Adherence

Rozenfeld et al (2008)

Higher adherence = lower HbA1c levels

Health system factors (Odegard & Capoccia, 2007)

- ability to provide patients follow up to check adherence/ side effects - knowledge of medication effects (if not convincing patient won't want to take it) - fear patients won't adhere (if try too hard to make them, they will be suspicious and not want to take it)

Therapy related factors (Reach, 2005)

- adverse side effects - complexity of regimen - restriction for use e.g. cannot drink alcohol - disagree with treatment prescribed

Patient related factors (Reach, 2005; Odegard & Capoccia, 2007; Padala et al, 2008)

- financial and personal cost of treatment adherence - psychosocial barriers e.g. stigma, psychological side effects which may interfere with interpersonal function - forgetfulness - personal beliefs about treatment - lack of educational understanding, sceptical of treatment - individual symptom severity (if 'not that bad' less motivated to adhere)

Homedes (1991)

200 variables affect compliance, e.g.: -Patient characteristics -Treatment regime characteristics -Features of the disease -Dr patient relationship -Clinical setting

Osterberg (2005) - Barriers to Medical Adherence Model

3 component model - relationships between patient, provider and system barriers. Patient barriers: - Understanding of disease - Understanding of risks and benefits of treatment - Beliefs about treatment quality - Affordability of treatment Patient-provider barriers: - Provider to patient communication (helps patient barriers e.g. understanding condition/ treatment, relationship, knowledge of budget) - Knowledge of alternative treatments to fit patient budget/ specific needs Provider barriers: - Instruction and counselling alongside prescription of treatment (how to take it, why, reassurance side effects will be monitored etc) - Relationship with patient (collaborative) - Complexity of regimen - Reimbursement for cognitive services (Drs payed enough to care about giving counselling/ reassurance alongside prescription of medical treatments) System barriers: - Copayments - Refill requirements (takes up time from services if frequent) - Lack of extended teams (e.g. psychological support for those going into new treatment) - Lack of infrastructure tracking systems - Lack of get-to-goal policies/ incentives to ensure Drs are motivated to give best care for best adherence - Not the best training for patient centred communication

Garber et al (2004) Cook et al (2005) Grymonpre et al (2006)

50% of adherence self reports by patients don't align with non SR measures

Lekkerkerker et al (2007)

65.4% of Diabetes 2 pts adhere for at least 80% of the first year of treatment 72.3% Hypertension 54.6% Hyperlipidemia 51.2% Osteoporosis

Taylor (1990)

93% of patients fail to adhere to some aspect of their treatment at some point

Paternalistic medicine

A type of medical decision making in which health care professionals exercise unilateral authority over patients. Doctor act like 'father' dictating to child what needs to be done and making them fit the treatment into their life event if inconvenient, patient complaints somewhat ignored as long as not affecting how treatment is working (e.g. takes up time in life, have to miss work)

Meichenbaum & Turk (1987)

Adherence is more active and voluntary Involvement is collaborative with the doctors recommendations Patient involvement and agreement on the behaviour change is vital or they won't actively do it. Adherence is not obedience, patient participation relies on agreement with course of action.

Horne et al (2005)

Adherence rates vary within and between individual patients e.g. Might adhere for a month then drop then go back up, equally may adhere overall more than someone else for whatever reason (attitudes?) Non adherence to appropriately prescribed drugs represents cost to patients, medical systems, drs and pharma companies

Sokol et al (2005)

Adherent patients cost 49% less to healthcare systems and significantly less on drugs from pharmaceutical companies. More adherent = less hospitalisation risk.

Bain (1977)

After a GP consultation: 37% of patients unable to recall the drug prescribed 23% unable to recall the frequency of dose 25% could not recall the duration of the treatment.

Measuring Adherence through self report: Beliefs about Medications Questionnaire (BMQ)

Beliefs about how much they need diabetes medication and concern about how it will affect them/ consequences of not taking it contribute to adherence.

