Lecture 16: Adherence Flashcards
What are the two primary reasons for non adherence?
Treatment efficacy, including ultimate or long term cost
Cost and opportunity cost of wasted medications
What is nonadherence? (Another working definition)
Patients do not adopt the behaviours and treatments that their providers recommend
What are some general observations on adherence?
Estimates vary from 15%-93%, average non adherence across domains appearing to be around 25%
Simple prescriptions can also be problematic - one estimate suggests of 750million written in a year, 520million are partially or totally un adhered to
What are some variations of adherence across domains?
Adherence varies across domains and types of health recommendation
Medication adherence is highest for HIV arthirits, GI disorders and cancer.
Medication adherence is lowest for pulmonary disorders, diabetes and sleep.
Ear infection medication 95%
Short term antibiotics 33%
Appointments for modifying preventative health behaviours 50-60%
Lifestyle change programmes 80% drop out
Cardiac rehabilitation 66-75%
Breast cancer suboptimal doses of chemo 16-45%
Adjuvant hormone treatment discontinuation 23-50%
What is creative nonadherence?
Also termed intelligent non adherence.
This phenomenon is where the patient modifies supplements as established regimen
Including alterations in dosage to extend treatment period
Retaining medication for recurrences or for use with other family members
Supplementing prescribed treatments with other treatments
Double dosing
Why is adherence so hard to assess?
We have to clearly distinguish between non-responsive and non-adherent patients
Deriving accurate objective measurements of adherence to complex medical and behavioural treatment regimens is not simple:
There is often a difference between what doctors beleive, what charts indicate, what prescription records indicate and what patients self report
In general asking patients about adherence yields inflated estimates of adherence generally because they know they are supposed to take medicines as directed
We can use CMAs which are more objective, but they do not prove the patient has actually utilised filled prescriptions
What are continuous medication acquisition indices?
An objective measure aimed at measuring adherence, but only keeps track of the prescriptions filled. It does not prove the patient has actually taken the medication they collected the prescription for
What have physicians historically ascribed patient non adherence to?
Patient uncooperative personalities, ignorance, lack of motivation, forgetfulness.
To some extent this is still true…
What are the predictors of nonadherence?
Treatment characteristics Practical considerations Demographic characteristics Psychosocial characteristics Social network factors Cognitive factors Side effects Affective and regulatory factors
What are treatment characteristics?
Duration of treatment (inverse relationship with adherence)
Frequency of medicarion/dosage (also inverse relationship)
Complexity of medication or treatment regimen (inverse relationship)
Storage/perishabilitiy
Interference with lifestyle
Side effects
What are practical considerations?
Travel times/locations of prescription pick up, travel or medication costs
What are demographic characteristics?
Extremes of age, minority status
What are psychosocial characteristics?
Generally show larger effect sizes than demographic patient characteristics e,g, age
What are social network factors
Practical and emotional support,
family cohesiveness or conflict,
Marital status and living arangements
Mechanisms
What are cognitive factors?
Risk/benefit and estimation- also necessity vs, concerns
Estimations of treatment efficacy
Health locus of control
Knowledge
Illness belief, e.g. Fatalism
Beliefs about the medication including efficacy, necessisty, concerns about potentially adverse side effects
How do side effects cause nonadherence?
Patients who report more frequent or serious side effects and poorer management of these side effects are less adherent
Most treatments for serious disease have side effects e.g. Cancer - physical side effects include hair loss, nausea, fatigue, diarrhoea, weight gain, change in taste and smell, changes in sexual self image, menopausal symptoms
Cognitive- memory deficits, attentional problems, interference with motor function which often lasts 2+ years post treatment
Affective- uncertainty, anxiety, isolation, vulnerability, depression
How do affective and regulatory factors predict nonadhence?
HQOL scores- a lower score = reduced adherence
Depression - consistently linked to poorer adherence esp. In hypertensive and diabetes patients
Likely due to sensitivity to side effects.
Anxiety - predicts more rapid initiation of treatment but has a variable link to adheence
Avoidant/inhibited coping - predicts reduced adherence
Stress- reduces adherence
Disgust, at the treatment - reduces adherence
What is disgust?
An evolved characteristic that has facilitated adaptation to particular classes of stimuli (health threats)
What are the different forms of disgust?
Core
Animal reminder
Contamination
Socio moral forms
What does disgust impact?
Cognitive, motivational, physiological, expressive, social and behavioural systems
What is the core function of disgust?
Promote both intermediate and anticipatorily adaptive responses to certain classes of stimuli
Immediate - physical protective/ejection type movements
Anticipatory - predominantly avoidant/protective behaviours
What are the elicitors of disgust?
Violations of body envelope Exposure to bodily product Rotten foods or remainders of rotten food Contamination threats Aberrant sexuality
How can adherence be improved?
Improving communication between patient and provider.
Alter aspects of institutional behaviour
Emphasising importance of adherence
Treating affective characteristics linked to adherence
How can improving communication improve adherence?
Providers can
Listen more to patient, ask patient to repeat instructions back
Keep prescriptions simple, give written instructions, be concrete
Use pill containers and reminders
Call for missed appointments
When determining regimen, take patients lifestyle into account
Acknowledge patient efforts
Involve spouse or partner
Ascertain patient worries and expectations, probe for barriers
Share the decision making
What institutional factors can be improved to increase adherence?
Use telephone or mail based reminders
Reduce waiting times for appointments
Using incentives as intrinsic motivation
How can emphasising the importance of adherence improve it?
Emphasise the fact that interventions have hit a plateau, treatment adherence is vital for recovery
How can treating affective emotions improve adherence?
Emotions like depression and anxiety are linked with reduced adherence so treating these emotions can increase adherence
What is adherence like in diabetes?
Diabetes is a chronic disease which affects 7% of the population
Treatment is based on tightly controlling glucose levels which requires regular assessments of blood sugar and insulin injections as well as dietary control, weight loss and exercise
Adherence to managing diabetes can be classed into six variables
What are the six classes of adherence to diabetes?
Demographics Physician related Technological Cognitive Socio-affective
