Kohlenberg > HTN Adherence & Behavioral Mgmt

Question 1

what is Dr. Kohlenberg’s main question in this lecture?

Answer 1

How do we understand impossible-to-understand behavior?

Question 2

what % of pts do NOT take meds as prescribed?

Answer 2

50%

Question 3

is medication adherence SOLELY the pt’s responsibility?

Answer 3

nope (somehow)

Question 4

medication-taking behavior involves what 3 components?

Answer 4

pt
physician
process

Question 5

what does identification of nonadherence require?

Answer 5

specific interviewing skills

Question 6

what are some solutions for med non-adherence?

Answer 6

encouraging a "blame-free" environment
less frequent dosing
improved pt education
assess health literacy
pay attn to rational nonadherence

Question 7

what 2 meds have adherence rates BELOW 50%?

Answer 7

statins & anti-HTN

Question 8

what is primary adherence?

Answer 8

measured by filling prescriptions (i.e. does the pt take the 1st step)

Question 9

what % of pts do not fill their initial statin RX?

Answer 9

58%

Question 10

T/F: if meds are free, adherence is over 70%

Answer 10

FALSE

still under 50%!

Question 11

what is the most important cause of failure to achieve BP control?

Answer 11

lack of adherence

Question 12

how much does anti-HTN therapy reduce the risk of stroke & MI?

Answer 12

stroke: 30%
MI: 15%

Question 13

what % of pts being treated for HTN are nonadherent?

Answer 13

50-80%

Question 14

how long does it take 25-50% of pts to discontinue statins?

Answer 14

within 6 months to a year

Question 15

at 2 years, how many pts prescribed statins have discontinued them?

Answer 15

75%

Question 16

what does the word “compliance” imply?

Answer 16

that the pt passively follow’s dr’s orders
AND
that treatment plan is NOT based on an alliance or contract btwn pt & dr

Question 17

what is adherence?

Answer 17

a collaborative model in which healthcare providers have some responsibility in creating a treatment contract w/ a pt

Question 18

what are the pt-related factors that cause poor med adherence?

Answer 18

lack of understanding/involvement/literacy
health beliefs
costs, transportation, support

Question 19

what diseases have a big obstacle in family support & adherence to meds?

Answer 19

mood disorders & CVD

Question 20

what % of 65+ yo in Medicaid programs are adherent to anti-HTN meds?

Answer 20

20%

Question 21

what is the greatest risk factor assoc w/ increased incidence of heart failure in the elderly?

Answer 21

medication nonadherence

Question 22

what gender is MORE NONadherent w/ anti-HTN meds? (less adherent)

Answer 22

women

Question 23

T/F: drs always recognize nonadherence

Answer 23

false

Question 24

when are dr estimates of nonadherence WORSE?

Answer 24

if the pt is high-fxning

Question 25

what are physician-related factors assoc w/ nonadherence?

Answer 25

overly complex drug regimens ineffective communication communication among physicians

Question 26

T/F: discharge summaries are always available at all post discharge visits

Answer 26

false | only in less than 34%

Question 27

what are the health system factors that cause poor pt adherence?

Answer 27

costs lack of time fragmented systems poor coordination

Question 28

what are the pt-related factors that can improve medication adherence?

Answer 28

flexible education pt empowerment avoid numerous meds & behavioral mods at any one visit

Question 29

what can you do to increase pt empowerment?

Answer 29

MI "what time of day would you like to take your meds?" "how quickly do you want to gain control of your BP?"

Question 30

what can a doctor do if a pt is health illiterate?

Answer 30

tune into it (& economic status) create a shame-free env have materials in native languages recognize mental illness

Question 31

what % of adults have proficient health literacy?

Answer 31

12%! that's it!

Question 32

what % of adults have basic or below basic health literacy?

Answer 32

35%

Question 33

T/F: adherence is improved when a good relationship exists btwn pt & dr

Answer 33

TRUE

Question 34

how does patient-centered communication & trust w/ a clinician affect nonadherence?

Answer 34

if a pt feels like it's a bad relationship, 7-16% WORSE nonadherence rates to med refills

Question 35

T/F: "what meds are you on" is a sufficient convo about adherence

Answer 35

FALSE | you gotta go in depth

Question 36

what is the key to adherence?

Answer 36

reduce complexity!

Question 37

how can you reduce complexity?

Answer 37

limit pharmacy visits adhere to formulary respect economic realities try to decrease # of pills/day

Question 38

what 2 things can you try to reduce to INCREASE adherence?

