Transcript No Slide Title

Strengthening Medication Adherence:
From Evidence to Practice
David Sobel, MD, MPH
Medical Director, Patient Education and Health Promotion,
The Permanente Medical Group, Inc.
Physician Lead, Self-Care and Shared Decision-Making Initiative
Care Management Institute, Kaiser Permanente
(510)987-3579
[email protected]
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Regional Health Education
Health Improvement in Chronic Conditions
Requires:
 Correct diagnosis
 Prescribing correct treatment
 Treatment adherence over time: a
shared responsibility
Taking medications is a fundamental
self-management task for patients with
chronic conditions.
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Regional Health Education
Self-Assessment
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Have you ever had any difficulty taking a
medication as prescribed? If so, why?
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“I am worried about side-effects”
“I forget”
“I’m not really sick”
“I’m already taking too many medications”
“Too busy”
“I’m not sure they do me any good”
“Too expensive”
etc.
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Regional Health Education
Address 4 questions today
1.
2.
3.
4.
What are key factors in medication adherence?
What is the extent of medication nonadherence?
What is the impact of poor adherence?
What are evidence-based strategies to screen for
nonadherence and strengthen adherence?
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Regional Health Education
What exactly is adherence?
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Taking 80+% of pills or doses of one
or more prescribed medications
McDonald HP. JAMA 2002;288:2868-2879
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Regional Health Education
5 Dimensions of Adherence
Unique combination of 5 different factors:
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Health system & health care team: health care coverage,
patient-clinician relationship, clinician skill and training, etc.
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Social and economic: patient SES, literacy & education
levels, age, culture, degree of social support, etc.
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Therapy: regimen complexity, duration of treatment,
immediacy of beneficial effects, side effects, etc.
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Health condition: severity of symptoms, level of disability,
rate of progression, co-morbidities, etc.
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Patient and caregiver: resources, knowledge, attitudes
and motivation, beliefs, expectations, etc.
World Health Organization. Adherence to Long Term Therapies: Evidence for
Action, 2003.
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Regional Health Education
Can you predict adherence?
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63 year old Mexican American woman
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10th grade education; English speaking
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Type 2 diabetes; HTN; BMI 27; osteoarthritis
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No depression or other psychiatric problem
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No physical disability
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Regional Health Education
Can you predict adherence?
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Clinicians do not demonstrate more than chance accuracy in
predicting adherence of their patients
Age, sex, race, intelligence, education level not reliable
History of depression is associated with poor adherence
People with physical disabilities more likely to adhere
Adherence rates fluctuate over time. Cannot assume ongoing high
or low adherence.
Suspect nonadherence if patient not making progress on clinical or
laboratory indicators and/or if patient fails to keep appointments
Note: Certain characteristics in specific disease populations linked to adherence,
e.g. in older women with asthma: greater severity, lower SES, increasing
age & other factors associated with treatment nonadherence
McDonald HP. JAMA 2002;288:2868-2879
Barr RG et al. Arch Intern Med 2002; 162(15): 1761-1768.
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Regional Health Education
Adherence to Prescribed Medications:
The Scope of the Problem
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Common: Average adherence rates estimated at
50 percent. Lower rates with long term and
complex regimens. Problem grows as burden of
chronic disease grows.
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Costly: Lack of medication adherence is
associated with poorer prognosis, hospitalization,
mortality & significantly higher health care costs
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Complex: Usually more than 1 factor involved.
McDonald HP. JAMA 2002;288:2868-2879.
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Regional Health Education
Improving Adherence to Prescribed Medications:
The Potential Impact
Strengthening adherence may have greater impact
on improving health outcomes than:
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Improved diagnosis
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More effective treatments
McDonald HP. JAMA 2002;288:2868-2879.
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Regional Health Education
Medication Adherence and Health Outcomes
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Taking a medication has both a physiological and
psychological effect that influences health
outcomes
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Regional Health Education
Medication Adherence and Mortality
Coronary Drug Project (clofibrate)
30
25
5-Year 20
Mortality 15
%
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Drug
Placebo
5
0
All Subjects
High
Low
Adherence Adherence
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Regional Health Education
Medication Adherence and Mortality
Beta Blocker Heart Attack Trial (BHAT)
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7
7
6
1-Year 5
Mortality 4
(men) 3
2
4.2
3
Drug
Placebo
1.4
1
0
HIgh Adherence
Low Adherence
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Regional Health Education
Medication Adherence and Health Outcomes
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Patients who adhere to treatment, even when the
treatment is a placebo, have better health
outcomes than poorly adherent patients
The effect of adherence remains even when
controlling for severity of disease, race, gender,
martial status, smoking and life stress.
Each time patients swallow a pill they
are swallowing their expectations along
with the medication.
Horwitz RI, Arch Int Med 2993:153:1863-1868
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Regional Health Education
Polypharmacy
of “Heart Protective” Medications
Patient without symptoms are prescribed:
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Antithrombotic agent
ACE inhibitor
Statin
Metformin, glyburide, etc.
