Patient adherence – what’s the problem?
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Patient adherence – what’s the problem?
John Weinman | Professor of Psychology as applied to medicineKing’s College London
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John Weinman
Institute of Pharmaceutical Sciences,
Kings College London
PATIENT ADHERENCEWhat’s the problem?
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The problem of non-adherence
WHO report on non-adherence
• Estimated that over 30 -50% medicines prescribed for long term illnesses are not taken as directed
• Similar levels for psychol treatments - e.g . Attendance/homework for CBT
• If treatment is evidence- based, then this represents a loss for patients and for the health care system
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Risk of hospitalisation & non-adherence
Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on
hospitalization risk and healthcare cost. Medical Care. 2005;43:521-530.
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Health care cost of non-adherence
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CAUSES OF
NON-ADHERENCE
• Common myths• Current evidence
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Myth 1: Non-adherence is a feature of the disease
Non-adherence is not linked to type of disease
Low adherence rates are problematicin most chronic diseases e.g.•HIV1 •Cancer2 •Heart disease3
1Friedland, Williams. AIDS 1999;13(Suppl 1):S61–72.2Lilleyman, Lennard. BMJ 1996;313:1219–1220.3Horwitz et al. Lancet 1990;336:1002–1003.
• Rheum. arthritis4 • Diabetes5
• Asthma6
4Hill et al. Ann Rheum Dis 2001; 869-875.5Glasgow et al. J Behav Med 1986;9:65–77.6Cochrane et al. Respir Med 1999;93:763–769..
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Myth 2Myth 2
•Non-adherence is related to:
Gender Educational experience Intelligence Marital status Occupation / income Ethnic background
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Most patients will be non-adherentsome of the time
Most patients will be non-adherentsome of the time
Adherence Rates Vary
Between patients
Within the same patient over time and across treatments
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Myth 3Myth 3
•Non-adherence is easily fixed by : -
Providing information Providing reminders Being authoritative Fear arousal
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ADHERENCE INTERVENTIONS
Cochrane review: Haynes et al (2008)
“Current methods of improving adherence are mostly complex and not very effective, so that the full benefits of treatment cannot be realized.
High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term disorders”
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How can the problem be tackled?How can the problem be tackled?
• Need to understand types and causes of non-adherence
•Need to tailor interventions to take account of this
•Develop & test theoretical models
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TYPES OF NON-ADHERENCE
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RANGE OF POSSIBLE FACTORS :-
•Poor HCP-Patient Communication•Low patient satisfaction and/or recall•Problems in planning/executive function
or prospective memory•Financial or other barriers
UNINTENTIONAL NON-ADHERENCE
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Beliefs influence unintentional non-adherence - forgetfulness 2
1 BCG Harris 2002; Conrad Soc Sci Med 1985;20:29–37; Ley 1988; Peterson Am J Health-Syst Ph 2003;60:657–652 Unni , Pat Edu Coun 2010 doi:10.1016/j.pec.2010.05.006
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Patients know what to do & how to do it
BUT are reluctant to adhere because either :-
•TREATMENT DOESN’T MAKE SENSE
•WORRIES/CONCERNS ABOUT TREATMENT
INTENTIONAL NON-ADHERENCE
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Predictors of non-adherence : Overview of Evidence
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What are the key beliefs influencing adherence to
treatment?
1) Patients’ perceptions of illness
2) Patients’ perceptions of treatment
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Core beliefs about Illness
• IDENTITY Abstract label eg, hypertension;asthma; arthritis
Concrete symptoms that aperson associates with thecondition
• CAUSAL BELIEFS Stress, environment, genetics,own behaviour, ageing etc
• TIMELINE Perceived duration and profile eg,chronic, acute, cyclical
• CONSEQUENCES Personal, economic, social
• CURE / CONTROL Beliefs about the amenability tocontrol or cure
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ILLNESS PERCEPTION & treatment adherence
• Some illness perceptions are associated with treatment adherence in some conditions :-e.g. - causal beliefs predict adherence behaviour in post- MI
- timeline beliefs predict preventer medication
adherence in asthma etc
- causal, timeline & control beliefs predict adherence to CBT for Psychosis (Freeman et al, in press)
• BUT – illness beliefs per se are not strong predictors of treatment adherence – need to consider more proximal predictors (ie patients’ beliefs re. treatment)
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TreatmentTreatmentIllnessIllness
What are the links between illness and treatment beliefs?
