reflexões a propósito da adesão ao tratamento -...
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Dani Figuerola
Reflexões a propósito da
adesão ao tratamento
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Adherence means
Adesão / adhesió
but not
Aderência / adherència!
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• 395 pacientes, 790 consultas presenciales
• 45-60 minutos por consulta
• 1250 consultas “virtuales” ( email, telef, fax)
• Actividad privada
• Clase media – media/alta
• Distancia a la consulta • Menos de 25 km 37 %
• 25 a 100 km 34 %
• 100 a 250 km 24 %
• Más de 250 km 5 %
Datos asistencia ambulatoria
a personas con diabetes (2012)
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153
228
Tipo de DM
DM1 DM 2
381 pacientes
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0
25
50
25
42
29
15
5
DM1: años evolución
0 a 10 11 a 20 21 a 30 41-50 > 50
Edad media 37 a
Evolución media: 21 a
153 pacientes
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0 0
DM1: Tratamiento con insulina
2%
20% 78%
3 dosis iSCI bolus/basal
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0
20
40
60
80
62
48 44
34 40
DM 2: años evolución
0-5 6 a 10 11 a 15 16 a 20 > 20
Edad media 70 a
Evolución media 11.3 a 228 pac.
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0
40
80
120
160
17
67
144
100 115
DM 2: tratamiento farmacológico
GLP1 SU/Glinidas MET DPP4 inh INS
228 pac.
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0
25
50
75
100
44
74
55
77 83
DM1 + DM2 Resultados on target (en %)
HbA1c CT LDL TG TA
(HbA1c < 7, CT < 180, LDL <100, TG <150. TA < 140/80)
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Adhesión tratamiento
Resultados terapéuticos
Educación terapéutica Adhesión y outcomes
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Adhesión tratamiento
Resultados terapéuticos
Educación terapéutica Adhesión y outcomes
Calidad de la prescripción
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Adherence to healthy lifestyle habits
in US adults, 1988-2006 King DE, Mainous AG, Carnemolla N, Everett CJ
Am J Med 2009; 122(6): 528-34
En adultos de 40-74 a en este período de tiempo...
- BMI > 30 pasa de 28 a 36 % (p<.05)
- Actividad física >11 días/mes de 53 a 43 % (p<.05)
- Frutas y vegetales > 3/día de 42 a 26 %
- Tabaquismo 27 a 26 % (p NS)
- Uso moderado de alcohol 40 a 51 % (p <.05)
- Adhesión a los 5 hábitos saludables 15 a 8 % (p<.05)
- Peores resultados en pacientes con HTA, DM, CVD
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Multidimensional analysis of treatment adherence
in patients with multiple chronic conditions.
A cross-sectional study in a tertiary hospital. Jansà M. et al.
Patient Educ Couns (2010);doi:10.1016/j.pec.2009,12.012
- A los 6-12 meses del alta hospitalaria 18 % tienen una
buena adhesión a la pauta terapéutica.
- Los de mala adhesión tienen más CI (21 vs 4 %), más
HTA (44 vs 15 %) más dislipemia (19 vs 6 %), más edad
(64 vs 55 a.) y mayor complejidad terap. (95 vs 70%).
- El número de CC, la complejidad terapéutica, el número
de pastillas y la HTA son predictivos de mala adhesión.
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Nenhuma adesão quando o doente...
Não quer fazer.
Não sabe o que fazer o como fazer.
Não se sente capaz de fazer isso, ou pode fazê-
lo, acredito que as vantagens superam as
desvantagens.
Acha que é perigoso.
Não tem recursos para fazê-lo
(Health belif model Bradley 1982)
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Adhesión al
tratamiento
Inercia
clínica
Resultados
terapéuticos
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Inercia clínica
“Perfectamente consciente que el paciente está
tratado de forma insuficiente, el PS decide
deliberadamente no intensificar el tratamiento
(Philips, 1999)” porque
Sobrevalora la atención que proporciona.
Tiene “buenas razones” para pactar con el
paciente retrasar la decisión del cambio.
Carece de formación suficiente en objetivos
terapéuticos y cómo alcanzarlos.
Tiene dudas razonables sobre la necesidad de
cambiar.
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Steward B. Clinical Inertia in patients with T2DM requiring insulin in
family practice. Can Fam Physician 2010; 56:418-24
x = 9.5 % x = 8.1 % x = 7.9 %
109 GP, 379 T2DM 9.4 a evolución
Ontario, Canadà
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• Technology for Hospital Management of Diabetes: Understanding and Improving Management of
Inpatient Diabetes Mellitus:
• The Mayo Clinic Arizona Experience
J Diabetes Sci Technol. 2008 ;2(6): 925–31.
A: el dia de l' ingrés.
B: durant l’estada
C: el dia de l’alta.
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Inercia clínica y falta de adhesión
Dos fenómenos homólogos muy frecuentes en
enfermedades crónicas.
Denominador común: la resistencia al cambio.
Una y otra son dos formes de “miopía clínica”.
Luchar eficazmente en contra supone más
benefici o que cualquier descubrimiento
biomédico (WHO, 2006)
G Reach, 2008 (*)
(*) Patient non-adherence and HCP inertia are clinical myopia.
