adherence to treatment Flashcards
why wont people adhere *
se
cost
people stop dm treatment to prevent weight gain
time
lack of percieved use
disagree with treatment
forget
too much effort
easier to not comply
what do we mean by treatment
med
lifestyle interventions
compliance def *
“the action or fact of applying with a wish or command”
refers to the extent to which patients follow doctors’ prescription about medicine taking
why is compliance less used
implies level of pt lack of involvement - paternalistic
adherence *
refers to the extent to which patients follow through decisions about medicine taking
“attachment or commitment to a person, cause, or belief”
bring in pt involvent
concordance *
refers to the extent to which patients are successfully supported both in decision making partnerships about medicines and in their medicines taking.”
aspirational term - adherence and compliance need to be used to see whether people are taking their drugs
problem with chronic condition *
longer and more complicated condition becomes makes compliance harder
measuring non-adhereance *
non-adherence is taking <80% - can be taking more
there is no gold standard for measuring adherence - different studies define different ways to do it
Macintyre et al. (2005) found limited concordance in health professionals’ judgement of patient adherence
depends whether you look at pharmacy report, self-report, whether pick up prescription or whether you pick up the medication itself
what is the WHO definition of adherence *
“the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider”
this places emphasis on the need to differentiate adherence from compliance
describe the spectrum of adherence *
might adhere in some ways and not others
can be under adherence - take meds <80%
overadherence - people can take more medicine than you recommend
what are methods for measuring adherence *
direct methods
- directly observed therapy
- measurement of med in blood
- measurement of biological marker in blood
indirect methods
- pt qn
- pt self-report
- pill counts
- rate of prescription refils
- electronic med monitors
- pt diaries
pros and cons of measuring bio marker *
pros - cant lie
cons - reduces trust between dr and pt, cost
what is the scale of non-adherence
in developed countries - 50%
this is significant
impact and consquences of non-adherence *
poor health outcomes
increased healthcare cost
viswanathan et al - 2012 - estimated that lack of adherence in USA = causes 125000deaths a yr, causes 10% of all hospital admissions, costs healthcare system $100-289billion/yr
old theories for non-adherence *
early theories were based on non-adherence being due to poor communication and the impact of this on pt understanding and memory
therefore interventions were focussed on healthcare professional communication, information provision and reminders
new theories of non-adherance *
appreciation that provision of information alone is not enough to change behaviour - although it is essential
unintentional non-adherence - patient ability and resources leading to practcial patient barriers to adherence - cognitive, financial, practical reason why person couldnt adhere
intentional non-adherence - patient beliefs and motivations lead to patient perceptual barriers adherence - dont understand treatment/worried about SE/personal beliefs
there is overlap between them - eg heath beliefs will influence unintentional non-adherence ie if you believe that treatment is not useful - then more likely to forget
you need to understand the causes of non-adherence in order to recommend effective intervention
describe COM-B *
choose the intervention that is most likely to be effective
the performance of a behaviour is caused by interaction between capability, opportunity, motivation - explain why recommended behaviour isnt engaged
example of application of COM-B *
jackson et al - considered how COM-B could be applied to the wide range of factors that have been used to describe medicine non-adherence
make clear explanatory framework for non-adherence
identify techiques to imporve adherence
bidirectional relationship between the factors
capability in COM-B *
the individuals physical and psychological capacity to engage in the behabuior
physiological - capacity to engage in necessary thought processes- comprehension of disease and treatment, cognitive functioning, (eg memory, capcity, thinking), executive function (eg capacity to plan)
physical - capacity to engage in necessary physical properties - physical capability to adapt to lifestyle changes (eg diet or social behaviours), dexterity
motivation in COM-B *
all brain processes that energise and direct behaviour
reflective - evaluation and plans - preception of illness (eg acute, chronic, cause) beliefs about treatment (eg necessity, efficacy, concers about adverse events, general aversuion to taking med), outcome expectancies, self-efficacy
automatic - emotions and impulses arising from associative learning and/or innate dispositions - stimuli/cues for action, mood state/disorder eg depression and anxiety
opportunity - COM-B *
all factors lying outside the individual that make performance of the behaviour possible or prompt it
physical - physical opportunity provided by the environment - cost, access (availaibilty of med), packaging, physical characteristics of the medicine (taste, size, smell, shape, route of admin), regimine complexity, social support, HCP patient relationship/communication
social - cultural mileu that dictates the way we think about things - stigma of disease, fear of disclosure, religious/cultural beliefs
illness beliefs in Leventhal’s self regulation model *
- identity - what do i call my illness
- consequences
- cause
- timeline - trajectory it will take and whether it is acute/chronic/cyclical
- control/cure
relationship of illness peception and adherence *
causal beliefs predict adherence behaviour in post MI - weinman
timeline beliefs predict preventer medication adherence in asthma - horne
causal timeline and control beliefs predict adherence tp CBT in psychosis - freeman
however - illness beliefs are not the strongest predictors of treatment adherence and other more proximal factuirs ie pt beliefs about treatment need to be considered - if you dont think the treatment will work, or yuou are worried about the SE - unlikely to take the medication
beliefs about medication that influence adherence *
necessity - belefs about necessity of prescribed medication for maintaining health
concerns - arising from beliefs of potential SE
feed the specific beliefs - views about a prescribed med
fundamental things about pt beliefs about treatment and illness *
influence adherence
have internal logic
are influenced by symptoms - people only take medication to relieve their symptoms
may differ from the medical view - belief in herbal medicine
may be on mistaken beliefs - eg fropm friend, vaccines and autism, stop taking a course of AB
may not be disclosed in the consultation
are not set in stone and can be changed
significance of improving patient adherence *
improves pt safety
single most important modifyable factor that modifies treatment outcome
“increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments”
(Haynes, 2001)
difficulty with adherence *
Nonadherence is often a hidden problem: undisclosed by patients and unrecognised by prescribers”
(Horne et al., 2005)
how can we imporve adherence *
improve understanding of illness and treatment
help pts to plan and organise their treatment
use the consultation to fascilitae informed adherence - check the pts understanding of treatment and if necessary - provide rationale for necessity of treatment, ellict and adress concers, agree a practical plan for how, when and where to take treatment, identify any possible barriers
improving adherence - Petrie - text *
a text message programe designed to modify pts illness and treatment beliefs - improves self reported adherence to asthma preventer medication
pts selected who didnt take inhaler as prescribed - baseline assessment was completed to understand reason for non-adherence
given either normal care e of tailored text messages for 18weeks
then had adherence assessments
in comparision to the control group, the intervention group improved their percieved necessity of med, belief in long term nature of asthma, percieved contol over asthma
therefore improved adherence
improving adherence - O’carrol 2013 - stroke *
in previous study after 1 year 4 thing slimited adherence - younger age, concerns about medication, reduced percieved benefit, cognitive func - 6 weeks later cognitive fuinction didnt influence adherence
randomised control trial
intervention - 2 sessions aimed at increasing adherence via introducing a plan linked to environmetal cues (implementation intentions) to help establish a better medication-taking routine
eliciting and modifying any mistaken pt belied regarding medication/stroke
primary outcome was adherence to antihypertensive med using an electronic pill bottle
increased adherence on people with the intervention
A simple, brief intervention increased medication adherence in stroke survivors, over and above any effect of increased patient contact or mere measurement”