Answer 38

``` # of pills/day frequency of dosing ```

Question 39

T/F: starting long-term meds during a hospitalization for an acute event may DECREASE adherence

Answer 39

FALSE it may improve adherence (as opposed to prescribing at discharge)

Question 40

How can you use non-physician staff to help w/ pt adherence?

Answer 40

team based approach | phone reminders

Question 41

what is a health system factor you can use to help w/ med adherence?

Answer 41

medication reconciliation

Question 42

what is medication reconciliation?

Answer 42

take a list of all meds & all details (dose, route, etc) & compare it w/ transfer/discharge orders

Question 43

what is an example of a primary adherence intervention?

Answer 43

automatic messaging to pt if the RX was not filled

Question 44

what was the result of the "After ACS Hospital Discharge" study?

Answer 44

improved adherence by 7% but did NOT improve clinical targets

Question 45

what 6 things contribute to essential HTN?

Answer 45

``` obesity stress lack of exercise diet (XS salt) alcohol intake smoking ```

Question 46

in the "super-sedentary epidemic" paper, what was the mean duration of moderate physical activity?

Answer 46

less than 1 minute/day | NO time spent in vigorous physical activity

Question 47

what is the difference btwn nurse & dietician led programs for risk factor management after ACS?

Answer 47

none

Question 48

what is early nonpersistence?

Answer 48

filling a script but not refilling it w/i 90 days

Question 49

what is nonadherence?

Answer 49

not having meds available for 20% or more days during a 12 month pd following therapy initiation

Question 50

what % of pts (in the "racially & ethnically diverse" group) were nonpersistent & nonadherent?

Answer 50

30%+ nonpersistent | 20% nonadherent (1 in 5 pts)

Question 51

are there racial/ethnic diffs in treatment?

Answer 51

yes, early on

Question 52

what closes the gap btwn racial groups?

Answer 52

reduced copay ease of access to meds optimize choice for initial therapies

Question 53

what racial group is MORE likely to exhibit early nonpersistence & nonadherence?

Answer 53

nonwhites

Question 54

what group is disproportionally affected by HTN?

Answer 54

african americans

Question 55

why do african americans w/ HTN have poor BP control?

Answer 55

poor med adherence

Question 56

is pt education or positive affect a more effective intervention w/ adherence?

Answer 56

positive affect! 42% vs 36% 1 in 16 pts will benefit

Question 57

what accounts for more than 50% of cardiac deaths in women?

Answer 57

sudden cardiac death (SCD)

Question 58

what is the first manifestation of heart disease among women?

Answer 58

most SCD events

Question 59

what is primary prevention in high-risk SCD events?

Answer 59

cardioverter-defibrillators

Question 60

what are independent risk factors for SCD?

Answer 60

smoking, obesity, physical inactivity

Question 61

what can increase the risk of SCD?

Answer 61

low n-3 fatty acid intake alcohol abstinence heavy alcohol intake

Question 62

what things are assoc w/ lower risk of CHD, stroke, diabetes, cancer, HTN, chronic disease, CVSD, & total mortality?

Answer 62

not smoking good diet regular exercise healthy weight

Question 63

specifically, what puts you at low risk of SCD?

Answer 63

not smoking BMI less than 25 exercise 30+ min/day mediterranean diet

Question 64

what % of SCD can be attributed to unhealthy lifestyle practices?

Answer 64

79%

Question 65

what is the key to motivational interviewing?

Answer 65

respectful communication

Question 66

what is the most important factor in determining adherence to treatment?

Answer 66

communication

Question 67

T/F: less time spent w/ pt discussing meds is a strong predictor of higher adherence

Answer 67

FALSE | lower adherence

Question 68

how can you drive your pt to be NONadherent?

Answer 68

use complex talk rather than pt talk tell, don't ask communicate that your pt is wrong rather than learning what they think

Question 69

what is the philosophy behind motivational interviewing?

Answer 69

ppl are generally persuaded better by reasons they discover THEMSELVES

Question 70

what things make up the spirit of MI?

Answer 70

collaboration/partnership evocation respect/acceptance compassion

Question 71

what are the underlying MI values?

Answer 71

``` inherent worth potential for growth trust & respect positive growth & paradox of acceptance autonomy ```

Question 72

what should your PT be able to articulate w/ MI?

Answer 72

how imp this change is to THEM obstacles to change change that might work how to increase chance of success

Question 73

what are the 4 general techniques of MI?

Answer 73

express empathy develop discrepancy roll w/ resistance support self-efficacy