LPT - Adherence To Medication And Appointments (Sept07)
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Transcript of LPT - Adherence To Medication And Appointments (Sept07)
Adherence Compliance Concordance:pDifficulties following medical advice
Alex J MitchellAlex J Mitchell
Ack. Dr Shoka, Dr Shanka, Dr Selmes
“Adherence”
The extent to which the patientsThe extent to which the patients behaviour coincide with the clinical prescription/advice [ Haynes et al 1979 ].prescription/advice [ Haynes et al 1979 ].
Wh t if di l d i iWhat if medical advice is wrong, inadequate or missing?
Sometimes, does the patient know best?Sometimes, does the patient know best?
Does not attend / delays asymptomatic screening
At Risk Population
Does not attend / delays asymptomatic screening (if offered)
Symptoms
Dela s or does not seek helpDelays or does not seek help (where available)
Diagnosis
R l di i
Adherence and attendanceare linked
Reluctant to accept diagnosis (if told)
Early Treatment
Reluctant to start treatment (if offered)
Follow Up
Does not attend further appointments (if offered)
Continuation Treatment
Does not follow course as prescribed
Types of Medication difficulty
Ladder of Discontinuation
Full discontinuationIs unmonitored
Trial discontinuationIs harmless
T i l Di ti ti
Full Discontinuation4
Missing odd doses has no adverse effects
Partial non-adherence
Trial Discontinuation3
Benefits are unclearOr hazards are clear
Partial non-adherence
Thoughts of stopping
2
Medication is costlyor a hassle or linkedwith stigma
Concordant
g pp g
0
1
Concordant0
Poor Compliance is Normal (Barber et al)N Barber et al Patients’ problems with new medication for chronic Patients’ conditions.Qual Saf Health Care 2004;13:172–175.
Taking All Medication As Prescribed& Problem Free & with sufficient information 10%
Taking some Medication As Prescribed & Problem Free
Taking some Medication As Prescribed with Issuesg
Stopped taking medication against medical advice
10%
Types of Adherence Problems
Initial vs follow upInitial vs follow upRefusal vs discontinuationNon-attendance vs drop outNon-attendance vs drop out
Partial vs Full vs OverPartial vs Full vs OverPartial attender, takes some medication, takes too much medicationtakes too much medication
Overview
Y
Initial TreatmentRefusal
Medication Course StartedN
Course interrupted
Conversion to discontinuationExtra Doses
Full non-adherence Partial non-adherence
Discontinuation Missed Dosesu o ad e e ce a t a o ad e e ce
Course interrupted
Y
Initial TreatmentRefusal
Medication Course StartedN
Conversion to discontinuation
P ti t i h d t dj t di ti d ?P ti t i h d t t t ki di ti ?
Extra DosesFull non-adherence Partial non-adherence
Discontinuation Missed Doses
Patient wished to adjust medication dose?Patient wished to stop taking medication?
Y Y
intentional Non intentional Intentional Non-Intentional
Y Y NN
External Internal External Internal
Explanation
Course interrupted
Y
Initial TreatmentRefusal
Medication Course StartedN
Course interrupted
Patient wished to adjust medication dose?Patient wished to stop taking medication?
Extra DosesFull non-adherence Partial non-adherence
Discontinuation Missed Doses
intentional Non intentional Intentional Non-Intentional
Patient wished to stop taking medication?
Y Y NN
External Internal External InternalWith medical advice?*
Lapse or SlipBarrierWith medical advice?*
Lapse or SlipBarrier
Collaborative Self-DirectedCollaborative Self-Directed
Y YN N
Collaborative Self Directed
Based on adequate information?
Collaborative Self Directed
Based on adequate information?
* Advice implies consultation and discussion of risk and benefits not necessary sanction to act
Low Risk of HarmHigh Risk of HarmLow Risk of HarmHigh Risk of Harm
Y YNN
Course interrupted
Y
Initial TreatmentRefusal
Medication Course StartedN
Course interrupted
Conversion to discontinuation
Patient wished to adjust medication dose?Patient wished to stop taking medication?