Horne et al (1999)

Beliefs about specific medications Beliefs about medication in general Both influence adherence to treatment by providing thoughts on the benefits/ barriers

Guillausseau (2003)

Better glycemic control in 100% adherent patients compared to those missing doses

Zola (1981)

Changes in relationships from medical compliance to therapeutic alliance increases adherence as the patient is more involved/ empowered and feels in control increasing motivation for active participation in treatment

Rothendler, et al (2008)

Diabetics with a medication possession ratio of less than .8 were 20% less likely to achieve lower HbA1c (<7% desired glucose level maintenance) than those with higher MPRs

Cameron & Gregor (1987)

Doctor patient collaboration is necessary for adherence. The patient is expert in their own body, know what is out of the ordinary and how treatments will affect daily life. Doctors are experts in what is the best/ more effective course of treatment/ lifestyle change for health.

Non adherence effects on medicine

Economic impact. Non adherence causes deterioration or slower improvement of conditions creating greater demands on health services. $300b per year in avoidable medical spending on hospitalisations etc which could be prevented by adhering to treatment. Not getting the drugs you were prescribed costs pharmaceutical companies half a billion.

DiMatteo & DiNicola (1982)

Emotional and cognitive effects of recall of information after Drs appointments. Cognitive: Instructions and advice are more likely to be forgotten than other information The more a patient is told the greater the proportion a patient will forget (cog load) Prior medical knowledge aids recall. Emotional: Patients remember a) what they are told first and b) what they consider to be important

Hevey (2007)

Evidence for personality causing non adherence is shit, hasn't been linked to a personality type, trait, or temperament. Although neuroticism, impulsivity, hedonism, extroversion, assertiveness, openness, hostility, cooperativeness, novelty seeking, agreeableness, defensiveness, and friendliness have been tested.

Donnan et al (2002)

Frequency of dosage affects adherence rates. The more frequently it needs to be taken the lower the consistent adherence.

McHorney (2009)

In a sample of 1100 US patients 68% said they wouldn't tell their doctor if they disagreed with the drug treatment they were administered. For each medication, patients conduct a value proposition between perceived medication concerns and perceived need for medications filtered through perceived medication affordability and other patient beliefs (e.g. knowledge, trust in physician, perceived disease severity). Strong evidence that these predict adherence: Side effects Perceived need for treatment Concerns about treatment Costs of treatment Moderate evidence: Susceptibility beliefs Severity beliefs Dr trust, communication, explanation Pt involvement, knowledge Coping skills, SE Social support Weak evidence: Demographics, age, race SES, income, education Personality

Lapane (2007)

In a sample of 1100 US patients 83% said they wouldn't tell their doctor if they had no intention of adhering to/ buying the drug treatment at all.

Balkrishnan et al (2003)

Increased medical possession ratio (getting the meds you were proscribed rather than not) predicts significant decrease in healthcare costs. Helps avoid emergency hospitalisation, comorbidities and initiation of injectable therapy

Wroe (2002)

Intentional and unintentional nonadherence. Qualitative research suggests people go through rational process of decision making about medical adherence. Intentional nonadherence is predicted by the balance of individuals' reasons for and against taking medication as suggested by the Utility Theory. Patient is bias in pros and cons they focus on - focus on ones believe are most important/ relevant. Unintentional nonadherence is less strongly associated with decision balance, and more so with demographics. Would choose to adhere if believed it to be an option but SES, age, race produce perceived barriers e.g. 'can't afford to miss work to recover'

Horne (2005)

Interventions for adherence not great, small short lived effects - why? Limited designs and testing, need to be applicable to real patients Failure to address true causes of non adherence, based on myth not evidence

Pladevall, et al. (2004)

Inverse relationship between adherence and HbA1c/ glucose levels. 10% increase in non adherence (decrease in adherence) led to a .14% increase in glucose

Measuring Adherence through self report: Morisky's Medication Adherence Scale

Level of adherence to medication based on an interview. Scored out of 4 (0 being low adherence).

Measuring Adherence through self report: The Diabetes Self Management Scale (DMS)

Measures how well the patient is doing on self care (direct adherence) and caregiver support of adherence (encouraging patient to actively be involved in remembering to take and taking meds etc).

