Transcript What is Poor Adherence?

Jacqueline Dunbar-Jacob, PhD, RN, FAAN
Dean, School of Nursing
University of Pittsburgh School of Nursing
Center for Research in Chronic Disorders
“On Several Occasions
I Have Been With My Brother Herodicus
Or Some Other Physician
To See One of His Patients,
Who Would Not Allow The Physician
To Give Him Medicine,
Or Apply the Knife or Hot Iron To Him”
- Plato (427? - 347 B. C.)
What is Poor Adherence?

Deviation from Optimal Prescription
Extent of the Problem
50% of Patients Fail to Adhere

To Pharmacotherapy

To Diet

To Exercise Programs
Clinical Impact of Poor Compliance

Decline in health status

Increase in disease complications

Relapse

Unnecessary hospitalizations

Loss of transplanted organs

Development of disease resistant organisms

Death
Impact of Poor Compliance on Research

Lack of Study Power

Increased Sample Size Needs

Overestimate of Safety

Underestimate of Risks, Adverse Effects

Underestimate of Effectiveness

Increased Cost
Costs of Non-Compliance
$ BILLIONS
Hospital Admissions
25
Lost Productivity
50+
Nursing Home Admissions
5
Premature Deaths
??
Treatment Costs In Ambulatory Patients ??
TOTAL COSTS
100+
Emerging Issues In Pharmaceutical Cost Containment 6/92
Why Do Patients
Fail to Adhere Effectively?
Why Prescriptions Are Not Filled
Upjohn Survey
21%
Thought
22%
medication
Concerned about
Would Not Help
Side Effects
20%
Condition
Improved
14%
Cost
AARP Survey
5%
Not Available in Store
10.5%
Cost
10.5%
Other
21.7%
Did Not
Want to Take
51%
Did not need the
medication
2.8%
Lost or
Forgot It
Task Force on Compliance (1994). Noncompliance with medications.
Reproduced by permission of the Task Force for Compliance via the
Copyright Clearance Center, Inc.
Cognitions/Beliefs

Readiness (TTM)

Beliefs about Disorders and Treatments (CSM)
Reasons for Poor Adherence
Patient Perspective
 Forgetting
 Symptom Management
 Thought Medication
Wouldn’t Help
 Schedule Disruptions
 Did Not Need Medication
 Adequacy or Completeness
 Did Not Want to Take It
of Instructions
 Multiple or Complex Regimens
 Concerned About Side Effects
 Condition Improved
 Lost Medication
 Cost
 Not Available In Stores
Relationship of Regularity of Routine and
Medication AdherenceACT
(Days Compliant):
Once a Day Medication Taken At Bedtime
Regularity of Bedtime Hours
x2 = 3.866
d = 2
p = .145
Regularity of Bedtime Routine
x2 = 5.996
d = 2
p = .050
Most of These Reasons Have Been
Identified by Self-Report with
Adherence Also Evaluated
by Self-Report
What Does Poor Adherence Look Like?
Once a Day Dosing Prescription
3 Extra Doses
12 pm
10 pm
8 pm
6 pm
4 pm
2 pm
Noon
10 am
8 am x x x x x x x x x x
4 am
 Missed Doses
x
x
x
x
x
x
x
x
x
x
x
    
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
16 17 18 19 20
Days of Observation
21 22 23
Twice a Day Dosing Prescription
5am
6am
7am
8am
9am
x
10am
11am
12N
1pm x
2pm
3pm
4pm
5pm
6pm
7pm
x
8pm
9pm
10pm
x
11pm
x
12M x
x
1am
2am
3 Extra Doses
 Missed Doses
x
x
x
x
x
x
x x
x
x
x
x
x
x
x
x x x
x
x x
x x
x
x
x
x x x
x
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64
Days of Observation
Three Times a Day Dosing Prescription
5am
6am
7am
x
8am
x x
x x
9am
x
10am
x
x
11am
x
12N
1pm
2pm
3pm
4pm
5pm
x x x x
6pm
x
7pm
8pm
9pm
x
x
10pm x
11pm
x
12M
x x x
x x
1am
x
2am
3 Extra
x Doses
x
 Missed Doses
x
x
x x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x x x
x
x
x
x
x
91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114
Days of Observation
x
Adherence Rates
Medication Exercise
Diet
Smoking
Smokers Relapse
1970’s
50%
50%
50%
34.4%
70-80%
2000’s
50%
50%
50%
22.7%
70-80%
Adherence Refers to Multiple
Behavioral Errors
Types of Behavioral “Errors”
Failure to Adopt the Regimen
 Early Stoppage of Treatment
 Reduction in Levels of treatment
 Over Treatment
 Variability in the Conduct of Treatment
 Dosage Interval Errors
 Performance Errors

How Much of a Behavioral Deviation or
Error Constitutes Poor Adherence?

Standard in the Field

Loss of Therapeutic Effectiveness
Is This Likely to be Influenced By
Measurement Method?
Relationship of Adherence to Cholesterol Change
Adherence
EEM1
EEM2
7-Day EEM1
7-Day EEM2
Pill Count
7-Day Recall1
7-Day Recall2
# pills
2 #pills in correct dosing interval
1
% D Total
Cholesterol
.26
.18
.34
.26
.12
.20
.00
p-value
.043
NS
.009
.050
NS
NS
NS
Correlation (rs) Between Days Adherent
and Clinical Outcomes
Diary
Pain
FSI
MPI
Diary
Difficulty
FSI
Assistance
FSI
Symptom Rating Diary
*p < .05 (two-tailed)
EEM
-.091
.151
-.104
.265*
.120
-.108
-.091
.172
-.029
-.111
.108
.017
RAC-1
MEMs Cap and Monitor
ADHERENCE
MEMs ELECTRONIC
MEDICATION CAP
Thus, Poor Adherence Refers to
Multiple Behavioral Errors at Varying
Levels Occurring in Varying Patterns
Due to Varying Reasons
Most of the Adherence Research
Treated Poor Adherence as a Single
Behavior with a Stable Pattern That is
Primarily Due to a Motivational Deficit