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Block 9 Week 2 > Kohlenberg > HTN Adherence & Behavioral Mgmt > Flashcards

Kohlenberg > HTN Adherence & Behavioral Mgmt Flashcards

1
Q

what is Dr. Kohlenberg’s main question in this lecture?

A

How do we understand impossible-to-understand behavior?

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2
Q

what % of pts do NOT take meds as prescribed?

A

50%

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3
Q

is medication adherence SOLELY the pt’s responsibility?

A

nope (somehow)

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4
Q

medication-taking behavior involves what 3 components?

A

pt
physician
process

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5
Q

what does identification of nonadherence require?

A

specific interviewing skills

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6
Q

what are some solutions for med non-adherence?

A 
encouraging a "blame-free" environment
less frequent dosing
improved pt education
assess health literacy
pay attn to rational nonadherence
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7
Q

what 2 meds have adherence rates BELOW 50%?

A

statins & anti-HTN

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8
Q

what is primary adherence?

A

measured by filling prescriptions (i.e. does the pt take the 1st step)

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9
Q

what % of pts do not fill their initial statin RX?

A

58%

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10
Q

T/F: if meds are free, adherence is over 70%

A

FALSE

still under 50%!

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11
Q

what is the most important cause of failure to achieve BP control?

A

lack of adherence

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12
Q

how much does anti-HTN therapy reduce the risk of stroke & MI?

A

stroke: 30%
MI: 15%

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13
Q

what % of pts being treated for HTN are nonadherent?

A

50-80%

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14
Q

how long does it take 25-50% of pts to discontinue statins?

A

within 6 months to a year

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15
Q

at 2 years, how many pts prescribed statins have discontinued them?

A

75%

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16
Q

what does the word “compliance” imply?

A

that the pt passively follow’s dr’s orders
AND
that treatment plan is NOT based on an alliance or contract btwn pt & dr

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17
Q

what is adherence?

A

a collaborative model in which healthcare providers have some responsibility in creating a treatment contract w/ a pt

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18
Q

what are the pt-related factors that cause poor med adherence?

A

lack of understanding/involvement/literacy
health beliefs
costs, transportation, support

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19
Q

what diseases have a big obstacle in family support & adherence to meds?

A

mood disorders & CVD

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20
Q

what % of 65+ yo in Medicaid programs are adherent to anti-HTN meds?

A

20%

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21
Q

what is the greatest risk factor assoc w/ increased incidence of heart failure in the elderly?

A

medication nonadherence

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22
Q

what gender is MORE NONadherent w/ anti-HTN meds? (less adherent)

A

women

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23
Q

T/F: drs always recognize nonadherence

A

false

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24
Q

when are dr estimates of nonadherence WORSE?

A

if the pt is high-fxning

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25
Q

what are physician-related factors assoc w/ nonadherence?

A

overly complex drug regimens
ineffective communication
communication among physicians

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26
Q

T/F: discharge summaries are always available at all post discharge visits

A

false

only in less than 34%

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27
Q

what are the health system factors that cause poor pt adherence?

A

costs
lack of time
fragmented systems
poor coordination

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28
Q

what are the pt-related factors that can improve medication adherence?

A

flexible education
pt empowerment
avoid numerous meds & behavioral mods at any one visit

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29
Q

what can you do to increase pt empowerment?

A

MI
“what time of day would you like to take your meds?”
“how quickly do you want to gain control of your BP?”

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30
Q

what can a doctor do if a pt is health illiterate?

A

tune into it (& economic status)
create a shame-free env
have materials in native languages
recognize mental illness

31
Q

what % of adults have proficient health literacy?

A

12%! that’s it!

32
Q

what % of adults have basic or below basic health literacy?

A

35%

33
Q

T/F: adherence is improved when a good relationship exists btwn pt & dr

A

TRUE

34
Q

how does patient-centered communication & trust w/ a clinician affect nonadherence?

A

if a pt feels like it’s a bad relationship, 7-16% WORSE nonadherence rates to med refills

35
Q

T/F: “what meds are you on” is a sufficient convo about adherence

A

FALSE

you gotta go in depth

36
Q

what is the key to adherence?

A

reduce complexity!

37
Q

how can you reduce complexity?

A

limit pharmacy visits
adhere to formulary
respect economic realities
try to decrease # of pills/day

38
Q

what 2 things can you try to reduce to INCREASE adherence?

