W2 Adherence to treatment

Question 1

Why is adherence to treatment a problem?
STATISTICS

Answer 1

WHO shows only 62% of people required to take over 2 medications do so daily.
Cost over £500 million a year, with a further £300 million on wasted medication.
50% of UK prescribed medications are not taken as intended.

Question 2

What is a doctor-centered consulation style?

Answer 2

Doctor gives off a paternalistic or superior vibe.
Tightly controlled interviewing aimed at reaching an organic diagnosis based on the biomedical model.
Doctor is the leader, very little time for patient involvement in decision making or consideration of holistic care.

Question 3

What is a patient centered consultation style?

Answer 3

Fits more into the biopsychosocial model.
Is more co-operative, encouraging the patient to share their thought and concerns.
Open questioning interested in the patient as a person, more holistic in factors and diagnosis.
Aims to understand patient ICE, context of life, and encourage health promotion and prevention.
Shared decision making with the patient. encourages self management such as lifestyle changes.

Question 4

What is compliance?
In regards to a patient

Answer 4

The degree to which a patient conforms to the recommendations and instruction they were given by the doctor. Prescriber has ultimate authority.
‘Doing what your told’
More doctor focused consultation style, little patient involvement in treatment plan

Question 5

What is adherence?

Answer 5

A neutral term to show the extent to which a patient behaviour matches agreed recommendations from the prescriber.
Patient would have been involved in deciding what instructions to follow.
Agreement is important, the patient is not forced to follow treatment.

Question 6

Why is is difficult to measure adherence?

Answer 6

Patient opnions - give the answer they believe socially acceptable, want to be seen as good -so overestimated
Pill counting - time consuming, patients often throw pills away
Biomedical tests - only shows short term compliance, patient more likely to comply before test
Differences in prescriptions issued and presented - just because a prescription is taken does not mean it is followed correctly e.g may just keep in a cupboard at home.

Question 7

What IDEAS show that non adherence to treatment is a problem?

Answer 7

Negatively affect health outcomes.
Large cost implication - produce medicine that is not used, treatments may need more expensive treatment when symptoms worsen.
Waste a consultation time - repeat consultations are needed when patient redevelops or never loses symptoms.

Question 8

What does Edelmann 2000 show is the most common ways for patients to not adhere to treatment?

Answer 8

Don’t follow instructions properly - 50-75%
Lifestyle changes - 50%
Discontinue medication -50%
Missed appointments - 15-60%

Question 9

What does Tamoxifen show about non-adherence?

Answer 9

Breast cancer patients do not take Tamoxifen as prescribed after cancer treatment to increase chance of survival and decrease relapse
Severe symptoms of drug are considered worse severity that not taking drug, when the patient in remission feels fine.

Question 10

What are the social factors why a patient may fail to follow treatment?

Answer 10

Low levels of education
Low levels of social support
Young women - least likely to follow treatment as align more with social, psychosocial and treatment factors.

Question 11

What are the psychological factors why a patient may fail to follow treatment?

Answer 11

Anxiety and depression around treatment
Non-acceptance of illness and avoidant coping strategies
Perceived stigma of condition
Negative beliefs around medicines (big pharma or addiction concerns etc)

Question 12

What are some treatment factors why a patient may fail to follow treatment?

Answer 12

Misunderstanding about treatment
Treatment is too complex or has bad side effects
Poor relationship and communication between doctor and patient.
Patient feels like they want more control in the relationship, method of rebellion.

Question 13

What are the five different dimensions of compliance given by the WHO?

Answer 13

Social and economic dimension
Healthcare system dimension
Condition related dimension
Therpay related dimension
Patient Related dimension
Tom Cruise Has Serious Payment.

Question 14

What are some key social and economic factors relating to non compliance?

Answer 14

Cultural belief around illness
Level of health literacy
Living conditions
Burdensome schedule
Healthcare insurance
Cost and access to treatment.

