Download As presented at the CRA ASM 2016 Lake Louise, Alberta

As presented at the CRA ASM 2016 Lake Louise, Alberta
OPENING REMARKS
Andy Thompson, MD, FRCPC
Rheumatologist, Associate Professor of
Medicine, Western University, London
As presented at the CRA ASM 2016 Lake Louise, Alberta
DISCLOSURE
Dr Regan Arendse
— Grants/Research Support: None
— Speakers Bureau/Honoraria: Abbvie, Roche, Janssen & Amgen
— Consulting Fees: Abbvie, Roche, Janssen & Amgen
As presented at the CRA ASM 2016 Lake Louise, Alberta
DISCLOSURE
Dr Tavis Campbell
— Grants/Research Support: Abbvie (investigator-initiated)
— Speakers Bureau/Honoraria: Abbive, Boehringer Ingelheim, Janssen,
Novo Nordisk, Pfizer
— Consulting Fees: Janssen, Novo Nordisk, Pfizer, Servier
As presented at the CRA ASM 2016 Lake Louise, Alberta
DISCLOSURE
Dr Andrew Thompson
– Grant/Research Support: Amgen, Abbvie, Celgene, Janssen, Roche
– Speaker’s Bureau: Janssen
– Consultant: BMS, Celgene, Amgen, Abbvie, Janssen, Roche, Eli-Lilly
As presented at the CRA ASM 2016 Lake Louise, Alberta
DISCLOSURE
Dr. Martin Cohen
– Investigator / Speaker / Consultant
• Abbvie
• Amgen
• BMS
• Celgene
• Hospira
• Janssen
• Lilly
•
•
•
•
•
•
•
Merck
Novartis
Pfizer
Purdue
Roche
Takeda
UCB
As presented at the CRA ASM 2016 Lake Louise, Alberta
THE HEALTH AND SAFETY ADHERENCE QUIZ
1. Do you have a smoke detector in your home and change the batteries at least
once a year?
2. Do you buckle up every time you are in a car, even in the back seat?
3. Do you exercise at least 30 minutes 3 times a week?
4. Do you wear a bicycle helmet every time you ride a bike?
5. Do you wear a personal flotation device every time you get in a boat?
6. Do you make sure that every child who is under 8 years old and weighs less
than 80 lbs is in an appropriate car seat or booster seat every time you drive??
7. Do you have a fire extinguisher in your kitchen?
8. Do you floss daily?
9. Have you practiced a fire safety plan at home and picked a meeting spot
outside your home?
10. Do you abstain from using your cell phone while driving?
As presented at the CRA ASM 2016 Lake Louise, Alberta
PATIENT DIALOGUE 1
As presented at the CRA ASM 2016 Lake Louise, Alberta
PROGRAM FACULTY
Chair:
Andy Thompson, MD, FRCPC
Rheumatologist, Associate Professor of Medicine, Western University, London
Speakers:
Regan Arendse, MD, FRCPC
Rheumatologist, Assistant Clinical Professor, University of Saskatchewan,
Saskatoon
Martin Cohen, MD, FRCPC
Rheumatologist, Montreal General Hospital, McGill University, Montreal
Tavis Campbell, PhD
Professor, Department of Psychology, University of Calgary
As presented at the CRA ASM 2016 Lake Louise, Alberta
LEARNING OBJECTIVES
• Increase the understanding of the impact of real-world evidence,
including registry data and medication utilization, on patient
management plans
• Identify the factors rheumatologists can address in order to positively
impact the quality of patient care and decrease the burden on the
healthcare system (e.g., adherence, patient motivation, previous
medication experiences)
• Increase the understanding of how enabling open dialogue with a
patient through various communication techniques will support
positive patient behaviour
As presented at the CRA ASM 2016 Lake Louise, Alberta
TOUCHPAD QUESTION 1
HOW IMPORTANT IS PATIENT ADHERENCE TO YOU
WHEN YOU’RE MANAGING PATIENTS WITH RA?