A 
# of pills/day
frequency of dosing
39
Q

T/F: starting long-term meds during a hospitalization for an acute event may DECREASE adherence

A

FALSE
it may improve adherence
(as opposed to prescribing at discharge)

40
Q

How can you use non-physician staff to help w/ pt adherence?

A

team based approach

phone reminders

41
Q

what is a health system factor you can use to help w/ med adherence?

A

medication reconciliation

42
Q

what is medication reconciliation?

A

take a list of all meds & all details (dose, route, etc) & compare it w/ transfer/discharge orders

43
Q

what is an example of a primary adherence intervention?

A

automatic messaging to pt if the RX was not filled

44
Q

what was the result of the “After ACS Hospital Discharge” study?

A

improved adherence by 7% but did NOT improve clinical targets

45
Q

what 6 things contribute to essential HTN?

A 
obesity
stress
lack of exercise
diet (XS salt)
alcohol intake
smoking
46
Q

in the “super-sedentary epidemic” paper, what was the mean duration of moderate physical activity?

A

less than 1 minute/day

NO time spent in vigorous physical activity

47
Q

what is the difference btwn nurse & dietician led programs for risk factor management after ACS?

A

none

48
Q

what is early nonpersistence?

A

filling a script but not refilling it w/i 90 days

49
Q

what is nonadherence?

A

not having meds available for 20% or more days during a 12 month pd following therapy initiation

50
Q

what % of pts (in the “racially & ethnically diverse” group) were nonpersistent & nonadherent?

A

30%+ nonpersistent

20% nonadherent (1 in 5 pts)

51
Q

are there racial/ethnic diffs in treatment?

A

yes, early on

52
Q

what closes the gap btwn racial groups?

A

reduced copay
ease of access to meds
optimize choice for initial therapies

53
Q

what racial group is MORE likely to exhibit early nonpersistence & nonadherence?

A

nonwhites

54
Q

what group is disproportionally affected by HTN?

A

african americans

55
Q

why do african americans w/ HTN have poor BP control?

A

poor med adherence

56
Q

is pt education or positive affect a more effective intervention w/ adherence?

A

positive affect!
42% vs 36%
1 in 16 pts will benefit

57
Q

what accounts for more than 50% of cardiac deaths in women?

A

sudden cardiac death (SCD)

58
Q

what is the first manifestation of heart disease among women?

A

most SCD events

59
Q

what is primary prevention in high-risk SCD events?

A

cardioverter-defibrillators

60
Q

what are independent risk factors for SCD?

A

smoking, obesity, physical inactivity

61
Q

what can increase the risk of SCD?

A

low n-3 fatty acid intake
alcohol abstinence
heavy alcohol intake

62
Q

what things are assoc w/ lower risk of CHD, stroke, diabetes, cancer, HTN, chronic disease, CVSD, & total mortality?

A

not smoking
good diet
regular exercise
healthy weight

63
Q

specifically, what puts you at low risk of SCD?

A

not smoking
BMI less than 25
exercise 30+ min/day
mediterranean diet

64
Q

what % of SCD can be attributed to unhealthy lifestyle practices?

A

79%

65
Q

what is the key to motivational interviewing?

A

respectful communication

66
Q

what is the most important factor in determining adherence to treatment?

A

communication

67
Q

T/F: less time spent w/ pt discussing meds is a strong predictor of higher adherence

A

FALSE

lower adherence

68
Q

how can you drive your pt to be NONadherent?

A

use complex talk rather than pt talk
tell, don’t ask
communicate that your pt is wrong rather than learning what they think

69
Q

what is the philosophy behind motivational interviewing?

A

ppl are generally persuaded better by reasons they discover THEMSELVES

70
Q

what things make up the spirit of MI?

A

collaboration/partnership
evocation
respect/acceptance
compassion

71
Q

what are the underlying MI values?

A 
inherent worth
potential for growth
trust & respect
positive growth & paradox of acceptance
autonomy
72
Q

what should your PT be able to articulate w/ MI?

A

how imp this change is to THEM
obstacles to change
change that might work
how to increase chance of success

73
Q

what are the 4 general techniques of MI?

A

express empathy
develop discrepancy
roll w/ resistance
support self-efficacy

Block 9 Week 2 (5 decks)

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