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GOODNESS OF FITbetween illness reps and
treatment recommendations• Patients evaluate the need for treatment in the
light of their understanding of illness
• But some treatments may not make sense :- - exercises for back pain , balance disorder etc - daily adherence to preventer medication in
asthma - smoking cessation in early cervical cancer - phosphate binding medication in ESRD
• CHALLENGE TO HP – to identify these situations and to assess treatment
beliefs -- develop interventions to increase
adherence goodness of fit and increase motivation to adhere
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TREATMENT BELIEFS: What is the patient's perspective ?
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Beliefs about Medicines Questionnaire(BMQ)
GENERAL BELIEFSabout medicines as a whole
SPECIFIC BELIEFSabout medicines prescribed for a particular illness
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SPECIFIC BELIEFSViews about prescribed medication
NecessityBeliefs about necessity
of prescribed medication for maintaining health
Concerns Arising from beliefs about potential negative effects
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Low adherence
Doubts about
NECESSITY
CONCERNS about potential adverse effects
Studies in asthma, CHD, cancer, renal dialysis, HIV/Aids, hypertension, diabetes
Horne et al (in press), Cooper et al (2002), Horne et al (2001), Horne & Weinman (2002), Horne (2000), Horne & Weinman (1999) Horne et al (1999), Horne (1988)
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SUMMARY
• Influence adherence• Have an internal logic• Are influenced by symptoms• May differ from the ‘medical view’• May be based on mistaken beliefs/premises• May not be disclosed in consultation• Are not set in stone and can be changed
Patients’ beliefs about their illness and treatment
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Implications for health care ?
1. Use the consultation to anticipate and plan
2. Interventions to :-- improve goodness of fit
- improve understanding of illness and treatment
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Using the consultation to facilitate informed adherence
• Check patient’s understanding of treatment and , if necessary :-
• Provide clear rationale for NECESSITY of treatment
• Elicit and address CONCERNS
• Agree practical plan for how, where and when to take treatment
• Identify any possible barriers
NEEDS TRAINING OF HCPs – studies in progress
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Interventions to improve adherence
Now a number of successful approaches which are based on a good understanding of patients’ beliefs, using different media, such as :-
• text messaging• web-based interactive programmes• phone based support
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British Journal of Health PsychologyVolume 17, Issue 1, pages 74–84, February 2012
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Method212 patients aged 16-45 recruited from medicine package inserts or heath websites - dx asthma (not
COPD), not taking preventer meds as
prescribed
Normal careTailored Txt messages
18 weeks
Baseline assessment
Adherence assessments at 6,12, 18 weeks and 6 months
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Your asthma is always
there, even when you don’t have symptoms
Your preventer
controls your asthma over the long term
& stops attacks
Your preventer is safe to take every day
Timeline
Personal control
Treatment control
Illness consequen
ces
Medication necessity
Medication concerns
Targeted Texting
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Preventer Adherence Levels M
ean c
om
plia
nce
sco
re
Compliance = puffs taken/puffs prescribed Group difference p <.01
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Percentage of patients reporting adherence at 80% or greater in control and intervention groups
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Conclusions• A better understanding of patients
perspectives of illness and treatment is key to understanding adherence
• This approach offers a framework for identifying and addressing the key barriers to adherence to medication
• Urgent need to•1. develop interventions which can be delivered in routine consultations•2 provide patients with better access to specialist tailored interventions