HPsyHD S3 (needs small group LOs) Flashcards
Define Compliance
The extent to which the patient complies with medical advice
Define Adherence:
The extent to which the patient behaviour coincides with medical advice
What is the semantic difference between compliance and adherence
Compliance is based on the doctor knowing best, patient must obey
Adherence is an attempt to be more patient centred, implies a need for agreement and the patient’s right to choose
What are some severe consequences of non-adherence?
Transplant patients:
91% of non-adherent experience rejection
This compared to 18% of adherent
Give examples of some conditions where adherence is particularly good or bad
Good:
HIV
Arthritis
GI disorders
Cancer
Bad:
Pulmonary disease
Diabetes
Sleep disorders
What are the two major impacts of non-adherence?
Impact on patient’s health
Financial implications
What are the direct measures of adherence?
Give advantages and disadvantages of each
Urine or blood test:
Provides most direct measure of consumption/adherence
Expensive, limited to use in clinical practice, affected by metabolism, non-adherence may be masked (taking medication before attending surgery)
Observation of consumption:
Same issues as above
What are the indirect measures of adherence?
Give advantages and diadvantages of each
Pill counts:
More objective than self report
Still subject to innaccuracy (intentional masking/lost pills etc)
Mechniscal or electronic measure of dose:
E.g. Container that records when opened
Objectively measures dose dispensing
Doesn’t measure whether medication actually taken
Self-report:
Easy, inexpensive
Prone to innaccurcy and bias (non-adherence normally 10-20% higher than reported)
Second hand reports (E.g. from carers):
Same issues as self reports
What are the factors that may contribute to non-adherence?
Illness faxtors
Treatment factors
Patient factors
Psychosocial factors
Healthcare factors
Describe 2 examples of Illness factors affecting adherence
Symptoms:
Adherence better when symptoms experienced
Severity:
With less serious disease (E.g. hypertension/arthritis) patients in poorer health are more likely to be adherent
With serious disease (Cancer/HIV/Heart failure etc) patients in poorer health are less likely to be adherent
Give 4 the 4 types of treatment factors affecting adherence
For each type, what are the factors that might lower adherence?
Preparation:
Treatment setting, waiting time, referal timing, reputation, convenience
Immediate character:
Complexity of regimen, duration, degree of behavioural change required, convenience, expense, container design
Administration:
Supervision by health care provider, continuity of care
Consequences:
Side effects (Social or physical), stigma
What are the 2 types of patient factors affecting adherence?
Understanding and recall:
Understanding of information given and their illness/treatment
Recall of information on treatment (Name, frequency, duration)
Influenced by patient knowledge, importance, number of statements etc
Beliefs:
Health belief model
Adherence relies on:
Percieved severity (symptoms, understanding)
Percieved susceptibility to disease
Benefits of treatment
Barriers to following treatment
Beliefs about medication (harmful side effects, interference with daily life, tolerance, stigma)
What is a concequence of negative patient beliefs about a medication?
May become non-adherent
May seek alternatives
May modify regimen
What are the Psychosocial factors affecting adherence?
Psychological health:
Cognitive deficits or psychological problems impact compliance (E.g. Depression has negative impact)
Social support:
Isolation = less likely to adhere
Practical socail support and family support associated with higher adherence
Social context:
Homelessness a predictor of non-adherence
Healthcare factors include the setting of treatment, how does this affect adherence?
Wether treatment is given in primary or secondary care facilities affects adherence
Regular follow ups increase adherence
High Appeal and accessibility of provider increase adherence
Beliefs and attitudes of prescriber affect adherence
Healthcare factors affecting adherence include the doctor patient relationship, how might a doctor increase adherence through this relationship?
Warm, caring and friendly manner
Eye contact, smile
Good communication
Interpersonal and technical competance (higher percieved competance associated with better adherence)
Compare unintensional to intensional non-adherence
Intentional:
Arises from beliefs, attitudes and expectations that influence patient’s motivation to begin and persist treatment
Unintentional:
Capacity and resource limitations
Individual constraints (memory, dexterity)
Environmental constraints (Access to prescriptions, competing demands)
Outline the approach, effectiveness and problems associated with reducing non-adherence
Approaches:
Address perceptual factors influenceing motivation
Address practical barriers (capacity and resources)
Effectiveness:
Broadly effective but small effect
Better in comprehensive interventions (combining approaches) than focusing on a single cause
Problems:
Many lack theoretical basis (no-one knows why some interventions work and others dont)
Few are truly patient centered
What is concordance?
Negotiation between patient and doctoe over treatment
Respecting beliefs of patient
Patient is active and can make decisions in partnership with doctor
Does not refer to patients medicine taking behaviour but the nature of interaction between clinician and patient
How does concordance affect adherence?
Concordance leads to higher adherence because:
Shared ownership over treatment decisions
Beliefs, expectations, lifestyle and priorities taken into account
Barriers to adherence can be addressed
Promotes patient trust and satisfaction with care
Outline a procedure for a clinical interacting with a patient that would maximise concordance and therfore adherance
Define/clarify the problem
Convey equipoise (give no set opinions on best practice)
Describe treatments and consequences
Provide written information
Check patient understanding
Elicit patient’s ICE about treatments, condition and outcomes
Ascertain patient’s prefered role in decision making
Defer if neccessary (give patient time to consult with family)
Review decisions later
What issues are associated with always striving for maximum concordance?
Treatment given may not be best practice
Tension between healthcare responsibilities and patient’s right to choose