1.
2.
3.
4.
Not at all important
Somewhat important
Fairly important
Extremely important
As presented at the CRA ASM 2016 Lake Louise, Alberta
“DRUGS DON’T WORK IN PATIENTS WHO
DON’T TAKE THEM.”
— C. Everett Koop, MD
As presented at the CRA ASM 2016 Lake Louise, Alberta
“KEEP WATCH ALSO ON THE FAULT OF
PATIENTS WHICH MAKES THEM LIE ABOUT
TAKING OF THINGS PRESCRIBED.”
— Hippocrates, 500 BC
As presented at the CRA ASM 2016 Lake Louise, Alberta
RANGE OF ADHERENCE
Consistent adherence: 1/3 of patients
• Half come close to perfect adherence
• Half take nearly all doses but with some timing irregularity
Consistent non-adherence: 1/3 of patients
• Half have a drug holiday monthly or more often with frequent
omissions of doses
• Half take few or no doses
Good
Average
Bad
In the middle: 1/3 of patients
Range:
• Miss an occasional single day’s dose and have some timing inconsistency
• Take drug holidays three or four times a year with occasional omissions of
doses
Rheuminfo.com. Medication Adherence for Rheumatologists. Available at: http://rheuminfo.com/wp-content/uploads/2014/01/Medication-Adherencefor-Rheumatologists.pdf. Accessed January 2016.
As presented at the CRA ASM 2016 Lake Louise, Alberta
THE BURDEN OF CHRONIC DISEASE
“…poor adherence increases with the duration and
complexity of treatment regimens… duration and complex
treatment are inherent to chronic illnesses.
Across diseases, adherence is the single most important
modifiable factor that compromises treatment outcome.”
– World Health Organization, 2003
Sabate E. Adherence to long-term therapies. Evidence for action. 2003. Geneva, Switzerland: World Health Organization (WHO) 2003;
http://www.who.int/chp/knowledge/publications/adherence_report/en/index.html. Accessed January 2016.
As presented at the CRA ASM 2016 Lake Louise, Alberta
IMPACT OF INADEQUATE ADHERENCE ON OUTCOMES IN RA
With traditional DMARDs
Incidence of Disease
Flares (per 100 pts/year)
93 RA pts with early RA
(< 1 yr) treated with
traditional DMARDs;
68 (73.1%) of them in
remission (DAS < 2.4)
4 consecutive evaluations,
2 months apart
6 mos FU
•
•
47 (50.5%)
Adherent pts
compliance questionnaire (CQ)
drug record registry (DRR)
P = 0.002
RA Flares
60
50
40
30
20
10
0
Regimens with ≥ 3
DMARDs increased risk
of non-adherence vs
MTX mono (P ≤ 0.02).
