Adult adherence
* Enzymes/nebulised meds– 65-80% (self-report)
* Vitamins – 40-55%
* Dietary changes/Physio – 40-55%
* Aerosolized antibiotics – <40% (electronically measured)
complexity and time
implication of non adherence:
*— consequences:
– Poor health outcomes, unnecessary illness, decreased QOL,
increased hospitalisations, death, drug resistance, escalation of
doses
* —
– ~ 10-25% of hospital admissions due to non-adherence (e.g.,
asthma, heart failure, diabetes)
– 33-69% of all medication-related hospital admissions in the USA
are due to poor medication adherence → cost of ~ $100 billion
p.a.
info:
* Adherence to preventative medication and risk of cardiovascular
disease (CVD) and mortality
* Good adherence associated with
➢ 15-19% ↓in CVD
➢ 29-45% ↓in all-cause mortality
* Non-adherence estimated to account for 9% of all — events in Europe!
* — considerations
– Response to non-adherence?
* Stop therapy?
* What about risk of harm to other? e.g. infectious
disease
❖Important to understand contributing factors
health
cost
info:
CVD
ethical
Theoretical causes of non-adherence
* Complexities of non-adherence (5-dimensionWHO model; Cognitions/Beliefs)
* Two main types of non-adherence: — and —
* Adherence as a —-driven
problem is a misconception
* Adherence is — : multiple systemic, inter and intra- personal, and social factors play a role
intentional and non intentional
patient driven
multi
potential causes of non adherence:
1. Condition-related factors:
* Determinants of non-adherence include:
– — : Chronic compared to acute conditions
* Low adherence problematic across — conditions
* Considerable variation among patients with the same condition
– Greater — of symptoms and disease
– Greater level of —
– — rate of progression
– — of effective treatments
2. Therapy-related factors
* Determinants of non-adherences include:
– — duration of the treatment
– Frequent changes in —
– — treatment regimens rather than simple ones
– More medications
– More frequent the doses
– Greater interference with lifestyle
– Immediacy of benefits (long-term vs. immediate)
– Previous treatment —
– Greater and more severe —
example: type 2 diabetes and their side effects , no of meds and patient characteristics . 23% tho is from side effects
duration
chronic
severity
disability
faster
availability
duration
changes
complex
failures
side effects
potential causes of nonadherance:
3. — /Healthcare — factors
* Contributing factors to non-adherence:
– Poorly developed services
– Poor medication distribution systems
– Lack of knowledge
– Training for health care providers
– Short consultations
– Poor patient-provider relationships
4. Socio-economic-factors:
* Age, gender, socioeconomic status (SES) not consistent predictors of adherence
* But — SES may put patients in the position of having to choose between
competing priorities e.g. use limited resources for medication or to meet family demands
* Factors related to SES become important:
– Illiteracy
– Unemployment
– Lack of effective social networks
– Unstable living conditions
– Distance from treatment center
– High cost of transport
5. Patient-related factors:
* General — of patients
* Age, gender, social class, education?
* But determinants can change with age (Costello et
al, 2016)
* Lack of —
* Basic treatment-specific knowledge (how & when)
essential, BUT knowledge alone doesn’t guarantee
adherence
* Lack of —
* But non-adherence is often intentional or
deliberate
* Health — and —
health system / healthcare team
low SES
characteristics
knowledge
competence
beliefs ad perceptions ( * Faulty assumption: non-
adherence is lack of
competence
* Evidence:
non-adherence may be
deliberate as well as
unintentional.)
2 types of nonadherance:
1. Unintentional non-adherence
– — to adhere e.g. getting —
– — to adhere i.e. being unable to do the physical action required
e.g. inhaler use, do an exercise
2. Deliberate/intentional non-adherence:
– Choosing not to adhere
– Patients’ — and — are important
forgetting
distracted
inability
beliefs and cognition
Potential causes of non-adherence
* Health beliefs
– Leventhal’s Self-regulation model of illness : “Common-sense model”
– Examples: Beliefs about the…
1. — of the condition e.g. caused by genetics → no point in changing
behaviour
2. — / — of the condition e.g. acute timeline → over now, no point
continuing
3. — of the condition e.g. consequences are not severe or long term prospects are poor → less motivated to continue
4. —/— e.g. is there a cure? Can this be controlled by
self/others?
