Transcript Adherence-to-medical

Adherence to Medical
Advice
Reasons why patients do not adhere
Measuring adherence and non adherence
3. Improving adherence
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2.
Why is adherence a problem?
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Studies have suggested
that about half the
patients with chronic
illnesses such as
diabetes and
hypertension (high blood
pressure) are noncompliant with their
regime. There is clearly a
large financial cost for
this in wasted drugs but
also potentially in poor
health outcomes.
A study by Sackett (1976)
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50% of patients in America did
not take prescribed
medications according to the
instructions and scheduled
appointments for treatment
were missed 20-50% of the
time.
Taylor (1990) suggested that 93% of patients fail to adhere to some aspect of
their treatment.
Sarafino(1994) argued that people adhere reasonably closely about 78% of the
time for short-term treatments but only 54% for chronic illness.
A study by Becker (1972) looked at whether a prescribed anti-biotic was being
taken halfway through a 10 day treatment programme in young children. Over
half the mothers had stopped giving the medicine.
McKenny (1973) looked at
hypertension
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He studied 50 patients for
7 months. After detection
of high blood pressure
only 50%-70% sought
treatment
He found that only 65% of
pills were taken.
Only 20% of the patients
took as many as 90% of
the pills.
33% of those who sought
treatment dropped out.
The question is why?
Why patients do not adhere!
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Rational Choice Theory: people may not
adhere for good reason:
They have reason to believe the treatment is
not working
The side effects are unpleasant or effect the
quality of their lives YouTube - Ambien Side
Effects -- Research Findings
There are practical barriers to the treatment
such as cost or social difficulties
They may want to check the illness is still there
when they stop.
Rational non-adherence*
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The patient may not
believe what the doctor
has suggested is in their
best interest. Bulpit
(1988) looked at
treatments for
hypertension and found
that the side effects could
include impotence and
problems with ejaculation.
Clearly for some men this
would be seen as
unacceptable!
Bulpitt: Rational Non Adherence*
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Aims: to review research on adherence in
hypertensive patients.
 Method: Review article of range of research
which identified problems with taking drugs for
high blood pressure.
 Findings: anti hypertensive drugs have many
side effects including sleepiness, dizziness, lack
of sexual functioning. They also affect cognitive
functioning and so work and hobbies may be
curtailed.
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Bulpitt reported that one study by Curb found
that 8% of men stopped taking their medication
due to sexual problems.
 He also reported that research by the Medical
Research Council found that 15% of patients
had stopped taking the drug due to other side
effects.
 Conclusions of Bulpitt’s review were that the
costs of taking some medication appear to
outweigh the benefits for many patients,
especially with problems such as high blood
pressure which have no symptoms. Therefore
some types of treatment (asymptomatic ones)
may be more difficult to treat as people cannot
feel thje benefits of the adherence.
Cognitive / Behavioural Theories of
Adherence: Locus of Control –
Rotter 1966
Cognitive / Behavioural Theories of
Adherence: Locus of Control –
Rotter 1966
 The
more a person feels in control the
more likely they are to comply with their
treatment programme.
 If
we have an internal locus of control we
are likely to have a higher self efficacy –
more belief in what we do makes a
difference.
Other theories to explain
non/adherence:
 Psychoanalytic
explanations include
avoidance and denial of the problem
January
2012
Explain why people may not adhere to
medical regimes. (10)
evaluation
G
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Other e.g.
debates
How can we measure adherence?
What problems are there in each?
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Self-report – simply asking people - probably
with questionnaires
Therapeutic outcome – have they got better?
Health worker estimates – ask the doctor
Pill & bottle counts – raid the cupboard and see
what is left!
Mechanical methods – how much medicine has
been dispensed from the bottle?
Biochemical tests - blood and urine
YouTube - Medication Adherence
Don’t ask Drs about adherence
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One of the least
affective ways (Ley
1997) of measuring
adherence is to ask
doctors as they
appear to vastly over
estimate the extent to
which their patients
do adhere.
Chung and Naya 2000 *
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Was the first study to
electronically assess
compliance with an oral
asthma medication. Aimed to
see if patients did take their
medication regularly and at the
correct time of day.
Taking regular asthma
medication reduces attacks
and prevents deaths. This
study used an electronic Track
Cap, an electronic device on
the bottle top that recorded the
date and time of the use of the
medication.
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57 Patients were told that adherence rates were being measured but
not told about the Track Cap device and what it did. The treatment
was taken twice a day 8 hours apart.
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The study was carried out over a 12 week period.
Compliance was measured by the number of times the track cap
was opened, the number of days that the track cap was opened at 8
hour apart intervals and the number of pills left at the end of the 12
week period.
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Over the period the track cap monitoring showed compliance was
quite high at 71%. However the count of returned pills put the
compliance rate even higher at 92%. ( However 10 patients
dropped out of the study leaving the data being collected from only
47).
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These results show that compliance with adherence to a treatment
of oral, twice a day asthma, maintenance medication is high.
Lustman (2000)
Using
physiological measure to assess adherence to medication and the
treatment of depression in diabetics.
Aim:
to assess the effectiveness of fluoxetine as treatment for
depression in patients with diabetes
Method:
lab experiment using a double blind technique and placebo
control
Participants:
60 patients who volunteered to take part (self-selected
sample)
Had either type 1 or type 2 diabetes and had been diagnosed with
depression.
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Lustman (2000)
Using
physiological measure to assess adherence to medication and the
treatment of depression in diabetics.