48.41
13.31
Non-adherent
Adherent
Adherent pts: ≥ 80% DMARDs taken; Flare: DAS28 ≥ 2.4 in at least 1 evaluation
Contreras-Yáñez I et al. Am J Med Sci 2010;340:282
As presented at the CRA ASM 2016 Lake Louise, Alberta
A LARGE NUMBER OF PATIENTS ARE RELUCTANT TO TAKE
DMARDS PRIOR TO AND POST-BIOLOGIC INITIATION
DMARD acquisitions by Canadian RA patients (n = 1,652) in the
6–12 months immediately prior to and post-biologic initiation*
No purchase of any form of
DMARD
Patients (%)
100
80
No purchase of MTX
60
43
41
40
29
25
41
37
22
26
20
0
6 months pre-biologic
initiation
•
•
6 months post-biologic
initiation
12 months pre-biologic
initiation
12 months post-biologic
initiation
A large proportion of patients do not acquire any form of DMARD in the 6–12 months prior to being initiated
on a biologic for the first time
Many patients report reluctance or refusal to take DMARDs due to side effects that include headache, GI
discomfort, malaise, fatigue, nausea, hair loss and lifestyle restrictions
*Includes all patients who were initiated on a biologic between August 2009 and July 2010 and remained compliant on their biologic
Choquette D et al. Arthritis Rheum 2012;64(Suppl 10):S783
As presented at the CRA ASM 2016 Lake Louise, Alberta
IMPACT OF INADEQUATE ADHERENCE ON OUTCOMES IN RA
With SC anti-TNFs
286 patients with active RA (median DAS28 5.94, IQR 5.45-6.55) and disease duration
7 years (IQR 3-15) starting SC anti-TNF; FU for 6 months with evaluations at 3 and 6
months
27% selfreported nonadherence
Factors associated with change in DAS28 score after 6 month
Demographic or
clinical characteristic
β-coefficient
(95% CI)
P-value
Ever non-adherent
0.47 (0.10, 0.85)
0.014
Female
0.33 (-0.05, 0.72)
0.084
Age at baseline
0.02 (0.01, 0.04)
0.002
NSAID usage
-0.10 (-0.44, 0.19)
0.561
42
DMARD usage
-0.19 (-0.67, 0.29)
0.446
19
Married/living with
partner
-0.20 (-0.59, 0.19)
0.307
Non-adherent (%)
Disease duration
-0.01 (-0.03, 0.01)
0.203
Baseline DAS28
-0.74 (-0.95, -0.53)
< 0.001
Nonadherence by EULAR
response
39
53
41
7
Adherent (%)
Good response
Moderate response
No response
Self-reported nonadherence, defined as whether the previous due dose of biologic therapy was reported as not taken
on the day agreed upon with the HCP
Bluett J et al. Rheumatology 2015;54:494
As presented at the CRA ASM 2016 Lake Louise, Alberta
ECONOMIC OUTCOMES ASSOCIATED WITH NONADHERENCE IN RA
Tang et al:
Persistence in RA patients taking a biologic plus methotrexate was
associated with:
o Lower non-pharmacy costs, including inpatient, outpatient, laboratory
and emergency department services
o Lower comorbidity
Tang B et al. Clin Ther 2008;30:1375;
As presented at the CRA ASM 2016 Lake Louise, Alberta
PATIENT DIALOGUE 2
As presented at the CRA ASM 2016 Lake Louise, Alberta
REAL-WORLD EVIDENCE
Martin Cohen, MD, FRCPC
Rheumatologist, Montreal General
Hospital, McGill University
As presented at the CRA ASM 2016 Lake Louise, Alberta
TOUCHPAD QUESTION 2
WHICH OF THE FOLLOWING QUESTIONS CANNOT BE
ANSWERED BY A RANDOMIZED CONTROLLED TRIAL?
1. What is the long-term safety and efficacy of a therapy?
2. How long will patients stay on the therapy (how durable
is it)?
3. What kinds of patients are taking the therapy in realworld practice?
4. All of the above
As presented at the CRA ASM 2016 Lake Louise, Alberta
QUESTIONS NOT GENERALLY ANSWERABLE BY RCTS
• What is the long-term safety and efficacy of a therapy?
• In the real world, who is taking the therapy and how?
• How does the therapy function in patients who were excluded
from clinical trials (e.g., patients with comorbidities)?
• In the absence of head-to-head trials, how do other treatment
options compare?
• How long will patients stay on the therapy (how durable is it)?
