Adherence

Question 1

What is concordance?

Answer 1

Process of shared decision making about treatment.

Question 2

What is compliance?

Answer 2

Old-fashioned term for adherence but implies patient should do as doctor tells them.

Question 3

What is adherence?

Answer 3

Umbrella term for initiating, correctly implementing and persisting with the full course of treatment,

Question 4

Why is non-adherence important?

Answer 4

It predicts mortality rate.

Question 5

What is the healthy adherer effect?

Answer 5

Adhering to placebo increases life expectancy.

Question 6

What burden on healthcare providers and systems does non-adherence cause? [5]

Answer 6

1. Cost of treating complications.
2. Cost of hospitalisation
3. Regimen changes
4. Cost of emergency care.
5. Increased primary care treatment seeking.

These costs outweigh any savings accrued from patients not collecting medication etc.

Question 7

What are three ways we can identify who isnt taking their medications?

Answer 7

1. Pharmacy records: examine pharmacy records to identify whether patients have collected their medications. However, patients can collect their medications and still not be adherent.
2. Questionnaires/self-reporting: easy, validated technique. Can lead to reporting biases, people who are most non-adherent may be least likely to complete time consuming report/reports don’t separate out different types of non-adherence.
3. New technologies, pills that text drs etc.

Question 8

Why don’t people take their medications? [5]

Answer 8

1. Socio-economic: education, access, cost.
2. Healthcare systems: relationships, communication skills, follow-up.
3. Condition: symptoms, mental health, chronic condition, physical/mental capability.
4. Therapy - complexity, administration, duration, benefit (perceived/actual), opinions/stigma.
5. Patient - visual/hearing/cognitive impairment, mobility/dexterity, motivation, knowledge, perception.

Question 9

What is the Perceptions and Practicalities Approach (PAPA) theory of adherence?

Answer 9

Unintentional non-adherence is due to capacity and resources.

Intentional non-adherence is due to motivational beliefs/preferences and perceptual barriers.

Question 10

What are the practical barriers to adherence? [4]

Answer 10

Cost
Distance to pharmacy
Being able to access the medication (pill caps, injections, can’t open containers).
More complex regimens.

Question 11

What is the common sense model? (Leventhal et al., 1992).

Answer 11

Illness is a threat to health and triggers a coping response including emotions and behaviours. Individuals seek to reduce symptoms and regain health.

Question 12

What are the cognitive representations of illness?

Answer 12

Cause (genetic, environmental, chance).
Control (treatment and other)
Timeline (chronic, short-term, episodic)
Identity (symptoms that form part of the illness)
Consequences (physical, expected emotions, social)

Question 13

What are some general beliefs about medicine patients may have?

Answer 13

HARM - medicines are typically dangerous.
OVERUSE - Doctors overprescribe medicines.
BENEFIT - Medicines are positive for society.
PERSONAL SENSITIVITY TO MEDICINE - I am generally vulnerable to side effects.

Question 14

What is the Necessity - Concerns Framework?

Answer 14

It is a framework which is useful for explaining low adherence.

Doubts about personal NECESSITY of medication.

CONCERNS about potential adverse effects.

Question 15

What are two things that can potentially reinforce the perception that maintenance therapy does not matter?

Answer 15

Taking doses does not make you feel better - just for maintenance. However, missing doses does not make you immediately feel worse.

This can lead to the perception that the medication isnt needed: hypertension medication etc.

Question 16

What are three steps to successful intervention design?

Answer 16

1. Have a theory of why a patient is adhering.
2. Develop intervention focused on this and existing evidence.
3. Report your intervention to help others.

Question 17

Adherence interventions can act at many levels, what are 4 things we can target?

Answer 17

1. Patients
2. Caregivers
3. HCP
4. Healthcare systems.

Question 18

What is the evidence pyramid?

Answer 18

Meta-analyses
RCTs
Cohort studies
Cross-sectional studies
Cross swries/reports/opinions.

Question 19

What are three specific intervention techniques for adherence?

Answer 19

1) Motivational Interviewing.
2) Changes to medication packaging
3) Providing information

Question 20

What changes can be made to packaging to increase adherence? [4]

Answer 20

1. Make it easier to open for patients.
2. Make it clearer which medication is to be taken when.
3. Daily pill boxes or dosette boxes etc.
4. High tech box that records number of openings/dates/times. Nurse can access this info and discuss with patient.

Question 21

How can tailored decision aids/tailoring information to each patient impact adherence?

Answer 21

Tailored decision aid included 1) 10-year estimated cardiovascular risk 2) risk reduction with statins 3) disadvantages.
98 Patients randomized to decision aid or standard information
Decision aid patients knew more, rated the aid more highly, and were slightly more adherent at 3 months follow-up.

ALSO can use text message service.

Question 22

What is the new medicines service?

Answer 22

4th Advanced service to be added to community pharmacy contract.

Specific clinical service targeting the main issues of intentional and unintentional adherence

Targeted at:
Asthma and COPD
T2 Diabetes
Antiplatelet/anticoagulant therapy
Hypertension