Medication adherence Reflection

[Adel Elmoghrabi]

Without a doubt both medication compliance and adherence are very challenging even perhaps more often when the patient him/herself is a physician. The articles did address many important points that determine why patients are non adherent and one can all agree that particularly in chronic conditions it is a great challenge to the patient and everyone involved in the patients care to sustasustain perfection in medication adherence. Given the multidisciplinary management that our patients are exposed to i believe that although physicians play a pivitol role in establishing a plan with the patient and formulating the foundation of a long-term management strategy including what medications,their uses side effects etc.. as mentioned in the article there are a myriad of factors to be addressed which need more than the regular time spent during a clinic encounter.In view of these time constraints it would greatly beneficial to include a social worker and a pharmacist during clinic encounters who can have great impact and close the loop of this multimodal style management ensuring that all barriers identified are adequately addressed.

[Wadah Ismael]

I found this nice article from American College of preventive Medicine website regarding SIMPLE methods physicians can follow to improve medication adherence:
Studies show that simple interventions are the most effective. The SIMPLE mnemonic below contains strategies to improve adherence. Sample conversations matching the SIMPLE approach are found in the Provider Strategies section of the Medication Adherence Clinical Reference.
S implify the regimen
I mpart knowledge
M odify patient beliefs and human behavior
P rovide communication and trust
L eave the bias
E valuate adherence

S – Simplify the Regimen
Adjust timing, frequency, amount, and dosage
Match regimen to patients’ activities of daily living
Recommend all medications be taken at same time of day
Avoid prescribing medications with special needs
Investigate customized packaging for patients
Break the medication regimen down into simple steps
Encourage the use of adherence aids

I – Impart Knowledge
Focus on patient-provider shared decision making
Encourage discussions with physician, nurse, and pharmacist
Provide clear instructions (written and verbal) for all prescriptions (See Medication Adherence: A Guide for Patients)
Limit instructions to 3 or 4 major points
Use simple, everyday language
Use written information or pamphlets and verbal education at all encounters
Involve family and friends in the discussion when appropriate
Provide quality web sites for patients wishing to access health education information from the Internet
Suggest computerized self-instruction for complex chronic conditions
Provide concrete advice for how to cope with medication costs
Reinforce all discussions often, especially for low-literacy patients

M – Modify Patient Beliefs and Human Behavior
Empower patients to self-manage their condition
Ask patients about their needs. Create an open dialogue with each patient and ask about his or her expectations, needs, and experiences in taking medication.
Ask patients what might help them become and remain adherent
Ensure that patients understand they will be at risk if they don’t take their medication
Ask patients to describe the consequences of not taking their medication
Have patients restate the positive benefits of taking their medication
Address fears and concerns (perceived barriers) of taking the medication
Consider the use of contingency contracting; provide rewards for adherence

P – Provide Communication and Trust
Modifying patient beliefs is only possible if a high level of patient trust exists. A physician’s communication style is one of the strongest predictors of a patient’s trust in his or her physician. Many physicians are weak in communications. Consider these statistics:
At least 50% of patients leave the office not understanding what they have been told
Physicians miss 50% of psychosocial and psychiatric problems due to poor communication skills
Physicians interrupt patients on an average of 22 seconds into the patients’ descriptions of the presenting problems
54% of patients’ problems and 45% of patient concerns are neither elicited by the physician nor disclosed by the patient
71% of patients cited poor relationships as a reason for their malpractice claims
Seven Ways to Improve Communication
Improve interviewing skills
Practice active listening
Provide emotional support
Provide clear, direct, and thorough information
Elicit patient’s input in treatment decision-making
Allow adequate time for patients to ask questions
Build trust

L – Leave the Bias
Learn more about low health literacy and how it affects patient outcomes
Examine self-efficacy regarding care of ethnically and socially diverse patient populations
Review communication style to see if it is patient-centered
Acknowledge biases in medical decision-making (intentional or unintentional)
Address discordant patient-provider race/ethnicity and language

E – Evaluate Adherence
The act of measuring adherence can lead to better patient compliance
Self-reports are the most commonly used tool in measuring adherence
Ask your patients simply and directly if they are sticking to their drug regimen
Ask about adherence behavior at every encounter
Ferret out adherence barriers and lack of receptivity to medical information
If self-report still leaves questions about adherence, try pill counting or measuring serum or urine drug levels
Periodically review patient’s medication containers, noting renewal dates

A Final Thought
Adherence is critical to patient outcomes but is often hard to achieve. Improving adherence is a complex and variable process. The most effective physician strategy is to build patient trust and better communicate the benefits of taking medication as directed.