As presented at the CRA ASM 2016 Lake Louise, Alberta
REGISTRIES VERSUS RCTS
RCT
Patient
Selection
Hypothesis
Control/
Standard of
Care
Randomization
Intervention
Drug A
Registry
Determine
Outcomes to
Measure
Enroll patients
prescribed A-C
Drug B
Drug C
Adapted from: Bessette L et al. Real-World Data For A Real-World Disease: Why We Need Registries in RA, Western University, 2015
As presented at the CRA ASM 2016 Lake Louise, Alberta
Record
Outcome(s)
of Interest
and
Compare
RCTs PROS AND CONS
PROS
CONS
Randomization eliminates the influence of
confounding variables
The study population is not representative
of the disease population (results less
generalizable)
Appropriate control (placebo or standard of
care or another treatment)
Short follow-up period
Double blinding eliminates observation biases
Can’t detect rare events, long-term efficacy
or durability
Close monitoring of efficacy, compliance and
side effects/treatment-emergent adverse
events
Costly
Better compliance and retention lead to more
favourable effect sizes
Single study question is addressed
Ability to show causal relationships
Lower number of participants
Adapted from: Bessette L et al. Real-World Data For A Real-World Disease: Why We Need Registries in RA, Western University, 2015
As presented at the CRA ASM 2016 Lake Louise, Alberta
REGISTRIES PROS AND CONS
PROS
CONS
Usually much larger N than clinical trials
Non-randomized design may lead to multiple
biases (selection, channelling, surveillance)
Greater power than RCTs to detect rare events
Missing data
Enrollment reflects clinical practice
Difficult to choose appropriate reference
(control) group
Potential for studying numerous outcomes
Time-consuming
Suited to long-term follow-up
Costly
Examine complex situations not suited to RCTs
Can’t establish causal relationship
Results can usually be generalized
Impossible to take into account all
confounding variables in the analysis
Can establish durability of response
Adapted from: Bessette L et al. Real-World Data For A Real-World Disease: Why We Need Registries in RA, Western University, 2015
As presented at the CRA ASM 2016 Lake Louise, Alberta
INTERNATIONAL REGISTRIES
Argentina
GBB – publication expected in near
future
Brazil
BIOBADABRAZIL – multicentre
registry
Czech Republic
ATTRA – biologics registry
Denmark
DANBIO – biologics registry
France
RATIO – enhanced
pharmacovigilance program in
hospitals that prescribe anti-TNFs or
manage patients with opportunistic
infection or lymphoma (with case
control design)
Germany
RABBIT – national registry to
describe long-term effectiveness,
comparing biologics with
conventional DMARDs
Spain
BIOBADASER – random samples of
RA patients from 34 units
EMECAR
Italy
GISEA – Italian Multicentre Registry
LOHREN – Northern Italian
Lombardy Registry Network
Sweden
ARTIS – nationwide, but organized
on a regional basis
STURE – Stockholm registry
SSATG – Southern Sweden
Mexico
BIO BADAMEX – biologics registry
Switzerland
SCQM – population-based registry
The Netherlands
Several local registries (e.g., DREAM)
UK
BSRBR – national registry
Norway
NOR-DMARD – registry based on
prescriptions for DMARDs (including
anti-TNFs)
US
CORRONA – across 33 states
RADIUS- multicentre registry
Adapted from: Bessette L et al. Real-World Data For A Real-World Disease: Why We Need Registries in RA, Western University, 2015