Simpson et al (2006)

Meta-analysis: Good adherence to active drugs = lower mortality. Good adherence to placebo also lowered mortality. "Healthy adherer effect" if believe adhering to the drug will make them better it will regardless of if it is real.

Horne (2009)

Necessity and concern on 2 dimensions: High necessity, low concern = accepting High necessity, high concern = ambivalent Low necessity, low concern = indifferent Low necessity, high concern = sceptical In order of adherence, accepting was highest, sceptical lowest. Accepting better than ambivalent because able to rationally think about treatment and get proactively involved due to acknowledging need to adhere but not being clouded by concerns about taking meds.

Wu (2011)

Nonadherence consequences: Higher risk of mortality Hospitalisation Emergency services use Suboptimal clinical outcomes

Bissell et al (2004)

Pakistani patients UK diabetes 2. Describes their medical encounters - not even close to concordance. Patients didn't understand that they should be able to negotiate and discuss with doctors best course of action and that relationship should feel like a partnership. Didn't understand the meaning of such words in a medical context. Words like concordance in this context are not explained to the general public - needs to be well known how relationships with doctors should and shouldn't be.

Concordance

Patients and doctors agree on the need for and type of treatment. Patient & professional have mutually agreed goals, neither is leader, negotiation between equals

Parkin et al (1976)

Patients discharged from hospital: 49% had poor or no knowledge of their illness 33% had little understanding of their drug regimen

WHO (2003)

Patients don't adhere due to: Health system factors Socio-economic factors - missing work for clinical treatments - unable to afford medication for treatment - unable to access healthcare regularly to check on treatment course Therapy related factors Patient related factors Condition related factors - how detrimental the condition is without treatment adherence Non-adherence to medication is the primary reason for suboptimal clinical benefit of therapy - don't take drugs/ treatment properly, therapy don't work as well. If non-adherence is not addressed the potential for medicine to reduce the burden of chronic illness will never be discovered. Should address each aspect of treatment non adherence independently e.g. may have a different problem against taking oral medication/ injections than testing glucose levels.

Measuring Adherence through self report: Revised Illness Perceptions Questionnaire (IPQ-R)

Patients perceptions/ understanding of the causes, consequences, trajectory and treatments of their condition contribute to adherence as well as beliefs about control over treatment/ condition

Boyle (1970)

Patients shit at understanding terminology

Illnesses which cause necessity related non-adherence

People who do not adhere to treatment for these illnesses are sceptical about the need to take treatment for their illness e.g. not that bad, not financial priority, consequences won't happen to me etc Cancer Asthma Heart Disease CHD Hypertension Renal dialysis Renal transplantation

Illnesses which cause concern related non-adherence

People who don't adhere to treatment for these illnesses are concerned about potential adverse effects of treatments e.g. side effects, stigma. HIV/ AIDS Rhumatoid arthritis Bipolar Depression Haemophilia Diseases needing new medicines

Adherence value proposition

Perceived need/ benefits/ pros to adhering to treatment Perceived concerns, cons, costs, barriers of taking treatment

Grymonpre et al (2006)

Physicians overestimate adherence by 50%

Walker et al (2006)

Predictors of adherence and non-adherence balance out either in favour of following treatment or not. Barriers affect adherence measured via pill box (how good at adhering to pill taking), Adherence barriers include: Forgetfulness, side effects, disruption to daily routine, combinations of these factors together. Treatment strategy: More structured treatments helped adherence (e.g. take at specific times rather than event related - when in pain)

Ley (1989)

increased recall of information after GP appointment: • Lowering of anxiety • Increased medical knowledge • Higher intellectual level (not age or IQ) • Importance and frequency of statements • Primacy effects

Adherence

Reflects how well the patient actively follows treatment, to adhere with something is to work towards making it happen, not to passively expect it to happen by itself. Includes patients active behaviour changes adhering to doctor recommendations e.g. exercising more.

Compliance

Reflects how well the patient passively follows treatment, to comply with something is to let it happen and not resist it, not to actively facilitate.