Extra DosesFull non-adherence Partial non-adherence
Discontinuation Missed Doses
intentional Non intentional Intentional Non-Intentional
Patient wished to stop taking medication?
Y Y NN
External Internal External InternalWith medical advice?*
Lapse or SlipBarrierWith medical advice?*
Lapse or SlipBarrier
Collaborative Self-DirectedCollaborative Self-Directed
Y YN N
Collaborative Self Directed
Based on adequate information?
Collaborative Self Directed
Based on adequate information?
* Advice implies consultation and discussion of risk and benefits not necessary sanction to act
Low Risk of HarmHigh Risk of HarmLow Risk of HarmHigh Risk of Harm
Y YNN
Examples of Medication difficulty
Compliance: Rheumatoid ArthritisCompliance: Rheumatoid Arthritis
40 345
35.7
40.3
30
35
40
Consistently
23.8
20
25
30
%
Compliant
Consistently Non-compliant
5
10
15 Other - ?partialcompliance
0
5
•556 pts with RA followed for 3 years
Viller F et al. J Rheumatol. 1999;26:2114-2122.
•Compliance assessed annually by interview
Compliance: Hypertension
50% 44%
40%
50%
Very Regular25%
20%20%
30%Very Regular
Regular
Irregular
2%10%
Forgetful
0%
Mallion et al, Mallion et al, J HypertensionJ Hypertension, 1998, 1998
The problem of poor compliance
80
90Patients not adhering by disease area
55
Arthritis
Epilepsy
Hypertension
disease area (%)
3540 40 Diabetes
Asthma
Contraceptionp
Whitney HAK et al. Annals of Pharmacotherapy 1993.
Medication Problems in Mental Health
Percentage of Patients Discontinuing Antipsychotics in 18month CATIE Trial
7480
74
60
70
40
50
14 9
23.7
29.9
20
30
5.5
14.9
0
10
0Other Intolerability Lack of Eff icacy Patient Decision Total
Discontinuations
Compliance challenges affect almost ALLCompliance challenges affect almost ALL patients*
5.2% 7.1%100
Continuous Medication
ANY Days Without Medication
350
Mean Number of Days Without Medication
92.9%94.8%
60
80
200250300350
snts
)
20
40 125.0110.2
50100
150200
Day
s
Patie
n(%
)
0Atypical Conventional
050
Atypical Conventionaln = 349 n = 326n = 349 n = 326 n = 349 n = 326
Mahmoud et al, 2004. Clin Drug Invest:24(5):1
n = 349 n = 326
Partial compliance increases with time
7080
75%Com
plia
nt
405060
50%Up to 25%Part
ially
C
102030
p
of P
atie
nts
010
7-10 Days 1 Year 2 Years* † †
% o
Keith & Kane. J Clin Psychiatry 64:11; 2003
Time From Discharge
Adherence in general clinical practice is poorAdherence in general clinical practice is poor
AntipsychoticsAntipsychotics(3–24 months)
(24 studies)Antidepressants p(1.5–12 months)
(10 studies)Non-psychiatric
0 20 40 60 80 100
(0.25–10 months)(12 studies)
Adherence (%)
Wide range of estimates across studies may reflect difficulty of assessing covert non adherence
Cramer & Rosenheck. Psychiatr Serv 1998;49:196–201
difficulty of assessing covert non-adherence
Data shown are mean and range
Predicting Medication difficulty
Why Do Patients Have Difficulty?
With medication?With medication?
With i t t ?With appointments?
Predictors of Difficulty with Medication
Medication not working (efficacy)Medication not working (efficacy)Medication harming (side effects)M di ti tiMedication stigmaMedication costsMedication availabilityMedication has helped (now not needed)Medication has helped (now not needed)
Predictors of Difficulty with Appointments?Predictors of Difficulty with Appointments?
