adherence strategies on htn, diabetes, hld

A Review of Overcoming Adherence Barriers in Primary Care

Brandon SamsonPharmD Candidate 2016

Western University of Health Sciences

Learning Objectives

• Discuss the current landscape of primary care and the involvement of ambulatory care pharmacists

• Identify adherence barriers and general strategies (SIMPLE) as promoted by the World Health Organization

• Understand concepts and framework of readiness to change and motivational interviewing

• Review current available literature on effective interventions with regard to hypertension, hyperlipidemia and diabetes

• Summarize the Sensemaking model and its effects on diabetes and self-management of chronic conditions

Definitions of Primary Care

• Direct, responsible provision of medication-related care

• Achieving definite outcomes that improve a patient’s quality of life

• Intended to improve the quality of care received by everyone in the United States

American Society of Health System Pharmacists. ASHP statement on Pharmaceutical care. Am J Hosp Pharm. 1993; 50:1720–3Rubin E. Beyond the rhetoric: ensuring the availability of primary care. Report of an AHC/FASHP retreat. Am J Pharm Educ. 1993;

57:191–3.

Responsibilities of Primary Care Pharmacists

• Perform patient assessment for medication-related factors• Order laboratory tests necessary for monitoring outcomes of medication

therapy• Interpret data related to medication safety and effectiveness• Initiate or modify medication therapy care plans on the basis of patient

responses• Provide information, education, and counseling to patients about medication-

related care• Document the care provided in patients’ records• Identify any barriers to patient compliance• Participate in multidisciplinary reviews of patients’ progress• Communicate with payers to resolve issues that may impede access to

medication therapies• Communicate relevant issues to physicians and other team members

ASHP statement on the pharmacist's role in primary care. (1999). Am J Health Syst Pharm, 56(16), 1665-1667.

Challenges to Success in Primary Care

• Five interacting dimensions of non-adherence– Health-care system/team factors– Patient-related factors– Therapy-related factors– Condition-related factors– Social and economic factors

Sabate, E., & World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization.

Healthcare System Factors

• Access to care• Continuity of care• Patient education material not written in plain

language

Healthcare Team Factors

• Stress of healthcare visits• Discomfort in asking providers questions• Patient’s belief or understanding• Patient’s forgetfulness or carelessness• Stressful life events• Lack of immediate benefit of therapy

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

prescriptionSabate, E., & World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health

Organization.

Patient, Condition, and Therapy Factors

• Patient-related– Physical– Psychological

• Condition-and therapy-related– Complexity of medication– Frequent changes in regimen– Treatment requiring mastery of certain techniques– Unpleasant side effects– Duration of therapy– Lack of immediate benefit of therapy– Medications with social stigma

Economic and Social Factors

• Economic– Health insurance– Medication cost

• Social– Limited English proficiency– Inability to access or difficulty accessing pharmacy– Lack of family or social support– Unstable living conditions

Significance of Non-Adherence

Source: National Association of Chain Drug Stores, Pharmacies: Improving Health, Reducing Costs, July 2010. Based on IMS Health data

Significance of Non-Adherence (cont.)

American Society of Consultant Pharmacists. Adult Meducation. Improving medication adherence in older adults. http://www.adultmeducation.com/downloads/Adult_Meducation.pdf. Accessed 6/20/15.

Significance of Non-Adherence (cont.)

• About 20% to 50% of patients are non-adherent to medical therapy

• People with chronic conditions only take about half of their prescribed medicine

• Rates of adherence have not changed much in the last 3 decades, despite WHO and Institute of Medicine (IOM) improvement goals

• Overall satisfaction of care is not typically a determining factor in medication adherence

McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient adherence to medication prescriptions. JAMA.2002; 288; 22:2868-2879.

The WHO’s Take on Improving Adherence

• S— Simplify the regimen• I — Impart knowledge• M— Modify patient beliefs and behavior• P — Provide communication and trust• L — Leave the bias• E — Evaluate adherence

S – Simplify the regimen

• Let the patient decide on cost benefit• Match pill taking to activities of daily living• Simplify the time of day the patient must

focus on medication taking• Let the patient decide if cost or convenience is

more important• Gradually step a patient into a complex

regimen

I – Imparting Knowledge

• Allow the patient to repeat back instructions in their own words

• Relay information at the patients’ level• Reinforce verbal instructions with written

information; provide access for questions• Involve family members• Help optimize adherence by addressing cost

M – Modifying Beliefs

• Ask about your patient’s needs• Tailor conversations to specific patient needs• Ensure patients know their risks• Identify perceived barriers• Provide contingency contracts and rewards

P – Providing Communication

• Confirm patient message• Paraphrase patient remarks• Provide empathy• Give feedback to the patient• Further the dialogue• Watch for patient acceptance; involve patient

in decision making

L – Leaving the Bias

• Relate to patient’s demographic• Take extra time to overcome cultural barriers• Elicit cultural norms• Use interactive engagement and linguistically

appropriate patient interventions• Tailor education to patient’s level of

understanding

E – Evaluating Adherence

• Ask direct questions– "Do you ever forget to take your medications?”