Kaplan & Simon (1990)

Review of adherence rates and reasons. Adherence varies greatly from 15-93 depending on: Patient population (demographic?) Medical condition Form of treatment Definition of adherence

Ley (1988)

Review of patient dissatisfaction. 41% of patients were dissatisfied with their treatment. Dissatisfaction stemmed from the consultation with the medical practitioner: • Emotional support and understanding received • Whether a prescription was given. • Whether an adequate explanation was given. • Whether the patient thought the practitioner was competent or not. • Whether the practitioner gave as much information as possible (even if it was bad news)

Mueller et al (2008)

Slower HbA1c/ glucose level decline in non-adherent patients. Takes longer to get better.

Measuring Adherence through self report: Medication Adherence Representation Questionnaire (MARS)

Statements on adherence/ non adherence behaviour to diabetes meds - how far do you agree. e.g. I do not take insulin as regularly as my doctor would recommend

Measuring Adherence through self report: The Diabetes Self Management Profile (DSMP)

Structured interview addresses diabetes self management adherence. Normalises to the patient that it's difficult to adhere to regimens, encouraging not to lie if they are struggling.

McHorney (2009) Davis (1966) Goldberg (1998) Huas (2010) Turner & Hecht (2001)

Studies showing 74% to 95% of surveyed physicians believed that the majority of their were adherent Physicians cannot predict adherence with any more efficiency than if they were guessing

Kent & Dalgleish (1996)

Study cases of parents not ensuring children get full course of strep meds (10 day penicillin). Majority understood strep and had access to meds Despite free meds and knowing they would be checked: By day 3 only 41% still being given penicillin By day 6 only 29%

Taddeo et al (2008)

There is no 'gold standard' to assess adherence to a medical regimen. Direct and indirect methods of measurement have been described, both of which have limitations and benefits. Information on adherence is more reliable when it comes from multiple sources including the teen, parents and other health care providers on the team

Donovan & Blake (1992)

Treatment actively accommodates patients responses to medical care e.g. if complaining disrupts life work around it if possible. Adherence implies this relationship is equal, neither in power - collaborative.

Farmer et al (2006)

Type 2 diabetics. Needs: 85% - believed meds will help stay healthy 69.6% - believed regular doctor visits will be helpful to review medication (likely to have side effect concerns addressed) Positive beliefs correlate with intent to adhere Concerns: 32.8% - believed meds cause side effects 13.9% - believed meds cause weight gain

Rubin (2005)

Type of treatment affects adherence rates in diabetes 2 pts: Oral blood gluecose lowering drugs (65-85%) Insulin (60-80%) BP/ cholesterol lowering (75-90%)

Lee et al (2006)

UK diabetes study. Already established than nonadherence causes higher HB1Ac gluecose, and higher adherence lowers it. Shown that lower HBA1c decreases micro-vascular events by 37% and diabetes related mortality by 21%. Therefore adherence indirectly affects mortality in diabetes.

Communication model of compliance (Ley, 1981)

Understanding of medical terminology, illness causes, prognosis, drug regimen and prevention contributes to satisfaction of treatment and therefore adherence to it. Memory for information about treatment regimen, drug characteristics, frequency and dosage, and other information they were told about their condition also contributes to treatment satisfaction and adherence.

Perceptions and Practicalities Model of Adherence (Horne, 2001)

Unintentional poor adherence is due to: Capacity/ resources, practical barriers Intentional poor adherence is due to: Motivational beliefs/ attitudes/ preferences, perceptual barriers

NICE (2009)

Uses perception and practicalities model to work through why the person isn't adhering (intentional or not) and how to address it according to well established influencing factors such as Dr patient communication, understanding, and involvement. If still not adherent implement another intervention Improve communication Increase patient involvement Understand the patient's perspective Provide information Assess adherence Review medicines Improve communication between healthcare professionals

Farmer (1999)

Various ways for doctors to measure adherence. Direct: Blood, urine, biological markers, direct observation of therapy e.g. in mental hospitals watch every day to make sure take meds Indirect: Counting pills to see if taken right dosage/ taken it today, electronic monitoring (sensor detects when meds are opened), prescription records/ claims (e.g. if haven't renewed prescription in right time likely not taking regularly).

Cook et al (2005)

Weak correlations between pharmacy files (as reported by patients) and pill counts