Chronic disease and medication adherence

PHCL 436 Lecture two

Objectives The role of cognition in influencing

adjustment to chronic conditions What is medication adherence, prevalence,

reasons, measurements

Facing an illness What people thinks/do when adjusting to

chronic disease? What are the behaviours associated with

managing chronic disease?

Chronic disease and medication adherence

Managing chronic disease ◦ @ social level◦ @ individual level

Pharmacists◦ What affects patients reaction to disease◦ Pharmacists can help patients cope better

Chronic disease and medication adherence

Why chronic diseases???

Chronic disease and medication adherence

Behaviour of taking medication

Adherence

( Patients may pretend taking their medication) Hippocrates

(Unpredictable responses to therapy due to low compliance) David Sackett , 1972

( It is the extent to which the patient's behaviour matches agreed recommendations from the prescriber with emphasis the patients' freedom to decide whether to adhere to the prescriber's recommendations, and that failure to do so should not be a reason to blame the patient)*

What is adherence?

*National Institute for Health and Clinical Excellence (NICE) guideline

1ry non-compliance ◦ patient fails to dispense the medication

2ry non-compliance◦ don’t take the medication as directed

Or Intentional

◦ patient decides not to follow the treatment recommended

Unintentional◦ the patient wants to follow the treatment

recommendations but has practicality problemsI

Type of adherence

9

Studies showed that 33-50 % of patients in developed countries are non-adherent to their medication*

A quantitative review research from 1948 to 1998 found that the average percentage of non adherence is 24.8%

Prevalence of non-adherence

10

HIV, arthritis, and gastroenterology disease

pulmonary diseases, diabetes, and sleep disorders

Prevalence of non-adherence

11

40-50% of patients do not persist with their initial treatment for chronic disease more than 12 months

This proportion is higher in developing countries due to other reasons◦ difficulties in accessing healthcare facilities,

availability of medication, deficiency of education

Prevalence of non-adherence

12

USA, it been estimated to cost $100 billion each year, including ◦ 10% of hospital admissions and 23% of

admissions to nursing homes, that is exclusive of indirect costs such as doctor's frustrations not accomplishing treatment outcomes

Canada, the cost of poor adherence has been estimated to be $7 to $9 billion per year because of avoidable negative outcomes not being prevented

Consequences

13

More than 200 variables have been identified to postulate the affect adherence ◦ positively i.e. variables that increase adherence◦ negatively i.e. variables that decrease adherence

Reasons for non-adherence

14

Demographic data have been poorly correlated to patient adherence◦ patient age, gender, social status, features of the

disease, in addition to referral process* negative effect

◦ Increasing psychiatric symptoms◦ numbers of medications◦ frequencies of medications◦ complexity of the regimen◦ Duration◦ cost

Reasons for non-adherence

15

Very few variables were found to have positive strong correlation with adherence◦ increasing the degree of disability◦ administering parental medications

Reasons for non-adherence

16

Patients own beliefs and understanding about medicine and medication

Patient's unresolved concerns about disease Effect of everyday life constraints Effect of poor communication with health

care provider Effect of community and health care provider

attitude Effect of receiving conflicting information

when health care provider do not adhere to diagnostic and therapeutic standard

Reasons for non-adherence

Reasons for non-adherence

18

Variation in outcome and adherence relationship*

There are more factors affects accomplishing therapy outcomes by improving adherence◦ nature of the disease studies, regimen

complexity, tool to be used◦ Improving medication adherence and outcome

relationship should be initiated by using the appropriate technique

Reasons for non-adherence

19

• Direct observation• Medication

concentration in body fluids

Direct

• Self reports• Administration records Indirect

Measures of Adherence

20

Direct methods of assessing patient's behaviour of medication taking

◦ Directly observing the patient taking the medication, such as in tuberculosis direct observation therapy strategy (DOT)

◦ Direct measurement of metabolites, drug markers, or drug concentration in the patient's body fluids

Measures of Adherence

21

Indirectly measuring adherence either◦ by using process measures of medication taking

self reports, tablet counting, prescription filling dates

◦ using outcome measures therapeutic or preventive outcome measures

Measures of Adherence

22

Self report◦ Widely used, general or specific◦ Validation◦ ex: ASK 20, MARS, ACT◦ validation◦ Semi-structured interviews

Measures of Adherence

23

Pill count◦ Widely used◦ Medication Event Monitoring System (MEMS)◦ Cut-off 80% (HTN), 90% (HIV).

Measures of Adherence

24

Administration records ◦ Medication possession ratio (MPR), proportion of

days covered (PDC)◦ Cut-off?

Measures of Adherence

25

Drug Concentrations

◦ Increasing numbers of adherence studies are being conducted utilizes the advancement in the medication analysis technologies Pain medication Antipsychotic medication Addiction therapy

Measures of Adherence

26

There is no ideal tool to assess adherence. Many confounding factor affect each tool using multiple measure with high sensitivity

and the other with high specificity Depth understanding of each patient factors

is the only way to assess adherence and improving achievement of treatment outcomes

Measures of Adherence

What is chronic disease ?

“illnesses that are prolonged, do not resolve spontaneously, and arerarely cured completely”

Domains of adjusting to a diagnosis of chronic disease

interpersonal

cognitive

emotionalbehavioural

Physical components

Psychological adjustment to a diagnosis of chronic disease domians

Psychological adjustment to chronic disease themes:

It requires adjustment across different domains of life.

It happens over time. There are marked differences in the way

individuals adjust.

Stanton et al (2007)

Psychological adjustment to chronic disease

What people do to adjust?

Adaptive task Enhancement of self steam

Psychological adjustment to chronic disease

Social factors and adjusting to chronic disease

Social factors

Culture and ethnicity

Gender Nature of the disease

Interpersonal support

Social recourse

Social isolation

Inherent optimism

Outlook on life and adjustment to chronic disease

التفائل

Lazarus’s appraisal modelRole of perception and

thought in response to illness and people management of their chronic disease

Cognitive appraisal processes and adjustment to chronic disease

Lazarus’s appraisal model

Cognitive appraisal processes and adjustment to chronic disease

Coping process and adjustment to chronic disease

Leventhal’s common sense model of self regulation

Managing chronic disease

The model propose that patients will decides to cope with illness and the threat of illness in way that are consistent with their own understanding of the experience

Heuristics (mental rules) associated with illness and illness representation

◦ Intuitive time and space representation◦ Pattern of symptoms relating to previous

experience◦ Cultural beliefs and social experience◦ Active social comparisons

Example of CSM

Why is that important ?

Necessity of medication

Concerns about

medications

pathways.nice.org.uk nice.org.uk

NICE guidelines

Haynrs et al 2008 Cochrane review

Intervention to improve adherence

How people think and behave when they have chronic disease

It is difficult to adjust and adjusting is a dynamic process!

Coping is affected by inner thoughts and their surroundings

Lazarus’s stress and coping theory Leventhal’s self regulation theory Overwhelming impact on medication taking

behavior

Conclusion

Next week quiz

Social and Cognitive Pharmacy. Donyai, Parastou. Chapter five.

Medicines adherence. Involving patients in decisions about prescribed medicines and supporting adherence. NICE guidelines 2009. http://guidance.nice.org.uk/CG76

Interventions for enhancing medication adherence (Review). http://www.cochrane.org/

References