Lecture 16: Adherence

Question 0

What are the two primary reasons for non adherence?

Answer 0

Treatment efficacy, including ultimate or long term cost

Cost and opportunity cost of wasted medications

Question 1

What is nonadherence? (Another working definition)

Answer 1

Patients do not adopt the behaviours and treatments that their providers recommend

Question 2

What are some general observations on adherence?

Answer 2

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

Question 3

What are some variations of adherence across domains?

Answer 3

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%

Question 4

What is creative nonadherence?

Answer 4

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

Question 5

Why is adherence so hard to assess?

Answer 5

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

Question 6

What are continuous medication acquisition indices?

Answer 6

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

Question 7

What have physicians historically ascribed patient non adherence to?

Answer 7

Patient uncooperative personalities, ignorance, lack of motivation, forgetfulness.
To some extent this is still true…

Question 8

What are the predictors of nonadherence?

Answer 8

Treatment characteristics
Practical considerations
Demographic characteristics
Psychosocial characteristics
Social network factors
Cognitive factors
Side effects
Affective and regulatory factors

Question 9

What are treatment characteristics?

Answer 9

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

Question 10

What are practical considerations?

Answer 10

Travel times/locations of prescription pick up, travel or medication costs

Question 11

What are demographic characteristics?

Answer 11

Extremes of age, minority status

Question 12

What are psychosocial characteristics?

Answer 12

Generally show larger effect sizes than demographic patient characteristics e,g, age

Question 13

What are social network factors

Answer 13

Practical and emotional support,
family cohesiveness or conflict,
Marital status and living arangements
Mechanisms

Question 14

What are cognitive factors?

Answer 14

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

Question 15

How do side effects cause nonadherence?

Answer 15

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

Question 16

How do affective and regulatory factors predict nonadhence?

Answer 16

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

Question 17

What is disgust?

Answer 17

An evolved characteristic that has facilitated adaptation to particular classes of stimuli (health threats)

Question 18

What are the different forms of disgust?

Answer 18

Core
Animal reminder
Contamination
Socio moral forms

Question 19

What does disgust impact?

Answer 19

Cognitive, motivational, physiological, expressive, social and behavioural systems

Question 20

What is the core function of disgust?

Answer 20

Promote both intermediate and anticipatorily adaptive responses to certain classes of stimuli

Immediate - physical protective/ejection type movements
Anticipatory - predominantly avoidant/protective behaviours

Question 21

What are the elicitors of disgust?

Answer 21

Violations of body envelope
Exposure to bodily product
Rotten foods or remainders of rotten food
Contamination threats
Aberrant sexuality

Question 22

How can adherence be improved?

Answer 22

Improving communication between patient and provider.
Alter aspects of institutional behaviour
Emphasising importance of adherence
Treating affective characteristics linked to adherence

Question 23

How can improving communication improve adherence?

Answer 23

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

Question 24

What institutional factors can be improved to increase adherence?

Answer 24

Use telephone or mail based reminders
Reduce waiting times for appointments
Using incentives as intrinsic motivation

Question 25

How can emphasising the importance of adherence improve it?

Answer 25

Emphasise the fact that interventions have hit a plateau, treatment adherence is vital for recovery

Question 26

How can treating affective emotions improve adherence?

Answer 26

Emotions like depression and anxiety are linked with reduced adherence so treating these emotions can increase adherence

Question 27

What is adherence like in diabetes?

Answer 27

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

Question 28

What are the six classes of adherence to diabetes?

Answer 28

Demographics
Physician related
Technological
Cognitive
Socio-affective