Clinician not helping (efficacy)Clinician not helping (efficacy)Clinician harming (criticism/hostile)A i t t tiAppointment stigmaAppointment travel (costs)Appointment availabilityClinician has helped (now not needed)Clinician has helped (now not needed)
Doctor-Patient FactorsTherapeutic alliance
Perceived helpfulness
Perceived Benefits of Care
Reduced symptoms
Perceived Costs of Care
Previous bad experiences
F d d t
Barriers to CareLack of transportation
Financial inequalities Perceived helpfulness
Communication style
Adequacy of explanation
Adequacy of monitoring
Prevention of complications
Enhanced therapeutic relationship
Improved Health Related QoL
Feared adverse events
Financial costs
Dislike of medical model
Inconvenience
Financial inequalities
Infrequent appointments
Inconvenient appointments
Stigmatization
Ideal Concordance Disengagement (drop-out)
Self-Medication Behaviour Attendance Behaviour
Desire to stop
Good Concordance
Partial Concordance
Low ConcordanceDesire to continue
medical care
Low Attendance
Partial Attendance
Good AttendanceDesire to stop medical care
+ DistractersCues to Act
Reminders
Discontinuation+ Encouragement
Non-intentional IntentionalIllness Factors
Ideal Attendance
Insight into current symptoms
Perceived risk of future decline
Previous treatment responsiveness
Likelihood of treatment benefits
Reminders
Flexible booking / Open access
Delivery or collection of medication
Encouragement / support by others
May Not be Disclosed
Reasons incoherent
No alternatives
Non-intentional Intentional
Likely to be Disclosed
Reasons coherent
Alternatives discussedLikelihood of treatment benefitsconsidered
Adherence and Satisfaction
Audience: what is the relationship?Audience: what is the relationship?
Higher rated treatment success => drop outHigher rated treatment success => drop-outLow rated clinician => drop-out
Rossi, A., Amaddeo, F., Bisoffi, G., et al (2002) Dropping out ofcare: inappropriate terminations of contact with community basedpsychiatric services British Journal of Psychiatry 181psychiatric services. British Journal of Psychiatry, 181,33 –338.
Measuring Medication difficulty
Measurement of adherence
INDIRECTClinicians enquiryClinicians enquiryPatient or relative report
DIRECTMeasurement of the medicationMeasurement of a biological markerMeasurement of a biological marker
Different Ratings Different ResultsDifferent Ratings, Different Results
Two separate studies found that both patients* and clinicians†
overestimate compliance
Rated as Compliant94.7
67.56080
100
of P
atie
nts Rated as Compliant
38.1
10.3204060
rcen
tage
o
0Pill Count Patient MEMS Cap Clinician
Per
*Criterion: ”took all pills.”†Criteria: >70% of days (MEMS cap); score >4 on clinician rating scale.
*Lam YWF et al. Poster presented at: Biennial Meeting of ICOSR; March 29 – April 2, 2003; Colorado Springs, Colorado.
†Byerly M et al. Poster presented at: Annual Meeting of APA; May 17-22, 2003; San Francisco, California.
Consequences of Medication Difficulty
Poor Compliance Affects Rehospitalisation Rates
Percentage of patients with a psychiatric admissionPercentage of patients with a psychiatric admission
35
40
20
25
30
P t
5
10
15Percent
0
10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% 130%
Medication Possession Ratio
Valenstein M, et al. Medical Care. 2002;40:630-639.
Continuous vs intermittent maintenance: 1 year relapse rates
5533
10
Carpenter, et al.
30
297
10
Jolley, et al.
Herz, et al.Continuous therapy
I t itt t th
35
30
20
15
S h l l
Pietzcker, et al.Intermittent therapy
3220
0 10 20 30 40 50 60
Schooler, et al.
Rates of Relapse (%)Kane et al, 1996. N Engl J Med;334:34-41.
