can adherence be improved?. status of adherence intervention studies t to medication t to exercise t...
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19 Adherence Intervention Studies Randomized Control Group Assessment of Adherence Assessment of Outcome 6 month Follow Up Haynes, R. B., Montague, P., Oliver, T., McKibbon, K. A., Brouwers, M. C., & Kanani, R. (2001). Interventions for helping patients to follow prescriptions for medications. [Systematic Review] Cochrane Consumers & Communication Group Cochrane Database of Systematic Reviews.TRANSCRIPT
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CAN ADHERENCE BE IMPROVED?
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Status of Adherence Intervention Studies
To Medication
To Exercise
To Diet
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19 Adherence Intervention Studies
Randomized Control Group Assessment of Adherence Assessment of Outcome 6 month Follow Up
Haynes, R. B., Montague, P., Oliver, T., McKibbon, K. A., Brouwers, M. C., & Kanani, R. (2001). Interventions for helping patients to follow prescriptions for medications. [Systematic Review] Cochrane Consumers & Communication Group Cochrane Database of Systematic Reviews.
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19 Adherence Intervention Studies
All Use Self - Report
1 Study addresses Remediation
Education/Counseling/Behavioral Strategies
All Address Single Regimen/Disease
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Characteristics of Successful Interventions
Educational/Behavioral
Multicomponent
Long-Term
(from Haynes, 1996)
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Adherence Monitoring as Intervention
Use of Electronically Monitored Data as Feedback
Improved Blood Pressure Control1 Improved Blood Pressure Management
Reduction in Seizures2 Improved Adherence
1 Bertholet et al, 20002 Schneider et al, 2000
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Summary of Interventions
Self-Monitoring
Counseling
Positive Reinforcement
Cuing
Verbal Persuasion
Education
Social Support
Self-Efficacy Enhancement
Behavioral Intervention
Electronic Monitoring/Feedback
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Interventions to Promote Adherence to Exercise
Self-Monitoring 1,6,8
Counseling 2,6,7
Positive Reinforcement 1,5
1 Atkins et al, 19842 Belise et al, 19873 Daltroy, 19854 Jakicic et al, 19955 Keefe & Blumenthal, 1980
Cuing 1,5
Verbal Persuasion 3
Education 4,9
6 King et al, 19887 King & Frederikson, 19848 Rogers et al, 19879 Schneiders et al, 1998
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Interventions to Promote Adherence to Dietary Regimen
Counseling 3,4,8
Social Support 1,2,6
Self-Efficacy Enhancement 6
1 Barnard et al, 19922 Borbjerb et al, 19953 Dolecek et al, 19864 Glueck et al, 19865 Karvetti, 1981
Education 5,7
Behavioral Intervention 9
6 McCann et al, 19887 Mojonnier et al, 19808 Simkin-Silverman et al, 19959 Wing & Anglen, 1996
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Summary
Interventions are not targeted to patient adherence patterns or to patient-reported reasons for poor adherence
Outcome measures are not reliable or accurate
Very few RCT’s have been reported
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Study 1. An intervention study designed to improve poor adherers - asymptomatic
condition
Study 2. An intervention study with poor compliers - symptomatic condition
Study 3. Adherence in clinical trials - an induction study
3 Randomized Controlled StudiesDesigned to Examine Strategies to Improve
Compliance
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Purpose: To evaluate a multicomponent behavioral strategy designed to improve compliance among poor compliers
Setting: Multi-center randomized controlled clinical trial designed to test the cholesterol hypothesis
* Coronary Primary Prevention Trial
An Intervention Study Designed to Improve Poor Compliers
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Proportion of Subjects > 75% Compliance
Pre-intervention Post-Intervention*Experimental 0 9
Attention Control 0 1
Usual Care 0 3
* 2 = 10.21, 2dƒ, p = .006
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Change in Cholesterol Levels
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Variability in Adherence and Treatment Response
Greater response to monitoring/attention overestimated compliance (r = .75) greater variability (r = .50)
Relationship between variability and overestimation (r = .54)
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Purpose:To evaluate a series of behavioral/problem solving interventions to improve poor adherence
Setting: Specialty practice sites
An Intervention Study Designed to Improve Poor AdherersRAC-1
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Group Differences Baseline To End Of Treatment
Average Change In Adherence x sdIntervention 4.30 + 24.7Usual Care -7.99 + 27.1 t = -2.02, p = .023
Proportion Greater Than 80% AdherenceIntervention + Maintenance = 29.7%Usual Care = 15.6% X2 = 2.25, df = 1, p = .065
RESULTS
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Relationship of Change in Adherence and Functional Status
Tx F/U Adherence: Pain rs = .02 rs = -.22*
(n = 96) (n = 98)
Adherence: Difficulty rs = .04 rs = -.11 (n = 95) (n = 97)
Adherence: Assistance rs = .03 rs = -.12 (n = 96) (n = 97)
*p<.01 Changes in adherence were associated with changes in pain in carrying out activities of daily living, but no level of difficulty or assistance required
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Predictors of Change
Baseline Correlates With Change Score
End of Treatment rs = -.20 p = .036Follow-up rs = -.32 p = .001
Session Attendance and Change ScoreFollow-up f = 9.07, df = 2, p = .0007
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Compliance in Clinical Trials - An Induction Study
Purpose: To evaluate a minimal strategy designed to promote initial compliance
Setting: Single center randomized, clinical trial designed to study the psychological and behavioral effects of cholesterol lowering*
* M. Muldoon, the CARE Study
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Group Differences in AdherenceACT
at 6 Months
n = 180 MEMS MEMS Pill Count(% days compliant) (% pills taken)
Usual Care (Mdn) 62.5% 85.7% 93.5%
Habit Training (Mdn) 67.9% 92.8% 96.1%
Habit Training (Mdn) 61.6% 90.2% 93.8%+ Problem Solving
p = NS NS NS
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Summary
Poor Adherence is: Wide Spread Costly Hard to Identify Difficult to Predict Who Does Not Adhere
Few Studies Point to Interventions
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Summary
Individuals vary in dosing adherenceMeasures to identify poor adherence need
to be sensitive to dosing patternsMinimal intervention does not appear to
improve long-term adherenceAdherence can be improved with intensive
interventions Improving adherence positively impacts
clinical outcomes
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Recommendations
Address individual adherence patterns in clinical and research setting
Take careful account of method of assessment in interpretation of adherence data
Design/evaluate adherence interventions
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Any Questions?Thank You!