Question 15

What are some key aspects of the healthcare system dimension of compliance?

Answer 15

Provider-patient relationship
Provider communication skills (understanding)
Long wait times
High drug costs
Accessibility to provider.
Doctor language and body language.

Question 16

What are some key aspects of condition-related dimensions of compliance?

Answer 16

Chronic conditions
Severity of symptoms
Psychotic disorder
Developmental disability

Question 17

What are some key aspects of the therapy-related dimension of compliance?

Answer 17

Complexity of medication regime
Duration of therapy
Frequent changes in medication regime
Speed of onset of benefits from treatment
Treatment interferes with lifestyle.

Question 18

What are some patient-related dimensions of compliance?

Answer 18

Motivation
Fear /other emotions around treatment
Confidence in the ability to follow the regime
Impairment affects the ability to understand or retain the information.

Question 19

How does the sick role link to treatment compliance?

Answer 19

Desire to be cured - encourage to take medication if works. complain if not immediate effect
Illness is perceived as undesirable - want to hide from stigma of long term treatment.

Question 20

What are the factors in the Lay evaluation of medicine?

Answer 20

Adverse v beneficial effects of medication
Acceptability of treatment regime - interference with daily life
Often stop medication to see what happens then decide if they want to keep taking it.

Question 21

What are behavioural solutions to non-adherence?

Answer 21

Trying to change a patients behaviour to increase chance of compliance, most common in secondary care.
Includes health coaching, motivational interviewing and CBT.
lacks robust evidence to show it is effective.

Question 22

What are the four Es used to intervene in adherence?

Answer 22

Explore - patients wants
Educate - patient understanding and questions
Empower - patients to take ongoing responsibility for taking medicine
Enable - behavioural change through discussion of practical issues around medicine

Question 23

What does Lays model of adherence show are the factors affecting adherence?

Answer 23

Understanding - of the information given by the doctor
Memory - ability to retain the information
Satisfaction - with the doctor-patient relationship and perceived competency of the doctor.

Question 24

How can doctors increase understanding leading to adherence?

Answer 24

Weiss 2007, encourages doctors to use plain language when communicating with patients e.g low blood pressure rather than hypotension.

Question 25

How can doctors improve memory leading to increase adherence?

Answer 25

Avoid long rabble as verbal informatino is harder to understand.
Consider what they say first and last, these are the easiest to remember
Ensure patient and doctor have similar perception of what information was important.
Ease patient anxiety so that is does not interfere with memory recall
Provide written information afterwards.

Question 26

How can doctors improve satisfaction linked to increasing adherence?

Answer 26

Provide a good level of emotional support and understanding.
Provide good level of explanations
Come across as competent by maintaining professional behaviour.
41% of hospital patients and 28% of GP patients were dissatisfied.

Question 27

What is the debate around if doctors should provide patient with a print out of information discussed?

Answer 27

Patients feel more understanding of the care they received, hence feel more satisfied and motivated
However, requires use of a computer during consultation, this will shift the focus of the consultation from the patient to the computer screen breaking rapport.

Question 28

What is concordance?
How is it different to compliance and adherence?

Answer 28

Is the agreement between the patient and the doctor and how, when and if medical treatment should be used. Focuses on the processes that underlie medication taking, supports the patient throughout long term condition management and creates an equal therapeutic relationship.
Focuses also on the doctors behaviour whilst compliance and adherence are mainly focused on the patients behaviour.

Question 29

How does the definition of compliance and adherence affect the doctor-patient relationship?

Answer 29

Implies an inbalance of power.
Doctor is shown as authoritative and powerful
The patient is shown as powerless, passive and appropriately obediant.

Question 30

What is the basis of shared decision making and why is it important?

Answer 30

NICE guidelines encourage healthcare professionals to create a partnership with patients.
Takes account of patients individual needs and preferences.
Allows patient to be more informed of their medical treatment and changes, more supportive of patients with long term conditions whose lifestyle may be affected.