Procedure: All patients screened for depression using the Becks
Depression Inventory
Randomly assigned to 2 groups
Grp 1: given fluoxetine
Grp 2: identical looking pill as
placebo
Daily does of medication for 8 wks
Patients and docs did not know
to which group they had been
assigned – avoidance of demand
 characteristics
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Patients re-assessed for depression
Assessed on their adherence to their medical regime (e.g. changing
diet/administering insulin by injection) for controlling their diabetes through
measuring blood sugar levels.
Lustman (2000)
Using
physiological measure to assess adherence to medication and the
treatment of depression in diabetics.
Findings:
Reduction in depression symptoms was significantly greater in patients
treated with fluoxetine compared with those receiving the placebo.
Researchers were able to measure that patients with nearer normal blood
sugar levels which indicated improved adherence to their regime.
Conclusions:
Measuring blood sugar levels in patients with diabetes indicates their
level of adherence to medical regimes.
Greater adherence shown by patients who were less depressed,
suggesting that reduced depression may improve adherence in diabetic
patients.
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evaluation
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Other e.g.
debates
How can we improve adherence
rates in patients
 E.g.
Watt et al (2003) Funhaler spacer:
improving adherence without
compromising delivery
 See
textbook for details on this study.
Make sure your patient is not
depressed.
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Studies have shown
that…..
Make sure your patient is not
depressed.
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Studies have shown that
often people who are ill
are depressed or anxious
and that treating the
patient in a more holistic
way (treating their
psychological or
emotional health as well
as their physical health)
can have a great effect.
Use the Behaviourist Approach to
improve adherence
Use the Behaviourist Approach to
improve adherence
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Feedback and self monitoring the patient gets regular
reports on the state of their health so reinforcing their
adherence
Contingency contracts the patient negotiates a contract
with the health worker concerning goals and rewards for
achieving their goals
Modelling the patients sees someone else who is
successful in a support group or as a mentor etc.
Direct reinforcements or incentives like being given
money to continue on a programme or come off drugs
Punishment In New York laws were changed so that
people had to take the treatment (tuberculosis) and
come to the clinic and be seen to take it or face
compulsory admission to hospital.
Problems with Adherence and
Measuring adherence
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Operationalising the variables of adherence is
very difficult and different studies may do this in
different ways making it difficult to compare
studies.
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For example….
Problems with Adherence and
Measuring adherence
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Operationalising the variables of adherence is
very difficult and different studies may do this in
different ways making it difficult to compare
studies.
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For example is someone who just misses one
dose non compliant ? If they just take it at the
wrong time of day is that non compliance? If
they take the wrong amount how much becomes
non compliant – it will surely depend on the
disease and on the medication.
of measuring adherence – for
example: the best way would be to use
scientific methods like blood tests but this
is unethical. It is also unethical to observe
people in their homes.
 Ethics
Social desirability bias and demand
characteristics
 For
example: 286 patients were asked
about compliance with a questionnaire
whilst at the same time electronically
monitoring their medication.
 21% admitted to missing a dose in the
questionnaire but the electronic monitoring
showed the true figure to be nearer 42%
Advantages of measuring and
improving adherence
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Usefulness is a really
important evaluating point for
this section as obviously there
are huge costs involved not
only actual cost in terms of
wasted medication but huge
costs in terms of poor health
and increased hospital
admissions: for example it has
been estimated that up to 70%
of hospital admissions could
be prevented if patients had
been more adherent to
previous health requests.
Scientific nature of some tests
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Blood and urine tests
are highly reliable as
they are scientific –
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Mechanical tracking
devices like the track
cap are also more
reliable then the self
report method.
Blood Tests
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Blood tests maybe highly
unethical and also
expensive to administer.
You also would not be
able to tell how often or
how regularly the
medicine had been taken
as they may just have
taken the medication
before the blood tests!
Cost benefits
 Society
has to weight up the costs and
benefits of actions against non adherence.
Some such as expensive pill counting
measures, producing funhalers or blood
tests may simply be too costly but others
such as making sure written information is
given to each patient would actually be
cost effective in the long run.
Reductionism
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It is important not to be reductionist when
considering adherence (that is not to consider
the bigger picture). For example it is reductionist
to assume that non adherence is as simple as
making a rational choice. The reason for
adherence may be a complex interaction
between past positive or negatives experiences
(behaviourism) and early trauma
(psychodynamic) combined with biological side
effects which may be very individual to one
particular person.
Individual v situational
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The situational hypothesis would predict that
adherence will differ in the same individual
depending on the situation they are in:
 For example….
Individual v situational
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The situational hypothesis would predict that
adherence will differ in the same individual
depending on the situation they are in:
 For example when at home or on holiday it may
be easy to take medication by leaving it in an
obvious place that is noticed but this maybe
more difficult if the person is at work.
Exam questions – 10
markers
January 2010
Describe
one way to measure non-adherence to
medical advice. (10) HWK
January
2012
Explain why people may not adhere to medical
regimes. (10) (Rational Choice Theory – Completed)
June 2013
How could adherence to medical regimes be
improved? (10) TIMED CWK
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Group task
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In pairs, answer the following questions
 Please title your work ‘group classwork’: adherence to medical regimes
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1. Discuss the difficulties of researching adherence to medical regimes. (15)
DON’T FORGET TO ALWAYS BACK UP YOUR POINTS WITH EVIDENCE AND
TRY TO ENSURE BALANCE IN YOUR ANSWER
 SOME POINTS TO CONSIDER:
Research could impact professions
Defensiveness from individuals
Sensitive nature of the topic
Ethics
Demand characteristics
Social desirability
The methods themselves
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Exam questions – 15
markers
 January 2010
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Assess the reliability of research into non-adherence to medical
advice. (15)
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January 2012
Discuss the difficulties of researching adherence to medical
regimes. (15) – GROUP TASK
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June 2013
Discuss the usefulness of research into adherence to medical
regimes. (15) - HWK