Gibofsky A, et al. J Rheumatol 2011;38:21
As presented at the CRA ASM 2016 Lake Louise, Alberta
CANADIAN REGISTRIES
National
• CATCH – Canadian Early Arthritis Cohort, early arthritis registry1
• BioTRAC – Biologic TRial Registry Across Canada, patients receiving
infliximab, golimumab and ustekinumab treatment2
Provincial
• OBRI – Ontario Best Practice Research Initiative, province-wide registry of
available RA treatments1,3
• Rhumadata – Institut de Rhumatologie de Montréal monitors patients with
RA, PsA and AS1
• ABioPharm – the Alberta Biologics Pharmacosurveillance registry4
1. Bessette L et al. Real-World Data For A Real-World Disease: Why We Need Registries in RA, Western University, 2015; 2. Biologic TRial Registry
Across Canada(BioTRAC), https://clinicaltrials.gov/ct2/show/NCT00741793. Accessed Jan. 21 2016; 3. OBRI, http://www.obri.ca/. Accessed Jan 21 2016;
4. Marshall DA et al. Institute of Health Economics. RA in A Policy Perspective: A Registry for Research and Better Treatment of Albertans, 2015
As presented at the CRA ASM 2016 Lake Louise, Alberta
NORTH AMERICAN REGISTRY DATA
RHEUMATOID ARTHRITIS DISEASE-MODIFYING ANTI-RHEUMATIC
DRUG INTERVENTION AND UTILIZATION STUDY (RADIUS) 1
(RA – FIRST BIOLOGIC)
Persistence was similar
among treatments (P > 0.05)
Proportion of Patients Continuing
on the Same Agent
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Adalimumab
Etanercept
Infliximab
0.0
00
55
10
10
15
15
20
20
25
25
30
30
35
35
42
40
45
45
Time on drug (month)
Markenson JA et al. J Rheumatol 2011;38:1273
As presented at the CRA ASM 2016 Lake Louise, Alberta
50
50
54
55
NORTH AMERICAN REGISTRY DATA
CONSORTIUM OF RHEUMATOLOGY RESEARCHERS OF NORTH
AMERICA (CORRONA)
(RA)
% Patients Continuing Treatment
Biologic naïve
100
80
First-time switchers
* P < 0.05 vs Infliximab
76
*
72
68*
100
80
65
63
60
53
*
*
53
60
60
57
43
40
40
20
20
0
0
1 Year
Infliximab (n = 460)
2 Years
Etanercept (n = 480)
Adalimumab (n = 535)
1 Year
Infliximab (n = 166)
Adalimumab (n = 311)
Greenberg JD et al. Ann Rheum Dis 2012;71:1134
As presented at the CRA ASM 2016 Lake Louise, Alberta
41
42
2 Years
Etanercept (n = 139)
INTERNATIONAL REGISTRY DATA
RHEUMATOID DISEASE – SUBCUTANEOUS TNF-ALPHA BLOCKERS NATIONAL
SWEDISH PRESCRIPTION AND PATIENT REGISTRIES
(RA, PSA AND AS – FIRST BIOLOGIC)
1.0
Golimumab had statistically
significantly higher
persistence over the study
period than adalimumab or
etanercept (p = 0.022 and
p = 0.004, respectively)
Survival Probability
0.8
0.6
0.4
0.2
Adalimumab
Etanercept
Certolizumab
Golimumab
0.0
0
6
12
18
24
30
Time (months)
Dalen J, et al. Rheumatol Int 2016 Jan 16 [epub]
As presented at the CRA ASM 2016 Lake Louise, Alberta
36
42
CANADIAN DATABASE FINDINGS
(RA, PSA AND AS)
Medication = estimated drug utilization over a defined period
Possession Ratio
expected drug utilization over that period
(MPR)
% of Patients
100
80
Proportion of Patients that Were Adherent (MPR > 0.80%)
24-Months Retained Patients
p < 0.0001
87
71
73
75
Certolizumab
Etanercept
Adalimumab
60
40
20
0
Golimumab SC
•
The proportion of bio-naïve vs bio-experienced patients is similar across treatment arms.
•
More specifically, the bio-naïve cohort represents 86% of the GOLIMUMAB arm versus
94%-95% of the ADALIMUMAB and ETANERCEPT arms.
Bhoi P et al. Poster presented at Canadian Rheumatology Association Annual Scientific Meeting; February 17-20, 2016.
