Responsibility for Treatment Outcomes

Question 1

Factors that contributed to the rise of the cigarette industry

Answer 1

• Developments in agricultural technique
• Production technology
• Industrial organization
• Invention of the portable match

Question 2

Time period of the cigarette’s rise to popularity

Answer 2

1900: 49 consumers per capita
1965: 4,318 consumers per capita

Prior to the early 1900’s innovations, tobacco was a luxury item. Only with these innovations was it actually made accessible to the masses for cheap.

Question 3

Impact of the Surgeon General’s Report on smoking

Answer 3

With this report, the government accepted new responsibility for the elucidation of health risks through epidemiological studies. This report expanded the vision of the government’s role in public health.

Question 4

Civil suits against tobacco companies

Answer 4

Smokers who have incurred serious disease have filed several civil suits against the tobacco industry itself claiming that the companies were selling a hazardous product while knowing and actively obscuring the risks.

These suits claim that companies must, in compensatory damages, accept responsibility for the debility and death that their products may cause.

These suits have been largely unsuccessful.

Question 5

As consensus around the risks of cigarettes has risen, . . .

Answer 5

As consensus around the risks of cigarettes has risen, industry has ironically been freed from the responsibility for the risks of their product.

Question 6

Social values in America have underscored norms which suggest that . . .

Answer 6

Social values in America have underscored norms which suggest that individuals can and should exert fundamental control over their own health through careful and rational avoidance of risks.

Ex, the “Just say no” campaign against drugs

Question 7

Emphasis on individual health responsibility inherently ignores. . .

Answer 7

. . . social and environmental determinants of disease

Question 8

The behavior of smoking is starkly stratified along lines of. . .

Answer 8

The behavior of smoking is starkly stratified along lines of education, social class, and race.

Question 9

Public perception of smoking is frought with the ____ bias.

Answer 9

Public perception of smoking is frought with the voluntaristic bias.

Question 10

Simplest definition of nonadherence

Answer 10

“the extent to which patients follow provider recommendations about day-to-day treatment.”

Question 11

The nonadherence literature generally focuses on. . .

Answer 11

. . . treatment for chronic disease and non-intentional nonadherence.

Question 12

Adherence exists along a ___

Answer 12

Adherence exists along a continuum

Question 13

How physicians dealth with nonadherence during the TB outbreaks of the 1900’s

Answer 13

When physicians did not trust patients to complete tuberculosis treatment on an outpatient basis, they confined them in hospitals for months, even years. By 1960, 31 states allowed detention of patients with tuberculosis.

This was seen ad justified in 2 ways:

1. An infected, untreated individual put their community at risk
2. Inconsistent antibiotic usage fosters drug resistance

Question 14

McMaster University definition of nonadherence

Answer 14

“the extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with the clinical prescription.”

Question 15

Adherence is ___ to the frequency of the dose

Answer 15

Adherence is inversely proportional to the frequency of the dose

Question 16

Most of the literature on adherence relies on ___.

Answer 16

Most of the literature on adherence relies on self-reporting.

Thus it is almost certainly an underestimate,

Question 17

Nonadherence represents. . .

Answer 17

1. A tole on morbidity
2. A tole on mortality
3. A large tole on economy

Question 18

Four broad categories that affect adherence

Answer 18

• Patient
• Provider
• Nature of treatment
• Health care system

Question 19

Patient factors of nonadherence

Answer 19

Largely a rational choice model: Patients will adhere if they accept the diagnosis and believe that the benefits of treatment outweigh the risks.

Question 20

Provider factors of nonadherence

Answer 20

• Perceived communication barrier between physician and patient
• Non-verbal provider behaviors which suggest that the provider is not invested in the patient’s care
• Perception that physicians are too busy or unaware to answer questions
• Cessation if the patient experiences side effects the physician did not warn them about
• Since physicians are often unaware of patient nonadherence, they do not intervene

Question 21

Treatment factors of nonadherence

Answer 21

• Treatments with delayed onset of action
• Treatments with intangible or unobservable (by the patient) effects
• Problematic side effects
• Complexities of managing multiple drug regimens
• Infrequent dosing (any longer than daily)

Question 22

Healthcare system factors of nonadherence

Answer 22

• Affordable access to healthcare
• Provider continuity
• Transportation
• Trust
• Many of the innovations that seek to reduce the costs of health care, for instance generic substitution or restricted formularies, can confuse patients (e.g., the physician writes a prescription for one drug, the pharmacist dispenses one by a different name; or a pharmacy benefit manager changes generic suppliers, resulting in pills with an unfamiliar appearance), leaving patients less willing or able to comply.

Question 23

“Throughout the world, those least likely to comply are those least able to comply”

Answer 23

Paul Farmer, 1997

Question 24

Perhaps the problem is not nonadherence itself, but rather . . .

Answer 24

. . . the physician’s baseline expectation of adherence

Question 25

While electronic pill monitors might provide doctors with valuable information, . . .

Answer 25

While electronic pill monitors might provide doctors with valuable information, they might be intrusive for patients or threaten their privacy.

Question 26

When physicians intervene to improve adherence, they must navigate between . . .

Answer 26

When physicians intervene to improve adherence, they must navigate between their reasonable desire to help patients achieve the best health outcomes and their respect for patients who might have other priorities and concerns.

Question 27

Adherence policy changes as part of ACO contracts

Answer 27

“ACO physicians will be held accountable not only for their own adherence to guideline-driven care but for their patients’ adherence as well. With their salaries indirectly tied to patients’ behavior, physicians in ACOs and PCMHs will theoretically be more motivated to educate patients about medication therapy and to address barriers to its use.”