Post on 16-Jun-2018
Strategies for AdherenceStrategies for AdherenceRenal Network 9 / 10
March 10, 2009
Paul W. Crawford, M.D. F.A.C.P.Associates in Nephrologyp gy
Medical Director, Evergreen Park FMC, Ross-Englewood FMC, Roseland FMC Dialysis Centers
Adjunct ProfessorAdjunct Professor, Feinberg School of Medicine, Northwestern University
Compliance
Compliance: The extent to which patientsCompliance: The extent to which patients follow medication or treatment advice given to them by providersgiven to them by providers. Compliance suggests an obedience-based approach to patient care in which theapproach to patient care in which the providers dictate the behavior the patient is supposed to followis supposed to follow
Berger, Krueger, & Felkey, 2004
Adherence
Indicates that goals of treatment are negotiated between patients and providerLevel of adherence depends upon the p padoption and maintenance of a range of therapeutic behaviors by both the provider p y pand the patient
Include biological, behavioral, and / or socialInclude biological, behavioral, and / or social factors
Kammerer, et al; Neprhology Nursing Journal: Adherence in patients on dialysis: strategies for success, Sept-Oct, 2007
WHO Adherence Project
Definition of adherence to long-term gtherapy:
The extent to which a person’s behaviorThe extent to which a person s behavior in taking medications, following a diet, and-or executing lifestyle changesand-or executing lifestyle changes, corresponds with agreed-upon recommendations from a health carerecommendations from a health care practitioner.
Persistence
A measure of whether a patient is continuing to use the prescribed therapy or medication.
Patient considered non-persistent if:Patient considered non persistent if:Prescription never filled / treatment never startedstarted
Stops taking prescription / ends treatment
or
Stops taking prescription / ends treatment prematurely
Persistence in Chronic Illness
Studies examining medicationStudies examining medication persistence among patients with newly diagnosed chronic disease demonstrate that persistence rates decrease over time
(Caro Salas Speckman Raggio & Jackson 1999)(Caro, Salas, Speckman, Raggio & Jackson, 1999)
Hemodialysis Non-Adherence1998 study by Leggat, et al.
Defined non-adherence as:Defined non adherence as:Skipping one or more dialysis sessions
Gaining >5 7% of dry weight during sessionsGaining >5.7% of dry weight during sessions
Or serum phosphate > 7.5 mg/dL
R ltResults:8.5% of patients skipped hemodialysis sessions
20% shortened sessions
10% had more than 5.7% IDWG
22% has serum phosphate levels >7.5 mg/dL
Dialysis Non-AdherenceDialysis Non Adherence
In another study by Kuther in 2001, it was estimated that about 50% ofwas estimated that about 50% of hemodialysis patients do not adhere to at least part of their dialysisto at least part of their dialysis regimen
Profile of Non-adherent Patients
Younger Ski i h t i i IDWGSkipping, shortening, excessive IDWG, hyperphosphatemia
Af i A iAfrican-AmericanSkipping and shortening
Female Excessive IDWG
Employed HyperphosphatemiaHyperphosphatemia
Profile of Non-Adherent Patients
Living AloneHyperphosphatemiaHyperphosphatemia
SmokingSkipping excessive IDWGSkipping, excessive IDWG
DepressionSki i h t iSkipping, shortening
Marital statusHyperphosphatemia
Time on dialysisyShortening, IDWG, hyperkalemia
Case StudySocial history
38 yr old African American female38 yr old African-American femaleReferred from Stroger Hospital (Cook County)Indigent, resides in drug rehab centerIndigent, resides in drug rehab centerh/o cocaine, heroin, tobacco and ETOH useuse10th grade educationPublic aid
Case StudyMedical History
h/o diabetes hypertension heart failureh/o diabetes, hypertension, heart failuremultiple hospitalizations for psychiatric illnesses
suicidal ideationdepressionschizophreniaschizophrenia
h/o MRSA, hepatitis Ccirrhosis, ESRD
Case StudyPhysical exam
A h ld th t t dAppears much older than stated ageSkin discolored, track mark scarring on both armsMassively distended abdomenPoor dentitionAppears malnourishedppHostile affect, speaking loudly, using profane languagelanguage
Case Study
First visit to dialysis center:yAngry about being there; did not want to undergo dialysisg yCursing at staffDemanding pain medicineDemanding pain medicineComplaining of shortness of breathN i t ff l d f i t k ithNursing staff already refusing to work with
patient
Put yourself in her shoes…Put yourself in her shoes…
Alienated by the healthcare systemAlienated by the healthcare systemDefined as:
Di tiDisruptiveUnwantedNon-compliant“Pain in the butt”
Rejected from other dialysis unitsGetting primary care from the EDg p y
Does this patient:Does this patient:Deserve health care?Deserve health care?Deserve to receive healthDeserve to receive health care?Deserve a health care provider?provider?
Multidisciplinary Teamwork Is Needed to Multidisciplinary Teamwork Is Needed to Optimize Care of CKD PatientsOptimize Care of CKD Patients
Nephrologist Social Worker
RNs, Nurse Practitioners
Patient DietitianPractitioners
Fitness Instructor Family
Social Workers – More Than T i ATransportation Arrangers
Reso rces forResources forDifficulties in obtaining medicationLack of housingPsychosocial evaluationsDetermining family dynamics and how they affect careFinancial issues – food, clothing, transportation
Dietitians Role
Determine patients baseline nutritional status
Work with family members to find a dietWork with family members to find a diet that both meets nutritional needs and is palatable to the patientpalatable to the patient
Cultural, traditional diets
Financial constraints
Working around food desertsWorking around food deserts
Fitness Instructor???Fitness Instructor???
Tend to ignore the need for physicalTend to ignore the need for physical exerciseGet wrapped up in treating the disease;Get wrapped up in treating the disease; ignoring the benefits of exerciseI h i l d t l f tiImproves physical and mental function; improves overall quality of lifeImproves self esteemStronger core = fewer fallsg
Non-Adherence Interventions
Depression screeningDepression screeningEducation
Determine level of understandingDetermine learning styleDetermine learning style
Visual, verbal, tactile, etcDetermine readiness and ability to learnDetermine readiness and ability to learnUse reinforcement; repeat, reward
Non-adherence Interventions
LISTENIt takes time
Saves time in the long run if you not onlySaves time in the long run if you not only listen, but respond
“Little things mean a lot”Little things mean a lot
OK to admit that you don’t have the answer on the spot
Note in chart; follow up with patient p p
Set the ToneFirst impression
T k tiTake timeGain a sense of trust with the patient
Plan on the visits in the first 6 months to take more time
f CTaking care of CKD patients is routine to you, but it’s all new to them.
Patients sense when you genuinely care about them
The patient expired in p pDecember 2008
She spent 80% of her last six S e spe t 80% o e ast smonths of life in the hospital.
“Every system is perfectly“Every system is perfectly designed to achieve exactly g ythe results that are actually
b d ”observed.”
Donald Berwick, MD, MPP, FRCPP id t d CEOPresident and CEO, Institute for Healthcare Improvement