• Ask about adherence often– "Do you ever find yourself not as careful about taking your

medications?”• Recognize lack of receptivity– "When you feel better, do you sometimes stop taking

medication?”• Identify adherence barriers– "Sometimes, when you feel worse, do you stop taking your

medicine?"Sabate, E., & World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health

Organization.

Spotlight: Evaluating Adherence

• Self-reports are the most commonly used tool in measuring adherence– Ask patients simply and directly if they are following their drug

regimen• Ask about adherence behavior at every encounter• Ferret out adherence barriers and lack of receptivity to

medical information• If self-report still leaves questions about adherence try pill

counting or measuring serum or urine drug levels• Periodically review patient’s medication containers, noting

renewal datesSabate, E., & World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health

Organization.

Assessing and Increasing Motivation

Stages of Change Continuum

Readiness to Change

• Help evaluate their readiness to change– “Are you willing to take a medication to treat your condition?”

• Quantitative scale– “How ready are you on a scale from 1 to 10 to initiate this

therapy (medication, diet, exercises) to treat your condition?”• Importance

– What value a person places on making the change• Self-efficacy

– A person’s belief or confidence in their ability to succeed at making the change

The Role of Motivational Interviewing

• Motivational interviewing– Used to determine a person’s readiness to engage in a

target behavior– Applying specific skills and strategies based on the

person’s level of readiness to create a favorable climate for change

• Techniques try to avoid simply telling a person what they need to do– People can easily dismiss such suggestions or come up

with a number of reasons why the suggested change is not possible

Principles of Motivational Interviewing

R - Roll with Resistance

• Resistance– Negating, blaming, excusing, minimizing, arguing, challenging,

interrupting, and ignoring.• Do not directly oppose resistance but, rather, roll or flow

with it• Resistance is expected, should not be viewed as a

negative outcome– Information about factors that foster or reduce motivation to

adhere to behavioral change• Includes involving the person actively in the process of

problem solvingAmerican Society of Consultant Pharmacists. Adult Meducation. Improving medication adherence in older adults.

http://www.adultmeducation.com/downloads/Adult_Meducation.pdf. Accessed 6/20/15.

E - Express Empathy

• Skillful, reflective listening to understand a person’s feelings without judging, criticizing, or blaming

• Demonstrates that the health care provider understands the person’s point of view

• Provides an important basis for engaging the person in a process of change

A - Avoid Argumentation

• Resistance to change is strongly affected by the health care provider’s response– Direct confrontations usually result in defensive

reactions and increased resistance to change• The health care provider should change

strategies rather than argue• Emphasis should focus on helping the person

with self-recognition of problem areas rather than coerced admission

D - Develop Discrepancy

• Motivation for change is created when the person perceives a discrepancy between their present behavior and important personal goals – Involves identifying and clarifying the person’s own goals

• The goals need to be those of the person and not those of the health care provider– Person will feel as though they are being coerced and

may become more resistant to change• Help a person recognize or amplify the discrepancy

between their behavior and their personal goalsAmerican Society of Consultant Pharmacists. Adult Meducation. Improving medication adherence in older adults.

http://www.adultmeducation.com/downloads/Adult_Meducation.pdf. Accessed 6/20/15.

S - Support Self-Efficacy

• A person’s belief or confidence in their ability to carry out a target behavior successfully– Enhances the person’s confidence in their ability

to overcome barriers and succeed in change• Support self-efficacy by recognizing small

positive steps that the person is taking to change their behavior

• It is important that the health care provider believes that the person can achieve the goal

Available Information on Strategies: Hypertension

Hypertension Treatment – Systematic Review

• How do we determine the effectiveness of interventions aimed at increasing adherence to BP–lowering medication in adults?

• Randomized clinical trials (RCTs) of interventions were searched to increase adherence to BP–lowering medication in adults with essential hypertension

• Outcomes: Adherence to medication and blood pressure control

Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database Syst Rev. 2004;(3):CD004804

Hypertension Treatment – Systematic Review (cont.)

• Results– 38 studies– 58 different interventions– 15,519 patients

• Identified strategies that increased adherence– Simplifying dosing regimens: (8-19.6% relative increase)– Motivational strategies: small increases in adherence (up to

23%)– Complex interventions involving more than one technique,

ranging from 5-41%• Patient education alone seemed largely unsuccessful

Hypertension Treatment – Systematic Review (cont.)