Relapse in 1st episode patients over 1 year: according to compliance
35
25
30
35
15
20
25
RelapseWell
5
10
15 Well
0
5
Compliant Non-compliant
Novak-Grubic & Tavcar P. Eur Psychiatry 2002;17:148-54
Helping with Medication difficulty
4 Steps
1 Basic communicationEstablish a therapeutic relationship and trustIdentify the patient’s concernsTake into account the patient’s preferencesExplain the benefits and hazards of treatment optionsInvolve patients in decisions
Don’t force medication as “one size fits all”Don t force medication as one size fits all
2 Strategy-specific interventions2 Strategy specific interventionsAdjust medication timing and dosage for least intrusionintrusionMinimise adverse effectsMaximise effectivenessMaximise effectivenessProvide support, encouragement and follow-upup
3 Reminders3 RemindersConsider adherence aids such as pill boxes and alarmsand alarmsConsider reminders via mail, email or telephonepHome visits, family support, encouragment
4 Evaluating adherencegAsk about problems with medicationAsk specifically about missed dosesp yAsk about thoughts of discontinuationWith the patient’s consent, consider direct methods: pill counting, measuring serum
Liaise with GP & pharmacists re prescriptions
Off lt tiOffer alternatives
Extras
Potential to Improve Relapse Rates With Depot vs Oral Antipsychotics
Difference in Relapse Rates
StudyNumber of subjects Oral Depot
Relapse Rates (oral minus depot) (%)
Studyduration
Crawford and Forest 29 40 k 27 0
Relapsed (%)
Crawford and Forest (1974) 29 40 weeks 27 0
del Guidice et al (1975) 82 1 year 91 4348
27
Rifkin et al (1977) 51 1 year 11 9
Falloon et al (1978) 41 1 year 24 40 -16
2
Hogarty et al (1979) 105 2 years 65 40
Schooler et al (1979) 214 1 year 33 24 9
24
Mantel-Haenszel: P < 0.0002.Davis JM et al. Drugs. 1994;47:741-773.
— +
Degree of difficulty to produce adherence sufficient for therapeutic effectfor therapeutic effect
Weight Reduction
Flossing
Exercise
Schizophrenia
Weight Reduction
Diabetes (oral)
Diabetes (insulin depot)
Hypertension
g
Asthma
Rheumatoid Arthritis
Depression
Headache
Birth Control Pills
Strep Throat
20 40 60 80 100Easy Difficult
Keith & Kane J Clin Psychiatry, 2003; 64: 1308-1315
Oral medication Tips
[ Churchill et al] proposed the following i t t t iimprovement strategies ;
Keeping the regime simple.Providing explicit written informationProviding explicit written information.Involving patients in decision making.Encourage patient participation in their own care.g p p pImplementing drug regimes gradually.Tailoring to daily rituals.Providing warm positive feedback.
Interventions to improve adherence
Osterberg et al 2005 grouped intervention inOsterberg et al 2005 grouped intervention in to four categories;
Patient educationPatient education.Improved dosing schedules of medication.Increasing clinic hours.Improved communication between the p
therapist and the patient.
Contd - 2
Further interventions studied include ;Providing more information [ both written and oral
material and programmed learning ].Compliance therapy.Manual tele follow up.S i l i d ill kiSpecial reminder pill packing.Appointment and prescription refill reminders.L d dLeverage and rewards.
Contd - 6
Other interventions ;In a systematic review [ Bennett & Glaziou 2003 ]
which included 26 RCTs of computer generated medication reminders or feedbacks provided tomedication reminders or feedbacks provided to the pts / health care providers concluded that the reminders are effective than feedback in improving adherenceimproving adherence.
Mugford et al showed that information was most effective when presented close to the time of d i i kidecision making.
Conclusion
In a systematic review [ McDonald et al 2005 ] of RCT f i t ti t i t ti tRCTs of interventions to assist patient adherence to meds concluded in psychiatric disorders the overall combination interventions and compliance counselling for pts appeared to be effective for improving adherence followed closely by family oriented therapies . The y y y peducation oriented therapies on their own were generally unsuccessful in improving the adherenceadherence.
Conclusion
Evidence for any single intervention toEvidence for any single intervention to improve adherence is weak however a combination of educational, cognitive andcombination of educational, cognitive and behavioural measures [ collaborative care ] have shown to improve the adherence to] have shown to improve the adherence to medication with the psychiatric patients. Further research is needed.Further research is needed.