Medical Adherence + Patient Communications

sporadic non-adherence:

individual took 1-19% more or less than the prescribed number of doses

repeat non-adherence:

individual took >20% more or less than the prescribed number of doses

non-adherence to a regimen is:

NOT limited to frequency of tablet consumption

• improper use

• taking dose w/ prohibited foods/liquids/other meds

• taking meds at wrong/inconsistent times

Which diseases see the highest non-adherence rates?

• asthma

• arthritis

• diabetes

• hypertension

What are common risk factors for non-adherence?

• complex regimens/multiple doses

• asymptomatic/chronic conditions

• cognitive/physical impairments

• dissatisfied w/ care or poor relationship w/ provider

• low healthy literacy

• hectic lifestyle/alternate health beliefs

• fears of addiction/long-term complications

• adverse drug rxns/side effects

What are consequences of non-adherence?

• misjudging efficacy of medication

• loss of confidence by pt in efficacy of med and skills of health care team

• poor clinical outcomes

• economic loss

value expectancy theory:

behavior is based on

• value placed by an individual on a particular outcome

• the expectation that a given action will result in that outcome

health belief model:

1.) model starts w/ perceived threat

2.) introduces factors related to illness that can affect likelihood of taking action

3.) cues that propel pt into action using factors from Step 2

4.) likelihood of taking action

What are factors that may influence pt’s likelihood of taking action?

• demographics, health system characteristics, attitudes, and relationship w/ provider

• pt’s health beliefs

• other positive/negative motivators

• enabling factors

• self-efficacy

theory of reasoned action:

introduces two important concepts in predicting behavior: behavioral intention and subjective norms

behavioral intention:

an individual’s inclination to perform a behavior

subjective norms:

the individual’s perception of others’ beliefs about whether or not a behavior is appropriate

What are four factors that affect one’s behavior according to Theory of Reasoned Action?

1.) expectations that a given behavior will lead to certain outcomes

2.) positive and negative evaluations about those outcomes

3.) beliefs of what others think about whether the behavior should/shouldn’t be performed

4.) motivation to comply

self-regulation theory:

pts use their own internal information (i.e. responding to their own symptoms and experiences) as a way to guide themselves toward treatment goals

locus of control theory:

internal vs. external locus of control:

• internal: YOU make things happen and are in control

• external: things happen TO you and others have control

What are methods of self-report to detect non-adherence?

• pt interview/diary

• drug levels in biologic fluids

• direct pt observation

• adherence surveys

What are methods using others to detect non-adherence?

• physician estimate

• family member

What are objective methods of detecting non-adherence?

• pill count/pharmacy profile

• insurance system records

• MEMS caps

medication possession ratio:

most commonly used method for claims-based adherence measurement; sums days supply in refills across an interval

proportionate days covered:

based on fill dates and days supply for each fill of a prescription; number of days in period covered DIVIDED by number of days in period (multiply value by 100 for %)

What is the RIM approach to improve non-adherence?

R: recognize non-adherence

I: identify reason

M: monitor non-adherence

How do we “recognize” non-adherence?

• ask pt about missed doses

• ask pt about knowledge of regimen

• be non-accusatory by using “I” statements

How do we “identify” non-adherence?

• uncover the reason

• classify the cause: is it knowledge deficit, process-related barriers, or motivational barriers?

knowledge deficit:

• doctor didn’t provide info/misinformed

• forgot info/misunderstandings

process-related barriers:

• difficult to open containers

• confusing dosing schedules/not compatible w/ lifestyle

• inability to pay

• side effects

motivational barriers:

• alternative health beliefs or cultural issues

• denial 

• lack of faith or frustration w/ prior treatments