As presented at the CRA ASM 2016 Lake Louise, Alberta
COMPARISON OF ADHERENCE MEASURES
AMERICAN DATABASE FINDINGS
(RA – ALL LINES OF THERAPY)
p < 0.001
p < 0.001
0.85
100
No. (%) of Patients
No. (%) of Patients
0.9
0.8
0.75
p < 0.001
80
60
40
20
0.7
0
Mean MPR
Adalimimab (n = 1,532)
Golimumab (n = 261)
Mean PDC
Etanercept (n = 2,099)
MPR ≥ 0.80 (%)
MPR = Medication Possession Ratio
PDC = Proportion of Days Covered
Tkacz J et al. Clin Ther 2014;36:737
As presented at the CRA ASM 2016 Lake Louise, Alberta
PATIENT DIALOGUE 3
As presented at the CRA ASM 2016 Lake Louise, Alberta
TOUCHPAD QUESTION 3
WHAT WOULD YOU HAVE DONE DIFFERENTLY IN THE
PATIENT SCENARIO JUST PRESENTED?
1. Nothing — I’d do exactly the same thing
2. Try to convince the patient to be more adherent to her current
therapy by emphasizing its importance to her health and
quality of life
3. Suggest reminder systems to help the patient remember to
take her medications
4. Ask the patient about other factors that may be contributing to
her nonadherence
As presented at the CRA ASM 2016 Lake Louise, Alberta
ADDRESSING ADHERENCE
Tavis Campbell, PhD, R. Psych.
Professor and Director of Clinical Training
Departments of Psychology and Oncology
University of Calgary
Past Head, Health Section
Canadian Psychological Association
Chair, Adherence
Hypertension Canada
As presented at the CRA ASM 2016 Lake Louise, Alberta
TOUCHPAD QUESTION 4
WHAT DO YOU BELIEVE IS THE MAIN REASON FOR A RA
PATIENT TO BE NON-ADHERENT TO A BIOLOGIC
MEDICATION?
1. Perceived lack of efficacy of the medication
2. Patient self-confidence in their ability to manage
their condition
3. Safety concerns / side effects
4. Complicated dosing regimen / multiple
medications
5. Fear of medication dependence
As presented at the CRA ASM 2016 Lake Louise, Alberta
THE PROBLEM OF POOR ADHERENCE
• On average, 50% of patients don’t take their medications as
prescribed; 6% to 44% never even fill their first prescription1
• Only 15% of Canadian adults achieve recommended physical
activity targets2
1. WHO, Adherence to Long-Term Therapies: Evidence for Action, 2003; 2. Colley RC et al. Heal Rep. 2011;22:7
As presented at the CRA ASM 2016 Lake Louise, Alberta
THE FIVE DIMENSIONS OF ADHERENCE
Healthcare1
Disease activity,
morning stiffness,
disease duration,
comorbidities
(depression),
functioning1
Health system/
HCT-factors 1
Conditionrelated factors 1
Social/economic
factors 1
Age, gender, education,
tobacco use, socialeconomic status, living
situation…1
Therapy-related
factors 1
Less frequent dosing
regimens result in
better compliance
across a variety of
therapeutic classes 2
Patient-related
factors 1
Patient knowledge, beliefs about
the disease and its treatment1
Adherence to prescribed medication in RA: 30%–80 %3
1. WHO, Adherence to Long-Term Therapies: Evidence for Action. 2003; 2. Claxton AJ et al. Clin Ther 2001;23:1296.; 3. van den Bermt et al. Expert Rev Clin
Immunol 2012;8:337
As presented at the CRA ASM 2016 Lake Louise, Alberta
FACTORS INFLUENCING ADHERENCE
Patient-related factors
Intentional
• Fear of medication dependence
• Reminder of illness
• Lack of investment in self-care
Condition-related factors
•
•
Unintentional
• Forgetfulness*
•
• Language barriers*
• Depression*
• Cognitive impairment
• Socioeconomic/demographic
barriers*
• Physical inability
• Lack of needed knowledge, skills
and confidence*
• Poor social/family support
Current level of
symptoms
Patient beliefs about the
condition (including
whether it needs
treatment)*
Need for long-term
medication use*
Therapy-related factors
•
•
•
•
•
•
•
•
•
Patient beliefs about the
medication
Fear of adverse events
and/or long-term
effects*
Cost/insurance issues*
Dosing frequency*
Regimen complexity*
Route of administration*
Length of time on
therapy
Success of previous
treatments*
Quality of
communication with
HCP*
*Factors that have been demonstrated in studies of RA patients
Thompson A et al. How can I better understand my RA patients’ perceptions of and relationship to their medication to improve adherence?, Western
University, 2016
As presented at the CRA ASM 2016 Lake Louise, Alberta
PROVIDER FACTORS
•
•
•
•
•
•
•
•
Communication skills
Knowledge of health literacy issues
Lack of empathy
Lack of positive reinforcement
Number of comorbid conditions
Number of medications needed per day
Types or components of medication
Amount of prescribed medications or
duration of prescription
Haynes RB et al. Cochrane Database Syst Rev 2008;(2):CD000011
As presented at the CRA ASM 2016 Lake Louise, Alberta
WHAT CAN PROVIDERS DO TO OVERCOME THESE
CHALLENGES?