+/- Beta-blocker
Members with diabetes & cardiovascular risk factors
often prescribed 4 to 7 medications
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Regional Health Education
Hypertension and Adherence
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One third to one-half of hypertensive patients do
not adhere to prescribed regimen
Half of those with “refractory” hypertension are
nonadherent
Predictors of adherence inconsistent but
depression associated with lower adherence
Simpler regimens associated with higher
adherence (QD ~8% > multiple daily dosing and ~ 6% > BID*)
Clin Ther 2002;24:302
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Regional Health Education
A Tasty Solution to
Antihypertensive Medication Adherence
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Randomized, crossover trial,
13 subjects with mild isolated
systolic hypertension
14 day trial of polyphenol-rich
dark or polyphenol-free white
chocolate (~100gr, 480 kcal)
Dark chocolate lowered blood
pressure an average of 5.1
mm Hg systolic and 1.8 mm
Hg diastolic (P‹.001)
BP returned to
preintervention values within
2 days.
Taubert D. JAMA 2003;290:1029-30
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Regional Health Education
Adherence to Prescribed Medications:
What Works?
Interventions:
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Combinations of the following interventions are the most effective approaches
to increase adherence to treatments for chronic conditions:
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Instruction and counseling and educational materials
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Simplifying the regimen
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Group sessions
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Reminders for medications and appointments
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Cueing medications to daily habits and events
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Reinforcement and rewards, e.g., explicitly acknowledge efforts to
adhere
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Self-monitoring with regular clinician review and reinforcement
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Involving family members and significant others
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Asking patients about adherence detects 50% non-adherence
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Nonjudgmental, supportive communication and problem-solving
Haynes RB. JAMA 288;2880-83
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Regional Health Education
Adherence to Prescribed Medications:
What Does NOT Work?
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Patient instruction alone did not have a lasting
effect on adherence
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Attempts to coerce or instill fear (may also cause
withdrawal from treatment)
Haynes RB. JAMA 288;2880-83
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Regional Health Education
Collaborative Problem Solving
for Medication Adherence
Behavior Change Principles
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PERVERSITY PRINCIPLE: If you are told what to do, it is
likely that you will do the opposite.
SELF-TALK PRINCIPLE: Your beliefs are more influenced
by what you hear yourself say than by what others say to
you.
CHANGE TALK: Self motivating statements made by
patients
– Recognition of an issue
– Personal reasons for making a change
– Potential consequences of current behavior
– Hope or confidence about making a change
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Regional Health Education
Collaborative Problem Solving
for Medication Adherence
Clinician style is one of the most powerful
predictors of motivation for behavior change
NonJudgmental
Collaborative
Empathic
Curious
Genuine
Miller & C’de Baca 1983; Miller et al 1993
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Regional Health Education
Screening for Adherence
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Ideal: Screen everyone, at each encounter
Real: Periodically screen higher risk
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Nonattenders: missed appointments
Nonresponders: not meeting treatment goals
Nonrefillers: not refilling medications at appropriate
intervals
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Regional Health Education
Communication Suggestions
for Medication Adherence
Normalize Non-Adherence and Ask Permission
Preamble to set the stage:
“Many people have trouble taking their medicines all
the time. To create a medication plan that is safe and
effective for you, it’s important to know how you are
taking your medications. Can we take the next few
minutes to talk about that?”
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Regional Health Education
Communication Suggestions
for Medication Adherence
Screening for Medication Adherence
1
“During the past
7 days, (including last
weekend), on how
many days have you
missed taking any of
your doses?”
OR
“During the past month approximately
what percentage of your medication
have you taken? For example, 0%
means you have taken no
medications, 50% means you have
taken half of your medications, 100%
means you have taken every dose of
your medications.”
Adherence = Taking > 80% of doses prescribed
2
“Have you decided to stop or start any medications on your own?”
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Regional Health Education
Communication Suggestions
for Medication Adherence
Ask Open - Ended Questions
Elicit the patient’s perspective and engage the patient in problem-solving
Build on Strengths
On the days you take your medicines, what helps you stay on track?
 Explore Barriers and Solutions
What gets in the way of taking your medications on some days?
What are your ideas for taking your medicines in those situations?
 Explore Ambivalence (Pros and Cons)
What are some reasons for not taking your medications?
What are some reasons for taking the medications?
 Provide Education & Check for Understanding (“Teach Back”)
We’ve discussed some strategies for taking your medication regularly. To help
me know whether I’ve explained things thoroughly, please tell me how you plan
to take your medications.
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Summarize
Summarize patient’s perspective, link to patient symptoms and aspirations,
affirm ideas for success, reinforce/clarify education prn
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Regional Health Education
Medication Adherence: Online Resources
members.kp.org
 Medication refills
Drug encyclopedia
 Health Encyclopedia
 Decision Points
 Action Sets
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Taking your high blood
pressure medications properly
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Regional Health Education
Communication Suggestions
for Medication Adherence
Strong, positive closing
“We have discussed some ideas for taking your medications
regularly. I strongly encourage you to take your medications as
prescribed. This is one of the best things you can do to manage
your ______ and to prevent health problems in the future. Of
course, the decision to take medications is entirely yours. I am
confident that should you decide to carry out the plan we
developed today, you can find a way to make it work for you.”
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Regional Health Education
Address 4 questions today
1.
2.
3.
4.
What are key factors in medication adherence?
What is the extent of medication nonadherence?
What is the impact of poor adherence?
What are evidence-based strategies to screen for
nonadherence and strengthen adherence?
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Regional Health Education
Principle of Dialog Education
“Never do what the learner can do.
Never decide what the learner can decide.
The learning is in the doing and deciding.”
Jane Vella
Learning to Listen, Learning to Teach
Jossey Bass, 2002
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Regional Health Education