Patient Adherence

Discuss the different methods to measure adherence. Explain whether or not they are effective.

1. Ask the doctor - not effective because they tend to overestimate for their patients 2. Ask the patient - not effective because patients tend to overestimate, risk of retrospective contamination 3. Medication diary - not effective, back logging, over estimation and over claiming 4. Count pills remaining - not effective, don't know when they took them, can still have erratic dosing 5. Examine medicine cabinet - not effective, don't know when medication was taken, can identify drug interactions 6. Clinical response - not effective, responses differ between people 7. Examine biomarkers - not effective, everyone metabolizes differently 8. Electronic monitoring - seems most promising

What are the medical benefits of patient adherence?

1. Fewer health complications 2. Wiser use of health resources 3. Better quality of life 4. Decrease in pain and interventions 5. Decrease in resistance 6. Increase in work productivity

What are some common examples of non-adherence?

1. Not having prescriptions filled 2. Taking too many or too little medication 3. Erratic dosing 4. Stopping medications early 5. Sharing prescriptions 6. Combining prescriptions

Discuss the transition to the modern patient-physician relationship.

1. Paternalism -> partnership 2. One-on-one strategies -> team approach 3. Knowledge gap -> educational empowerment 4. Doctor's orders -> mutual decision making 5. Intervention -> prevention

Explain and give examples of the three levels of prevention. What level does patient adherence fall under?

1. Primary prevention - taking certain precautions to prevent illnesses from developing (e.g. anti-smoking initiatives aimed at preventing people from starting smoking) 2. Secondary prevention - screening for illnesses to catch them in the early stages if its too late to prevent (e.g. mammograms to detect breast cancer) 3. Tertiary - treatment of illnesses (e.g. pain medications to treat symptoms of illness) Patient adherence falls under tertiary

Identify and explain the SIMPLE strategies to enhance adherence.

1. Simplify regime 2. Impart knowledge (written instructions, reminders) 3. Modifying patient beliefs (dismiss creative beliefs, modify within reason) 4. Patient communication (be patient and willing to repeat) 5. Leave the bias (cultural, SES, stereotypes) 6. Evaluate adherence (probe for barriers and find solutions)

Discuss what two factors affect maintaining adherence.

1. The longer you're on the medications, the lower the adherence rate 2. The more medications you take per day, the lower the adherence rate

Discuss the preliminary findings of glow caps.

100% adherence in first 3 months in comparison to 50% adherence among control group.

Discuss the Swedish study involving hypertension medication adherence and what was associated with higher adherence rates.

A Swedish study measured patients adherence to hypertension medication to see whether active patient decision making and involvement in care would increase adherence. The results showed no relation with patient reports of self-adherence and severity of blood pressure, but it did find a relation with patient reports of self-adherence and active patient decision making and involvement in care.

Discuss the study that examined the effectiveness of treatment matching in breast cancer screening.

A study looked at women who: - did not have cancer - was not waiting for cancer results - had received fewer than half of recommended mammograms - was not taking tamoxifen There coping styles were assessed as either: "Monitor" - distressed, concerned, and seek information "Blunter" - overwhelmed by threatening information and avoid information They were randomly assigned either informational brochures, phone messages, or fridge magnets. The study concluded that treatment matching was associated with increased reports of mammograms.

Explain how adherence rates have changed over the years, why its a problem, and why it is considered a world-wide issue. What is the dual burden?

Adherence rates have not changed over the years. Psychiatric and hypertension drugs may have slightly increased, if any. This is a growing problem because as the population ages, we are going to see more and more health problems. Its a world wide issue because adherence rates are even lower in developing countries. This is a dual burden because developing countries have lower adherence rates and higher acute illness rates.

Explain the difference between compliance and adherence.

Compliance is the extent to which a patient follows medical instructions and passively does what the physician says. Adherence is the extent to which a patients behaviours correspond with agreed recommendations from a health care provider. It focuses on the mutual understanding and agreement of medical instructions. Adherence is effective, whereas compliance is not.