SETTING THE PATIENT UP FOR SUCCESS
You’ve made a diagnosis, determined a treatment path and
made your recommendation/prescription
• Role now switches from expert to coach
• The outcomes you are looking for are more related to patient
adherence than to what you do
• Adherence applies to medication adherence, physical activity,
smoking cessation, etc.
• It is not your job to change the patient
• You can help the patient change within your scope of practice
(time, training, interest)
As presented at the CRA ASM 2016 Lake Louise, Alberta
SIMPLE
•
•
•
•
•
•
S — Simplify the regimen
I — Impart knowledge
M — Modify patient beliefs and behaviour
P — Provide communication and trust
L — Leave the bias
E — Evaluate adherence
American College of Preventive Medicine (ACPM), 2011. http://www.acpm.org/?MedAdherTT_ClinRef
As presented at the CRA ASM 2016 Lake Louise, Alberta
S — SIMPLIFY THE REGIMEN
•
•
•
•
•
Adjust timing, frequency, amount and dosage
Match regimen to patient’s activities of daily living
Recommend taking all medications at the same time of day
Investigate customized packaging for patients
Encourage use of adherence aids
ACPM, 2011. http://www.acpm.org/?MedAdherTT_ClinRef
As presented at the CRA ASM 2016 Lake Louise, Alberta
I — IMPART KNOWLEDGE
•
•
•
•
•
•
Focus on patient-provider shared decisionmaking
Keep the team informed (physicians, nurses
and pharmacists)
Involve patient’s family or caregiver if
appropriate
Provide all prescription instructions clearly in
writing and verbally
Suggest additional information from Internet if
patients are interested
Reinforce all discussions often, especially for
low-literacy patients
ACPM, 2011. http://www.acpm.org/?MedAdherTT_ClinRef
As presented at the CRA ASM 2016 Lake Louise, Alberta
M — MODIFY PATIENT BELIEFS AND BEHAVIOUR
• Empower patients to self-manage
their condition
• Ensure that patients understand
their risks if they don’t take their
medications
• Ask patients about the
consequences of not taking their
medications
• Have patients restate the positive
benefits of taking their medications
• Address fears and concerns
ACPM, 2011. http://www.acpm.org/?MedAdherTT_ClinRef
As presented at the CRA ASM 2016 Lake Louise, Alberta
P — PROVIDE COMMUNICATION AND TRUST
• Practice active listening
• Use plain language
• Elicit patient’s input in treatment
decisions
ACPM, 2011. http://www.acpm.org/?MedAdherTT_ClinRef
As presented at the CRA ASM 2016 Lake Louise, Alberta
Do you want to take care of yourself?
vs
Why do you want to take care of yourself?
How hard are you willing to work to take care of yourself?
How willing are you to make choices that might increase the burden
temporarily in order to improve your health in the long run?
