Kohlenberg: Adherence

Question 1

Approximately what percent of patients do not take medications as prescribed?

Answer 1

50%

Question 2

Increasing (blank) may have a greater effect on health than improvements in specific medical therapy

Answer 2

adherence

Question 3

T/F: Medication-taking behavior is complex and involves patient, physician, and process components

Answer 3

True

Question 4

What are some solutions to reducing nonadherence?

Answer 4

encourage a blame free environment
opt for less frequent dosing
improve patient education
assess health literacy
pay attention to rational nonadherence

Question 5

In what types of drug regimens might you see greater rates of adherence?

Answer 5

single drug
lower dose
RAAS drugs
Ca++ channel blockers

Question 6

In what types of drug regimens might you see the worst adherence rates?

Answer 6

diuretics
beta blockers
dietary changes (Na+ reduction)

Question 7

What is the adherence rate for statins and antihypertensives?

Answer 7

less than 50%

**50-80% nonadherent

Question 8

How is primary adherence measured?

Answer 8

by filling prescriptions

**58% do not fill initial statin Rx

Question 9

The most important cause of failure to achieve BP contron

Answer 9

adherence to meds

**according the WHO

Question 10

Within 6 months to 1 year after being prescribed statins, (blank)% of patients discontinue them.
At 2 years, (blank)% of patients discontinue them.

Answer 10

25-50; 75%

Question 11

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.

Answer 11

compliance

Question 12

More of a collaborative model, with health care providers having some responsibility in creating the treatment contract

Answer 12

Adherence

Question 13

What are some patient related factors that lead to poor adherence?

Answer 13

lack of understanding, involvement, or poor medical literacy
health beliefs
costs, transportation, support (a big problem with mood disorders and CVD)

Question 14

How does age factor in to adherence?

Answer 14

older pts are less adherent?

**20% over the age of 65 in Medicaid programs are adherent to antihypertensive medications.

Question 15

(blank) is the greatest risk factor associated with increased incidence of HF in the elderly.

Answer 15

medication nonadherence

Question 16

Which gender is less adherent when prescribed antihypertensives?

Answer 16

women are more nonadherent

Question 17

What are some physician related factors that lead to nonadherence?

Answer 17

physicians fail to recognize it, esp in high functioning patients
overly complex drug regimens
ineffective communication

Question 18

What are some health system factors that contribute to nonadherence?

Answer 18

costs
lack of time
fragmented systems
poor coordination

Question 19

How to improve patient related factors to nonadherence?

Answer 19

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)

Question 20

T/F: Adherence is improved when a good relationship exists between patient and doctor.

Answer 20

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

Question 21

How should you ask a patient about their current medication regimen?

Answer 21

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?

Question 22

Ways in which you can reduce complexity for the patient

Answer 22

limit pharmacy visits
adhere to formulary, respect economic realities
less frequent dosing

**increases number of pills per day can decrease adherence

Question 23

In what ways can the health system help improve adherence?

Answer 23

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)

Question 24

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?

Answer 24

this improved adherence by 7%

…but did not improve clinical targets (BP and LDL levels)

Question 25

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?

Answer 25

improved adherence 48%, but did not improve long term cardiovascular events

Question 26

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?

Answer 26

no difference between programs!

Question 27

What was the result of the study that compared rates of nonpersistence and nonadherence among different racial groups?

Answer 27

nonwhites were more likely to exhibit early nonpersistent and nonadherence

Question 28

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)?

Answer 28

positive affect is more effective than PE!!

**1 in every 16 will benefit

Question 29

What percentage of sudden cardiac deaths can be attributed to unhealthy lifestyle practices?

Answer 29

79% !!!

**not smoking, good diet, regular exercise, healthy weight

Question 30

(blank) is the most important factor in determining adherence to treatment

Answer 30

communication

Question 31

T/F: Less time spent with the patient discussing meds is a strong predictor of lower adherence

Answer 31

True

Question 32

What are some ways you can be sure to get nonadherence?

Answer 32

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.

Question 33

Describe the spirit of MI

Answer 33

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

Question 34

What is the underlying spirit of MI?

Answer 34

partnership
evocation
acceptance
compassion

Question 35

What are some underlying MI values?

Answer 35

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

Question 36

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

Answer 36

Yep!

Question 37

Four general techniques for MI?

Answer 37

express empathy
develop discrepancy
roll with resistance
support self-efficacy (build hope and confidence)