Kohlenberg > HTN Adherence & Behavioral Mgmt Flashcards
what is Dr. Kohlenberg’s main question in this lecture?
How do we understand impossible-to-understand behavior?
what % of pts do NOT take meds as prescribed?
50%
is medication adherence SOLELY the pt’s responsibility?
nope (somehow)
medication-taking behavior involves what 3 components?
pt
physician
process
what does identification of nonadherence require?
specific interviewing skills
what are some solutions for med non-adherence?
encouraging a "blame-free" environment less frequent dosing improved pt education assess health literacy pay attn to rational nonadherence
what 2 meds have adherence rates BELOW 50%?
statins & anti-HTN
what is primary adherence?
measured by filling prescriptions (i.e. does the pt take the 1st step)
what % of pts do not fill their initial statin RX?
58%
T/F: if meds are free, adherence is over 70%
FALSE
still under 50%!
what is the most important cause of failure to achieve BP control?
lack of adherence
how much does anti-HTN therapy reduce the risk of stroke & MI?
stroke: 30%
MI: 15%
what % of pts being treated for HTN are nonadherent?
50-80%
how long does it take 25-50% of pts to discontinue statins?
within 6 months to a year
at 2 years, how many pts prescribed statins have discontinued them?
75%
what does the word “compliance” imply?
that the pt passively follow’s dr’s orders
AND
that treatment plan is NOT based on an alliance or contract btwn pt & dr
what is adherence?
a collaborative model in which healthcare providers have some responsibility in creating a treatment contract w/ a pt
what are the pt-related factors that cause poor med adherence?
lack of understanding/involvement/literacy
health beliefs
costs, transportation, support
what diseases have a big obstacle in family support & adherence to meds?
mood disorders & CVD
what % of 65+ yo in Medicaid programs are adherent to anti-HTN meds?
20%
what is the greatest risk factor assoc w/ increased incidence of heart failure in the elderly?
medication nonadherence
what gender is MORE NONadherent w/ anti-HTN meds? (less adherent)
women
T/F: drs always recognize nonadherence
false
when are dr estimates of nonadherence WORSE?
if the pt is high-fxning
what are physician-related factors assoc w/ nonadherence?
overly complex drug regimens
ineffective communication
communication among physicians
T/F: discharge summaries are always available at all post discharge visits
false
only in less than 34%
what are the health system factors that cause poor pt adherence?
costs
lack of time
fragmented systems
poor coordination
what are the pt-related factors that can improve medication adherence?
flexible education
pt empowerment
avoid numerous meds & behavioral mods at any one visit
what can you do to increase pt empowerment?
MI
“what time of day would you like to take your meds?”
“how quickly do you want to gain control of your BP?”
what can a doctor do if a pt is health illiterate?
tune into it (& economic status)
create a shame-free env
have materials in native languages
recognize mental illness
what % of adults have proficient health literacy?
12%! that’s it!
what % of adults have basic or below basic health literacy?
35%
T/F: adherence is improved when a good relationship exists btwn pt & dr
TRUE
how does patient-centered communication & trust w/ a clinician affect nonadherence?
if a pt feels like it’s a bad relationship, 7-16% WORSE nonadherence rates to med refills
T/F: “what meds are you on” is a sufficient convo about adherence
FALSE
you gotta go in depth
what is the key to adherence?
reduce complexity!
how can you reduce complexity?
limit pharmacy visits
adhere to formulary
respect economic realities
try to decrease # of pills/day
what 2 things can you try to reduce to INCREASE adherence?
# of pills/day frequency of dosing
T/F: starting long-term meds during a hospitalization for an acute event may DECREASE adherence
FALSE
it may improve adherence
(as opposed to prescribing at discharge)
How can you use non-physician staff to help w/ pt adherence?
team based approach
phone reminders
what is a health system factor you can use to help w/ med adherence?
medication reconciliation
what is medication reconciliation?
take a list of all meds & all details (dose, route, etc) & compare it w/ transfer/discharge orders
what is an example of a primary adherence intervention?
automatic messaging to pt if the RX was not filled
what was the result of the “After ACS Hospital Discharge” study?
improved adherence by 7% but did NOT improve clinical targets
what 6 things contribute to essential HTN?
obesity stress lack of exercise diet (XS salt) alcohol intake smoking
in the “super-sedentary epidemic” paper, what was the mean duration of moderate physical activity?
less than 1 minute/day
NO time spent in vigorous physical activity
what is the difference btwn nurse & dietician led programs for risk factor management after ACS?
none
what is early nonpersistence?
filling a script but not refilling it w/i 90 days
what is nonadherence?
not having meds available for 20% or more days during a 12 month pd following therapy initiation
what % of pts (in the “racially & ethnically diverse” group) were nonpersistent & nonadherent?
30%+ nonpersistent
20% nonadherent (1 in 5 pts)
are there racial/ethnic diffs in treatment?
yes, early on
what closes the gap btwn racial groups?
reduced copay
ease of access to meds
optimize choice for initial therapies
what racial group is MORE likely to exhibit early nonpersistence & nonadherence?
nonwhites
what group is disproportionally affected by HTN?
african americans
why do african americans w/ HTN have poor BP control?
poor med adherence
is pt education or positive affect a more effective intervention w/ adherence?
positive affect!
42% vs 36%
1 in 16 pts will benefit
what accounts for more than 50% of cardiac deaths in women?
sudden cardiac death (SCD)
what is the first manifestation of heart disease among women?
most SCD events
what is primary prevention in high-risk SCD events?
cardioverter-defibrillators
what are independent risk factors for SCD?
smoking, obesity, physical inactivity
what can increase the risk of SCD?
low n-3 fatty acid intake
alcohol abstinence
heavy alcohol intake
what things are assoc w/ lower risk of CHD, stroke, diabetes, cancer, HTN, chronic disease, CVSD, & total mortality?
not smoking
good diet
regular exercise
healthy weight
specifically, what puts you at low risk of SCD?
not smoking
BMI less than 25
exercise 30+ min/day
mediterranean diet
what % of SCD can be attributed to unhealthy lifestyle practices?
79%
what is the key to motivational interviewing?
respectful communication
what is the most important factor in determining adherence to treatment?
communication
T/F: less time spent w/ pt discussing meds is a strong predictor of higher adherence
FALSE
lower adherence
how can you drive your pt to be NONadherent?
use complex talk rather than pt talk
tell, don’t ask
communicate that your pt is wrong rather than learning what they think
what is the philosophy behind motivational interviewing?
ppl are generally persuaded better by reasons they discover THEMSELVES
what things make up the spirit of MI?
collaboration/partnership
evocation
respect/acceptance
compassion
what are the underlying MI values?
inherent worth potential for growth trust & respect positive growth & paradox of acceptance autonomy
what should your PT be able to articulate w/ MI?
how imp this change is to THEM
obstacles to change
change that might work
how to increase chance of success
what are the 4 general techniques of MI?
express empathy
develop discrepancy
roll w/ resistance
support self-efficacy
