PATIENT ADHERENCE

Oguns E.A.
Clinical III
 Outline

• Introduction

• Definition

• Epidemiology

• Improving Adherence

• Summary

• Conclusion
 Introduction
• Non adherence is a well recognized problem
in literature
• One significant development has been the
inclusion of the patient in the determination
and success of therapy, with the term
"adherence" seeming to indicate this action
more accurately than "compliance”
 Definition

The extent to which a person's behaviour –

taking medication, following a diet, and/or
executing lifestyle changes, corresponds with
agreed recommendations from a health-care
provider.

Source: Sabate E, ed. Adherence to long-term therapies: evidence for action. Geneva, World Health Organization, 2003.
 Also
• The degree to which patients adhere to
medical advice and take medicines as
directed.
• Adherence depends not only on patient
acceptance of information about the health
threat itself but also on the practitioner’s
ability to persuade the patient that the
treatment is worthwhile and on the patient’s
perception of the practitioner’s credibility,
empathy, interest, and concern.”
Management Sciences for Health and World Health Organization 1997, 428
 Epidemiology
• Studies have shown that in the United States
alone, nonadherence to medications causes
125,000 deaths annually and accounts for 10% to
25% of hospital and nursing home admissions.

• Recent reviews have shown that as many as 40%

of patients still do not adhere to their treatment
regimens as it was 3 decades ago.
IMPROVING ADHERENCE
SIMPLIFYING REGIMEN CHARACTERISITICS

I
MPARTING APPROPRIATE KNOWLEDGE

M ODIFYING BELIEFS & HUMAN BEHAVIOUR

PATIENT COMMUNICATION

LEAVING THE BIAS

EVALUATING ADHERENCE
Simplifying Regimen characteristics
• Complexity of regimen can affect adherence
• Hence
– A once a day dosing
– Matching regimen to activities of daily life
– Clear instructions esp in elderly
 Imparting Appropriate Knowledge
• Research has consistently demonstrated that
patients' understanding of their conditions
and treatments is positively related to
adherence, and that adherence, satisfaction,
recall, and understanding are all related to the
amount and type of information given
 Imparting Appropriate Knowledge
• Many studies have shown that patients do not
always understand prescription instructions
and often forget considerable portions of
what healthcare practitioners tell them.
Studies have shown that patients who
understand the purpose of the prescription
are twice more likely to fill it than those who
do not understand the purpose.
 Imparting Appropriate Knowledge
• Effective patient education (Katz)
1.Limit instructions to 3or4 major points per discussion
2.Use simple everyday language,esp when explaining
diagnosis & giving instructions
3. Supplement oral teaching with written materials
4. Involve the patient’s family members & friends
5. Reinforce the concepts discussed
Counting instructions on her fingers
 Modifying Beliefs and Human
Behaviour
• For interventions that are complex and
require lifestyle modifications, it is worthwhile
to address patients' beliefs, intentions, and
self-efficacy (perceived ability to perform
action). This is because knowledge alone is
not sufficient to enhance adherence in
recommendations involving complex behavior
change.
 Modifying Beliefs and Human
Behaviour
• Clinicians can optimize behaviour change by
ensuring :
1. Perceived susceptibility
2. Perceived severity
3. Perceived benefits
4. Perceived barriers
5. Self-efficacy
by the patients
 Patient communication
• Patient communication encompasses
interventions ranging from physician-patient
communication, sending mail or telephonic
reminders, to involving patients' families in
the dialogue. Of these, the most problematic
is physician-patient communication

• At least 50% of patients leave their doctors'

offices not knowing what they have been told.
 Patient communication
• Studies have shown that
– 1.50% of psychosocial and psychiatric problems
are missed by physicians due to lack of proper
communication
– 2.Physicians interrupt patients on an average of 18
seconds into the patients' descriptions of the
presenting problems
– 3.54% of patients' problems and 45% of patient
concerns are neither elicited by the physician nor
disclosed by the patient
– 4.71% of patients stated poor relationships as a
reason for their malpractice claims
 Rosenberg & Associates suggest that
you
• Ask a patient about his feelings and concerns
(in addition to physical aspects of the
problem) and his view about psychological
factors on the adherence, so as to arrive at a
common understanding to the nature of the
problem. Then provide them with information
about all areas that [that] individual finds
pertinent, and encourage them to share in
decision making when a plan for management
is formulated.
 Leaving the Bias

DEMOGRAPHIC FACTORS PLAY ONLY A MINOR ROLE IN ADHERENCE IF AT ALL

 Evaluating Adherence
• Self reports
• Pill counting
• Serum/urine drug levels sometimes
SUMMARY
Some Commonly Used Interventions in Successful Adherence-
Enhancing Strategies
Strategies
Simplifying regimen characteristics
Imparting knowledge
Specific Interventions
Adjusting timing, frequency, amount,
and dosage
Matching to patients' activities of daily
living
Using adherence aids, such as
medication boxes and alarms
Discussion with physician, nurse, or
pharmacist
Distribution of written information or
pamphlets
Accessing health-education information
on the Web
Modifying patient beliefs
Patient and family communication
Leaving the bias
Evaluating adherence
Assessing perceived susceptibility,
severity, benefit, and barriers
Rewarding, tailoring, and contingency
contracting
Active listening and providing clear, direct
messages
Including patients in decisions
Sending reminders via mail, email, or
telephone
Convenience of care, scheduled
appointment
Home visits, family support, counseling
Tailoring the education to patients' level
of understanding
Self-reports (most commonly used)
Pill counting, measuring serum or urine
drug levels
 ADHERE: A MNEMONIC FOR
IMPROVING PATIENT ADHERENCE
WITH THERAPEUTIC REGIMENS
• A: Acknowledge the need for treatment with
the patient, and ask about previous
treatments utilized. Together determine
mutual goals and desired outcomes.
• D: Discuss potential treatment strategies and
options, as well as consequences of non-
treatment with the patient (consider issues
such as treatment effectiveness, prognosis,
use of complementary/ alternative medicine,
brand name vs. generics, off-label uses,
prescription plans, formularies, etc.).
• H: Handle any questions or concerns the
patient may have about treatment (e.g., fears
or worries, side effects, costs, dosage,
frequency, timing, sequence, duration of
treatment, drug or food interactions, proper
storage techniques).
• E: Evaluate the patient’s functional health
literacy and understanding of the
purpose/rationale for treatment, and assess
barriers and facilitators to adherence (e.g.,
environmental, economic, occupational, and
sociocultural factors, family situation and
supports)
• R: Recommend / Review the therapeutic
regimen with the patient.

• E: Empower by eliciting the patient’s

commitment and willingness to follow-
through with the therapeutic regimen.
 Conclusion

I HOPE YOU WOULD HAVE FORGOTTEN THIS IN

A FEW YEARS.
IT WILL BE PART OF YOU BY THEN
THANK YOU VERY MUCH