CAN ADHERENCE BE IMPROVED?. Status of Adherence Intervention Studies t To Medication t To Exercise t...
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Transcript of CAN ADHERENCE BE IMPROVED?. Status of Adherence Intervention Studies t To Medication t To Exercise t...
CAN ADHERENCE BE IMPROVED?
Status of Adherence Intervention Studies
To Medication
To Exercise
To Diet
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.
19 Adherence Intervention Studies
All Use Self - Report
1 Study addresses Remediation
Education/Counseling/Behavioral Strategies
All Address Single Regimen/Disease
Characteristics of Successful Interventions
Educational/Behavioral
Multicomponent
Long-Term
(from Haynes, 1996)
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
Summary of Interventions
Self-Monitoring
Counseling
Positive Reinforcement
Cuing
Verbal Persuasion
Education
Social Support
Self-Efficacy Enhancement
Behavioral Intervention
Electronic Monitoring/Feedback
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
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
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
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
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
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
Change in Cholesterol Levels
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)
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
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
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
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
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
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
Summary
Poor Adherence is: Wide Spread Costly Hard to Identify Difficult to Predict Who Does Not Adhere
Few Studies Point to Interventions
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
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
Any Questions?Thank You!