Kohlenberg: Adherence Flashcards
Approximately what percent of patients do not take medications as prescribed?
50%
Increasing (blank) may have a greater effect on health than improvements in specific medical therapy
adherence
T/F: Medication-taking behavior is complex and involves patient, physician, and process components
True
What are some solutions to reducing nonadherence?
encourage a blame free environment opt for less frequent dosing improve patient education assess health literacy pay attention to rational nonadherence
In what types of drug regimens might you see greater rates of adherence?
single drug
lower dose
RAAS drugs
Ca++ channel blockers
In what types of drug regimens might you see the worst adherence rates?
diuretics
beta blockers
dietary changes (Na+ reduction)
What is the adherence rate for statins and antihypertensives?
less than 50%
**50-80% nonadherent
How is primary adherence measured?
by filling prescriptions
**58% do not fill initial statin Rx
The most important cause of failure to achieve BP contron
adherence to meds
**according the WHO
Within 6 months to 1 year after being prescribed statins, (blank)% of patients discontinue them.
At 2 years, (blank)% of patients discontinue them.
25-50; 75%
Implies that the patient passively follows the doctor’s orders and that the treatment plan is not based on a therapeutic alliance or contract established between patient and physician.
compliance
More of a collaborative model, with health care providers having some responsibility in creating the treatment contract
Adherence
What are some patient related factors that lead to poor adherence?
lack of understanding, involvement, or poor medical literacy
health beliefs
costs, transportation, support (a big problem with mood disorders and CVD)
How does age factor in to adherence?
older pts are less adherent?
**20% over the age of 65 in Medicaid programs are adherent to antihypertensive medications.
(blank) is the greatest risk factor associated with increased incidence of HF in the elderly.
medication nonadherence
Which gender is less adherent when prescribed antihypertensives?
women are more nonadherent
What are some physician related factors that lead to nonadherence?
physicians fail to recognize it, esp in high functioning patients
overly complex drug regimens
ineffective communication
What are some health system factors that contribute to nonadherence?
costs
lack of time
fragmented systems
poor coordination
How to improve patient related factors to nonadherence?
patients only recall ~50% of what is said, so be flexible
empower the patient with MI
avoid prescribing numerous meds or behavioral changes at any one visit
determine if the patient is health literate (do they know how to take it, do they know what it’s for, etc…)
create a shame free environment (different language pamphlets, recognize mental illness, recognize economic status)
T/F: Adherence is improved when a good relationship exists between patient and doctor.
True
**There are worse adherence rates if the patient doesn’t feel that the communication b/w patient and doctor is patient centered and they have trust
How should you ask a patient about their current medication regimen?
don’t just ask what meds they are currently taking! dive deeper!
**how often do you miss taking your meds?
lots prescribed to you, which ones are you taking?
have you had to stop any for any reason?
how often do you forget to take medication X?
Ways in which you can reduce complexity for the patient
limit pharmacy visits
adhere to formulary, respect economic realities
less frequent dosing
**increases number of pills per day can decrease adherence
In what ways can the health system help improve adherence?
phone reminders start long term meds during a hospitilization, not after d/c medical reconciliation (long list of all meds with name, dose, frequency, route, etc)
In the study which tracked 4 cardioprotective meds, statins, and ACE inhibitors, after implementing reconciliation, patient education, collaborative care, and 2 types of voice reminders, what was the outcome?
this improved adherence by 7%
…but did not improve clinical targets (BP and LDL levels)
In another study which looked at adherence rates and improvement of cardio events after counting pills, family encouragement and education support, what was the outcome?
improved adherence 48%, but did not improve long term cardiovascular events
What was the result of the study that compared nurse and dietician led educational programs for risk factor management after ACS to treatment as usual?
no difference between programs!
What was the result of the study that compared rates of nonpersistence and nonadherence among different racial groups?
nonwhites were more likely to exhibit early nonpersistent and nonadherence
Which was determined to be more beneficial to adherence, patient education or positive affect (self affirmation, positive feelings, unexpected gifts, positive feelings, focus on proud moments in life)?
positive affect is more effective than PE!!
**1 in every 16 will benefit
What percentage of sudden cardiac deaths can be attributed to unhealthy lifestyle practices?
79% !!!
**not smoking, good diet, regular exercise, healthy weight
(blank) is the most important factor in determining adherence to treatment
communication
T/F: Less time spent with the patient discussing meds is a strong predictor of lower adherence
True
What are some ways you can be sure to get nonadherence?
Give advice outside of the lifestyle or ability of the pt.
Use complex talk rather than pt talk.
Don’t connect their views of treatment and the problem with your views.
Tell, don’t ask.
Label pt beliefs and behavior as irrational, rather than as trying to identify the beliefs that are important to them.
Communicate that the pt is wrong, rather than find out what they think.
Describe the spirit of MI
collaboration: working together on a problem
evocation: inspiring, and drawing motivation from the person
respect: respect their choices, their resources and whether or not they change
What is the underlying spirit of MI?
partnership
evocation
acceptance
compassion
What are some underlying MI values?
Inherent worth of every person
Human potential for health and growth
Trust and respect for person’s perspective
Tendency for positive growth and the paradox of acceptance
Autonomy support for self-determination
MI supports the patient in articulating how personally important their change is, what stands in their way of making this change, changes that would actually work in their life, and how to increase their chances of success
Yep!
Four general techniques for MI?
express empathy
develop discrepancy
roll with resistance
support self-efficacy (build hope and confidence)