Diabetes and Metabolism 2008; 34:382-5
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Algunos datos y
reflexiones personales
para mejorar la
adhesión terapéutica
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Camp d’actuació Recursos Impacte
Sistema Sanitari 90 % 11 %
Medi ambient 1.5 % 19 %
Estil de vida saludable 1.5 % 43 %
Recerca en biologia 7 % 27 %
(*) Aprender en entornos sanitarios: un reto saludable para usuarios y profesionales.
Viguera ediciones. Barcelona 2011. Citat per Xavier Cléries, 2012
Comparação dos custos e
impacto na saúde (*)
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Tener sentido de la realidad
Humildad
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Você acha que o sol gira em torno da terra ou da terra em torno do
sol?
O sol gira em...
Mas eles dizem que na escola?
Que a Terra gira...
Mas você quer saber o que eles dizem na
escola ou que eu acho?
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Respetar las creencias del paciente
No juzgar
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Medio minuto de silencio al empezar la entrevista…
...”invitando al paciente a contar ‘su’ historia sin
interrupciones, de manera se transforme de
‘reporter’ de sus síntomas en ‘co-investigador’ de
sus problemas de salud”.
Roter DL., The Evidence Base for Diabetes Care, 2nd ed. 2010
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The word 'listen' contains the same
letters as the word 'silent.'
(Australian pianist)
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En realidad todo está dicho,
pero como nadie escucha
hay que repetirlo tres veces.
(J. P. Sartre)
Repetir, repetir, repetir
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“El que aprende debe creer en el
mensajero, no sólo en el mensaje”
(Jaume Sarramona,
Teoría de la educación, 2008)
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De la información transmitida
en un mensaje… (Mehrabian, 1972)
7 % depende de la verbal estricta
38 % depende de la voz (tono, volumen, ritmo)
55 % depende del lenguaje corporal
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Dedicamos mucho tiempo a tratar de convencer a los pacientes y en cambio raramente usamos nuestras capacidades de persuasión y seducción, olvidando que…
el aprendizaje es un proceso más emocional que racional.
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Invictus (2009)
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"Comienza tu día con una sonrisa y verás lo
divertido que es ir por ahí desentonando con
todo el mundo”
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Registrar cuidadosamente los datos
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+1 -2 +3 +2 -3 -1
HbA1c, LDL col, TA, TG…
Calidad de vida, bienestar
MDI, ICSI, sensor de glucosa, tipo de insulina, ...
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+1 -2 +3 +2 -3 -1
Investigar sobre los “intangibles” (empatia, buen humor, convicción, entrega, soporte emocional...)
HbA1c, LDL col, TA, TG…
Calidad de vida, bienestar
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El afecto es el motor del cambio
“Aprendemos porque amamos“
(Ruffino, 1982)
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El humor es una potente herramienta de
seducción...
también en en la relación clínica
“O contrário de “divertido” é “aborrecido” e não “sério”,
portanto as coisas podem ser sérias e divertidas ao mesmo
tempo” (Gonçal Lloveras, médico humanista).
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Educación Sanitaria
ET Educación
Terapéutica
Educación Pacientes
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“La educación es
aquello que
permanece cuando
uno ha olvidado todo
lo aprendido en el
colegio.”
Einstein
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Algunos tests disponibles para
diagnóstico de depresión
• CES-D depression test
• QIDS-SR depression test
• Beck depression inventory
• Wakefield depression test
• Goldberg depression test (www.netdoctor.es)
• Hospital Anxiety Depression test
(www.patient.co.uk/doctor/HAD-scale.htm)
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Depression and Diabetes Treatment Nonadherence Gonzalez JS, Peyrot M, Mc Carl LA et al.
Diabetes Care 2008; 31:2398-403
n Z (P) r CI
Appointment 4 21.58 (<0.001) 0.31 0.29–0.34
Self-care 18 9.66 (<0.001) 0.29 0.23–0.34
Diet 18 7.60 (<0.001) 0.18 0.13–0.22
Medication 18 5.15 (<0.001) 0.14 0.09–0.20
Exercise 13 7.89 (<0.001) 0.14 0.10–0.17
Glucose monit. 15 3.50 (<0.001) 0.10 0.04–0.16
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Meeting DAWN,
Londres, 2004
Meeting DOWN,
London 2004
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• La lengua habla a los oídos, las manos a los
ojos (F Bacon)
• El éxito de la comunicación estriba en la calidad
de voz que sea capaz de transmitir
competencia, seguridad y afecto (Serrano)
• Las sonrisas son pequeños actos de solidaridad
(Hoffman)
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El efecto Pigmalión
Las expectativas que tenemos
sobre las personas, cosas y
situaciones tienden a
realizarse.
El experimento de Rosenthal
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0
30
60
90
45
72
24
12
DM1: HbA1c
< 7 7.1 a 8 8.1 a 9 > 9
Media 7.53 %, SD 0.9
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0
30
60
90
20
93 86
29
DM2: HbA1c
< 6 6.1-7 7.1-8 > 8
Media 7.17 %, SD 0.9
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0
30
60
90
9
17
90
70
44
DM 2: edad y sexo
41-50 51-60 61-70 71-80 81-91
228 pac., 68 mujeres
70 a media
9.9 a DS
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“Sonrían, no dejen de sonreír en ningún
momento. ¿Han entendido bien? “
(El secretario de Mandela dirigiéndose a los guardaespaldas
en la película INVICTUS)
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sorrisos são pequenos atos de solidariedade
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Agissez envers les autres
comme vous aimeriez qu'ils
agissent envers vous.
Confucius
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Devemos confiar outros
Começar ben o lenço
que está frio...
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