[Ahmad Abu-Heija]

Ms Y is a 74 year old pleasant AAF with PMHx of HTN, patient presented to the clinic with BP 180/110. Patient reports she last saw a physician >10 years ago, he never emphasized the importance of follow up to her and never explained to her underlying condition, and as such she never felt follow up was of any significance.

I explained the importance of follow up, especially in her age and given her lack of co-morbidities which will more likely than give her more room for medication adherence and compliance. One drawing later, she understood the impacts of elevated BP on her different bodily systems, and she indeed came in the next 5 weeks and the 5 weeks after that as well for follow up.

Explanation, simplification and emphasis go a long way. Most patients want to live longer, they understand drugs are used to treat diseases. However, not all understand the impact medications have on their diseases.

[Jasleen Kaur]

A 56 yrs old female patient came to the clinic for per- op clearance and her HbA1c was 11.4 with no follow up since 7 months. She felt fine otherwise and stated that she did not like the idea of taking medications.

I asked myself, “Who’s to blame?” for patients not taking their medications and cited a couple of papers describing the poor state of medication adherence. I concluded nonadherence was a huge problem, and doctors failing to educate their patients was not only a major cause.
To support my contention that physicians are not the reason why patients do not take their medications as ordered and advised, I share the following new information.
A randomized clinical trial published online in JAMA Internal Medicine looked at patients who had been discharged after myocardial infarction and prescribed drugs known to decrease the incidence of future negative outcomes such as readmission for MI, unstable angina, stroke, congestive heart failure, or death. The investigators looked at whether incentivizing patients to take their medications would have any impact on adherence.
The 1003 patients in the intervention cohort received electronic pillboxes for their various cardiac medications, daily lottery tickets with a 20 percent chance of a $5 payout and a 1 percent chance of a $50 payout based on medication adherence for the day before, the ability to choose a friend or family member who would be notified if the subject did not use his electronic pill bottle for two of the three previous days, access to social work resources, and a staff engagement advisor to monitor and encourage adherence.
The 506 control patients received no extra care nor did they have any further contact with those conducting the study. “There was no statistically significant difference between arms in the prespecified primary outcome of time to first readmission for a vascular event or death.” Medication adherence also did not differ significantly between the two groups and averaged less than 50 percent.
We now know money, fancy gadgets, interventions by others, or the specter of death did not motivate post-MI patients to take their medications.

Improving drug adherence will take more than money and technology. A small bit from my side, I try to remind my clinic patients to bring all their medications with them on next visit for a 2-minute medication reconciliation. I try to simply and explain the importance of compliance. I tried to answer their unanswered questions.

I believe, there are many reasons for nonadherence —a desire to do things “naturally,” pills represent reminders of their sickness, depression, social issues within families, self-experimentation with stopping medications and noticing no change in perceived health, and most important drug costs.
There could be a continuous multimodal approach to it. Physicians could provide with the 2-minute talk if some ancillary burden is lifted off them. Social worker could provide reinforcement as person to person visit to discuss insurance or travel issues, have dedicated psychologist to understand their mindset, etc.

Does anyone have any other ideas?

[Ghaith Alhatemi]

One thing about adherence is communication between providers. Sometimes we reconcile meds with patients without realizing that their cardiologist or nephrologist changed some sort of medications and can be challenging if patients continue using both meds of the same class from both primary care aand other speciality clinic. I think it’s very useful to send faxes or emails between providers and patients need to be aware of these changes. The point I wanted to bring is that we need to be part of adherence and don’t get biased about patient role.

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