• Reducing the number of daily doses appears to be effective in increasing adherence to BP–lowering medication– Should be tried as a first-line strategy

• Less evidence of an effect on BP reduction • Some motivational strategies and complex

interventions appear promising

Hypertension Treatment – Additional Commentary

• Simplification of treatment is most effective intervention– Medications taken once a day are preferred– If patient is taking other medications, consider

recommending that all be taken at the same time of day • While dosing simplification improved adherence in 7/9

studies, only one study showed improvement in adherence and SBP by changing from twice-daily to once-daily dosing

• No study found improvement in DBP with improved adherence

Domino FJ. Improving Adherence to Treatment for Hypertension. American Family Physician .Vol. 71 Issue 11, p2089-2190. 2p

Hypertension Treatment – Additional Information (Commentary)

• Successful motivational strategies– Daily reminder charts– Training in self-determination– Packaging medications in combination– Social and family support– Telephone calls – Electronic medication aid caps– Telephone-linked computer counseling

Domino FJ. Improving Adherence to Treatment for Hypertension. American Family Physician .Vol. 71 Issue 11, p2089-2190. 2p

Available Information on Strategies: Statin Therapy

Current Information on Statin Adherence

• Adverse events cited as the most common cause of statin discontinuation

• Adherence to medication for treatment of a symptomless condition, such as high LDL-C levels, is the challenge

Maningat, P., Gordon, B. R., & Breslow, J. L. (2013). How do we improve patient compliance and adherence to long-term statin therapy? Curr Atheroscler Rep, 15(1), 291. doi: 10.1007/s11883-012-0291-7

Current Information on Statin Adherence (cont.)

• The most promising interventions involved reinforcement and reminders to patients– Increased adherence by up to 24%

• Improving patient information and education– Increased adherence by 13%

• Patients suggested additional information about statins– Reasons for prescription, benefits, risks– Additional time for discussion with the clinician– Being provided written information about statin risks, side

effects, and drug interactions would improve adherence

Current Information on Statin Adherence (cont.)

• Conclusions– Interventions employed in various studies have

resulted in modest increases in adherence at best• Clinicians should emphasize non-

pharmacological approaches in addition to statins for reducing cholesterol levels in all patients, no matter what risk stratification

Available Information on Strategies: Diabetes

Built-in Challenges to Diabetes Treatment

• Individuals must re-examine mundane everyday activities– Grocery shopping– Cooking/eating meals– Participating in social gatherings

• Adjust their practices to the new demands of diabetes self-management

• Frequent and multiple gaps in their understanding and their ability to select appropriate action

• Must make sense of the new situation in order to construct their new reality

Mamykina, L., Smaldone, A. M., & Bakken, S. R. (2015). Adopting the sensemaking perspective for chronic disease self-management. J Biomed Inform. doi: 10.1016/j.jbi.2015.06.006

Improving Self-Management with Sensemaking

• Sensemaking is chiefly concerned with how individuals make sense of:– Complex social dynamic environments and phenomena– Developmental representations of these phenomena– Use of these representations to guide their actions– How to organize the chaos of lived experiences– Finding patterns– Discovering connections and dependencies– Making a myriad of daily choices with regard to

essential self-management activities

The Sensemaking Model

Applying the Model to Practice

• Review of literature to determine patterns in practice:– How do individuals with diabetes engage in self-

management?– What factors serve as barriers and facilitators of

self-management?– What difficulties and challenges do they

experience as part of self-management?

Systematic Review Results

Major categories consistent in literature:1. The need for individual discovery2. Sensemaking and habitual modes in diabetes

self-management3. Perception – Inference – Action cycle, including

a. Breakdowns as triggers for sensemakingb. From breakdowns to discoveriesc. Translating discoveries into action

4. Barriers to sensemakingMamykina, L., Smaldone, A. M., & Bakken, S. R. (2015). Adopting the sensemaking perspective for chronic disease self-

management. J Biomed Inform. doi: 10.1016/j.jbi.2015.06.006

The Need for Individual Discovery

• Need for individuals to flexibly adjust self-management recommendations to their unique lifestyles

• Difficulty translating general self-management guidelines into specific daily behaviors– Increasing intake of vegetables => what should I have for lunch

today?• Self-management requires many changes to one’s

lifestyle, impacting:– Individual’s routines and schedule– Ability to perform their job– Overall quality of life

Sensemaking and Habitual Modes

• Sensemaking involves individuals analytically engaging with the situations and examining their properties

• Habitual modes involve individuals following their established patterns and routines

• Current model used in practice according to literature is habitual

Sensemaking in Three Core Activities

• Perception and classification of new information related to diabetes

• Accounting for this information using existing mental models or by creating new ones

• Carrying out action consistent with individuals’ explanatory frameworks

From Breakdown to Discovery

• Breakdowns are triggers for sensemaking• After experiencing a breakdown, engage in

active examination of their past experiences of relevance looking for similarities and patterns

• Experiential learning versus traditional learning from experts

Translating Discoveries into Action

• If done correctly, sensemaking should result in driving individual action

• Barriers to sensemaking as identified by literature:– Lack of support from healthcare providers– Discouragement from checking BG levels regularly– Diabetes educators not fond of experiential

learning

Benefits of Current Study

• New theory and model can be used to inform patients about successful self-management

• Goal is to improve individual engagement in treatment and self-management from a behavioral aspect

• Future research continues to improve the future of diabetes treatment

Conclusion

• Ambulatory care pharmacists must overcome many barriers to make meaningful interventions with regard to non-adherence

• There’s no one way to address this:– Simplify the regimen– Impart knowledge– Modify patient beliefs and behavior– Provide communication and trust– Leave the bias– Evaluate adherence

• Stages of change and motivational interviewing• Patient education may not be enough in many scenarios• Empowerment is key in the patient-provider relationship

The End

adherence strategies on htn, diabetes, hld

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