Describe the relationship between efficacy and effectiveness.

Efficacy is how well medication works under optimal conditions (e.g. being tested in the lab) and effectiveness is how well medication works in the real world. It is possible to have a drug show greater efficacy, but less effectiveness. Placebo effect can be very strong, so it is crucial for a drug to show greater efficacy then placebo effect.

Discuss breast cancer screening recommendations and their benefits.

For women aged: 40-49 - talk to your doctor about risk of breast cancer 50-69 - mammogram every 2 years 70 + - talk to doctor about having mammograms 1/6 women do not get mammograms Mammograms reduce breast cancer mortality rate and prevents metastatic cancer.

Discuss where HIV prevalence is the greatest and why.

HIV prevalence is the greatest in sub-saharan Africa for: - total adults and children living with HIV - children under 15 living with HIV - total deaths from HIV - total deaths of children under 15 from HIV This is most likely because the government lied to its citizens and encouraged them to avoid western medicine.

What has the highest rate of non-adherence? Give three examples.

Lifestyle changes has the lowest adherence rate. Examples of this are: 1. Dietary recommendations 2. Exercise recommendations 3. Activity limitations

Explain the concept of treatment matching.

No single adherence strategy is the most effective, it must be tailored to the individual.

Explain what is the most important vital sign and why.

Of the four vital signs (heart rate, respiration, temperature, and blood pressure) blood pressure is the most important because it causes hypertension. Hypertension is the number 1 reason for doctor visits, medications, and is very costly. It is considered the "silent killer" because there are virtually no symptoms of it.

Explain what influences adherence rates and identify what is not a good predictor of adherence. Give examples of certain conditions that have high and low adherence rates.

Pain and symptoms in the moment influence patients adherence rates. Patients that experience pain are more likely to adhere in order to eliminate their symptoms, whereas patients who do not experience many symptoms tend to adhere less to medical instructions. Seriousness of the condition is NOT a good predictor of adherence rates. High adherence: HIV, arthritis, cancer, gesture-intestinal diseases Low adherence: COPD, diabetes, sleep disorders

Discuss the white coat adherence problem.

Patients are motivated to impress their physician when they are being regularly monitored and therefore are more adherent to medical instructions.

Discuss the issue of physician non-adherence, including which types of physicians and why.

Physician failure to wash hands contributes to 5% of all hospital deaths. Typically, the most vulnerable physicians tend to have the lowest hand washing adherence rates (e.g. surgeons, anesthesiologists, ER, and ICU). The main reasons for it are irritating soap, tedious, and CDC wasn't monitoring.

Explain the concept of "creative non-adherence".

Some patients may believe they are being intelligent or rational by having personal theories about medications ("don't trust drugs"/alternative medicine) or by saving medications.

Discuss the issue with antibiotics and adherence. Why does it happen?

The population is becoming resistant to some antibiotics as a result of not finishing their medications. When you stop taking antibiotics early, you're essentially wiping out all of the virus except for the most resistant ones. People stop taking their medications either because they feel better or because of the side effects.

Is there a gold standard for measuring adherence, explain.

There is no gold standard. The best that can be done is to leverage cross-sectional partnerships and the use of technology.

Discuss the hospital hand washing study associated with consequences. Where was the biggest improvement in adherence?

There were two experiments. The first experiment measured the actual amount of soap dispensed, and the second experiment was observational. They used two signs, one that displayed personal consequences and another that displayed patient consequences. The results showed the patient consequences resulted in higher adherence rates for both experiments. The physicians had the lowest adherence rate to begin with, but showed the greater improvement.

Discuss the Brigham and Women's hospital study.

This study was aimed to see what would influence physicians to wash their hands more frequently. They repositioned sinks, made them automated, introduced "precaution carts" that eased cleaning, gloving, and gowning, used admonishing signs, used hygiene report cards, and gave free movie tickets for adherence. The results were no changes.