5. — e.g. scared, distressed
casues
timeline/duration
consequences
curability/controllability
emotional
Potential causes of non-adherence
* Beliefs about the treatment
e.g. Not wanting to get addicted to medication
e.g. Not believing treatments are worth it
e.g. Being too worried about side effects
* Patients’ beliefs may be very different from HCPs and may not be
accurate!
* Behaviour may be influenced more by own beliefs than medical
advice…
* Important to elicit and address patient’s beliefs
Beliefs about the treatment:
* —- framework: weigh up pros and cons of treatment
* Beliefs about Medicines Questionnaire (BMQ; Horne et al., 1999)
– —- subscale
* e.g. Without my medicines I would become very ill
– —- subscale
* e.g. I sometimes worry about becoming too dependent on my medicines
– high adherence
– Literature review – 94 studies identified (N=3,777)
– Stronger beliefs in necessity
(Odds Ratio (OR) = 1.74 (95% Confidence Intervals (CI) 1.57-1.93)
– Fewer concerns (OR = 0.50 (95% CI 0.45 to 0.56)
Necessity-concerns
Necessity
concern
info:
Breast Cancer
* Semi-structured interviews- 31
women at two cancer centers
* 14 adherent
* 7 sub-optimal implementation
* 10 discontinued
* The reasons why they take or do not take their endocrine
therapy as prescribed- identify modifiable factors
* Adherent women -strongly believed in the necessity and efficacy of
their endocrine therapy, benefits outweighed the side-effects, risks
of not taking it and subsequent regret
* Suboptimal implementation: Women had negative perceptions of medication and had to
over come these fears and concerns to take their treatment.
* Discontinuation: Women had a preference for a better quality of life and wanted to be
finished with their treatmen
Useful questions? E.g.:
Elicit patient beliefs using open-ended questions (non-judgemental)
* — : Do you think you need that medication?
* — : Do you have any concerns about taking these?
* — : What does your condition mean to you?
* — : What do you think caused this?
* —- : How long do you think you need to take these for?
* —- : What do you think the consequences are?
* —- : How do you think you can control (cure) this?
=>You can clarify any misperceptions to aide adherence
necessity
concerns
identity
causality
timeline
consequences
control/cure
Facilitating Adherence: Consultation Factors
3 strategies to maximise adherence
1. — of the condition and its treatment
– Establish concordance, don’t lead the consultation too much, allow time to process the
information, encourage questions, ask patients about their understanding.
2. — for information given
– Primacy and recency effect, emphasise most important aspects, avoid jargon, provide written
material and encourage note taking.
3. — with the process of treatment
– Good communication, non-verbal behaviour, open-ended questions, asking for input, sufficient
time for discussion, good accessibility to HCP.
– Strategies should be tailored to the reasons for —
understanding
memory
satsifaction
non adherence
Facilitating Intentional Non-adherence
* Check adherence
– Normalise poor adherence: “lots of people forget to take their medications/do their exercises – have you?”
– Check at follow-up and factors that may have affected it
– Provide feedback about progress
* Good relationships and satisfaction with care
– Develop open, communicative, non-judgmental relationships with patients
– Ensure the patient is satisfied with the amount of information given
* Patient-centered care
– Elicit the patient’s views & experience of treatment
– Tailor treatments to patient preferences and behaviour patterns
– Involve patient in planning process; establish perceived barriers and challenges
* Clarify misconceptions
– Ensure good understanding and rationale for treatment - not the same as simple education!
– Bespoke information dependant on what patient believes
Facilitating Unintentional Non-adherence
* Tailor treatment plans and information to patient preferences, needs & capabilities
* Check understanding of how to take/execute treatment recommendations
* Provide written back-up information
* Simplify treatment where possible
* Provide extra skills training if necessary
* Develop systems (reminders) to prompt patients with long-term treatment plans
* Liaise with patients, their carers & health prof. to ensure continuity of care
* Initiate & facilitate regular reviews of treatments, and monitoring of adherence levels
Conclusions:
* Adherence is controversial and is difficult to measure; yet low levels
are evident and the implications are profound
* Several factors impact on non-adherence
– 5-dimension model: Health — / — , —/—,—,—-,—-
– Intentional and unintentional non-adherence
* Better adherence possible but strategies must be tailored to the
reasons for —
– — (e.g. reminders etc.) are excellent for unintentional non-adherence
– Eliciting, understanding and modifying patients illness and medicine beliefs are crucial for intentional non-adherence
Health systems/professionals, social/economic, condition,
therapy, patient
non ahderance
technologies
