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RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn
Better Patient Adherence:
Why patients don’t adhere and
what we can do about it (maybe)
Frank Doyle, PhD
Adherence
• Adherence: “...the extent to which a person’s
behaviour – taking medication, following a
diet and/or executing lifestyle changes –
corresponds with agreed recommendations
from a healthcare provider.” (WHO, 2003)
• Adherence to chronic therapies estimated at
only 50%
• Even lower for non-medication therapies…
Adherence and outcomes
• Treatment failure or reduced efficacy
• Poor outcomes, including long-term
complications
• Increased healthcare costs
• But how much?
Example: Cardiovascular disease
• Chowdury et al - Meta-analysis of
cardiovascular medication and
morbidity/mortality
• 44 studies (almost 2 million patients)
• 60% had good adherence (>80%)
• Comparing ‘good’ v ‘poor’ on preventive meds
– Development of CVD: RR 0.85-0.81
– All-cause mortality: RR 0.55-0.71
European Heart Journal (2013) 34, 2940–2948
Two main points about adherence
1. Adherence is multidimensional, and is therefore a
complex behaviour
– In terms of both the things patients have to do, but also in
terms of what influences their behaviour
– Influenced by environmental, social aspects, cognitive and
emotional aspects
2. There are actually two main types of non-adherence:
– Unintentional non-adherence, such as forgetting
– Intentional non-adherence, such as not wanting to get
addicted to your medication
• The intervention needs of each of these types is starkly different
Adherence is a complex behaviour
• Adherence is a complex behaviour
• Our behaviour is determined by a complex interplay of:
–
–
–
–
Environment
Social concerns and peer influences
Cognition or thoughts
Emotions
• Research in health psychology has established that each of
these factors predicts adherence in high quality studies
(systematic reviews etc)
–
–
–
–
Forgetting (environmental cues)
Social support
Beliefs about medicine and illness
Depression
Two types of non-adherence
• Unintentional non-adherence, such as forgetting
– We intend to take our medicine, but someone rings us and
we get distracted; or we are in a new location etc
– We are unable to do the physical things required, such as
using an inhaler properly is quite difficult
• Intentional non-adherence
– not wanting to get addicted to medication
– not believing they are worth it
– being too worried about side effects
– misperceptions about what caused the illness
Examples of misperceptions:
Medication holidays?
3. People who take medicines should stop
their treatment for a while every now and then
74
Pharmacists
Patients
30
0%
20%
Disagree/Strongly disagree
22
41
40%
Uncertain
4
29
60%
80%
100%
Agree/Strongly agree
* From: Ramstrom, Afandai, Elofsson, Petersson (2006). Differences in beliefs between patients and
pharmaceutical specialists regarding medications. Patient Education and Counseling, 62, 244-249.
Examples of misperceptions:
Addictive?
6. Most medicines are addictive
Pharmacists
92
Patients
49
0%
20%
Disagree/Strongly disagree
4 4
34
40%
Uncertain
60%
17
80%
100%
Agree/Strongly agree
* From: Ramstrom, Afandai, Elofsson, Petersson (2006). Differences in beliefs between patients and
pharmaceutical specialists regarding medications. Patient Education and Counseling, 62, 244-249.
Interventions?
• Lots of excellent research targets unintentional nonadherence
– Text reminders
– Colour-coded pill boxes etc.
• But is unintentional non-adherence the main problem?
– How do you change intentional non-adherence?
– Need to use the certain skillset
• Elicit beliefs, clarifying misperceptions
• Not the same as simple patient education!
Can psychological interventions
improve adherence?
• Pilot randomised trial to increase adherence in stroke
patients, using MEMS at 3-months
• 62 patients randomised to:
– Control group: 2 sessions addressing non-medication-related
conversation
• e.g. what had happened when they had their stroke
– Intervention group: 2 sessions addressing
• a plan linked to environmental cues (implementation
intentions)
• eliciting and modifying any mistaken patient beliefs regarding
medication/stroke
O’Carroll et al, Ann Beh Med, DOI 10.1007/s12160-013-9515-5
Intervention: session 1
• Implementation
intentions
– ‘If-then’ plans
• Enhances
memory through
environmental
cues, developing
habits
O’Carroll et al, Ann Beh Med, DOI 10.1007/s12160-013-9515-5
Intervention: session 2
• Reviewed effectiveness of ‘if-then’ plans
– Barriers/difficulties
• Then, elicit and challenge mistaken beliefs about illness or
medication
• Mistaken beliefs:
– Cause/effects of stroke
– Toxicity/dependence of drugs
• E.g. ‘why should I take statins if my cholesterol is normal’
• Goal: to make necessity beliefs outweigh medication
concerns beliefs
O’Carroll et al, Ann Beh Med, DOI 10.1007/s12160-013-9515-5
Results
•
•
•
% of doses taken
on schedule
significantly
higher for
intervention
group
Mean difference
9.8%, 95 % CI
0.2 to 16.2,
p=.048
5% increases in
pills taken, and
% days correct
dose taken; ns
O’Carroll et al, Ann Beh Med, DOI 10.1007/s12160-013-9515-5
Useful?
• ‘increasing adherence by one (antihypertensive) pill per week for a once-a-day
regimen reduces the hazard of stroke by 8–9
% and death by 7%’
– Bailey et al, J Gen Intern Med.
2010;25:495-503.
Is it that simple?
• No – but it’s a start
• May not address other issues:
– Depression, social support, etc
– Adherence is about more than medication
• Currently, it is unclear which predictor of nonadherence is the most important
• Large research studies needed to clarify these
issues
Example: Impact of depression on
smoking cessation in CHD patients
• 20 prospective
studies
• Depressed
patients far
less likely to
quit smoking
than nondepressed
patients
– Probably
impacts on
prognosis
Doyle et al, Psychosom Med, in press
Conclusions
• Adherence is a complex behaviour
– Requires complex interventions
• Technology can assist with unintentional nonadherence
• But people with special skillsets are needed to
address intentional non-adherence
– Can increase adherence significantly
– Resource issues – requires training, and time