As presented at the CRA ASM 2016 Lake Louise, Alberta
ELICIT POSITIVE, PERSONALLY RELEVANT REASONS
FOR CHANGE
The typical exchange:
“It’s very important for you to lose weight, stop smoking, and
control your symptoms with the medications. If not, you risk
developing serious complications.”
An alternative approach:
“How important would you say it is for you to change your diet?
Why are these changes important to you?”
• Need to connect to person’s values, principles, identity
As presented at the CRA ASM 2016 Lake Louise, Alberta
L — LEAVE THE BIAS
• Understand health literacy and how it affects outcomes
• Examine self-efficacy regarding care of ethnic and low SES
populations
• Acknowledge biases in medical decision-making
ACPM, 2011. http://www.acpm.org/?MedAdherTT_ClinRef; Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman;
Bandura, A. (1994). Self-efficacy. In V.S. Ramachaudran (Ed.), Encyclopedia of human behavior; 4. New York: Academic Press, pp. 71
As presented at the CRA ASM 2016 Lake Louise, Alberta
“Did you not warn him not to
touch a hot stove? I’m afraid we
can’t help him. Clearly he did this
to himself.”
As presented at the CRA ASM 2016 Lake Louise, Alberta
E — EVALUATE ADHERENCE
• Ask about adherence behaviour at every visit
• Periodically review patient’s medication
containers, noting renewal dates
• Use medication adherence scales — for
example:
o Morisky-4 (MMAS-4, also known as the Medication
Adherence Questionnaire or MAQ)
o Medication Possession Ratio (MPR)
ACPM, 2011. http://www.acpm.org/?MedAdherTT_ClinRef; Morisky DE, DiMatteo MR. Journal of Clinical Epidemiology 2011;64:262;
https://www.urac.org/MedicationAdherence/includes/Nau_Presentation.pdf
As presented at the CRA ASM 2016 Lake Louise, Alberta
COMPLIANCE QUESTIONNAIRE FOR RHEUMATOLOGY
(CQR)
•
•
•
•
The only rheumatology-specific adherence measure
Originally 19 items
Reduced to 5 items (CQR-5)
Uses a 4-point Likert scale
o 1 = definitely don’t agree, 2 = don’t agree, 3 = agree,
4 = definitely agree
o Scores range from 4–20, low scores indicate low adherence
Hughes LD et al. BMC Musculoskelet Disord 2013;14:286
As presented at the CRA ASM 2016 Lake Louise, Alberta
ASSESSING MOTIVATION FOR BEHAVIOUR CHANGE
Readiness Assessment
1. “Do you consider your current behaviour to be a problem?”
2. “Are you distressed by your current behaviour?”
3. “Are you interested in changing this behaviour?”
4. “Are you ready to change now?”
As presented at the CRA ASM 2016 Lake Louise, Alberta
GETTING TO THE BEHAVIOUR
Readiness Assessment
Not Ready
Understanding the
behaviour
• Personal meaning
• Seriousness
• Personal
•
•
responsibility
Controllability
Optimism
Ambivalent
Ready
Go right
to behaviour
modification
Expanding on
readiness
• Personal/meaningful
•
•
reasons to change
Willingness to work
hard – connect to
principles
Delay of gratification
As presented at the CRA ASM 2016 Lake Louise, Alberta
TAKE-HOME MESSAGES FOR PROVIDERS
• Display patience and empathy when interacting with patients
• Be mindful of the number of medications prescribed and their
frequency and dosages
•
•
•
•
Assess readiness
Tie to positive, meaningful outcomes
Offer a menu of options
Elicit reactions and feedback
As presented at the CRA ASM 2016 Lake Louise, Alberta
Q&A
As presented at the CRA ASM 2016 Lake Louise, Alberta
CONCLUDING REMARKS
THANK YOU
As presented at the CRA ASM 2016 Lake Louise, Alberta