[Purple Cohort] Module 3

[Adam Qazi]

Please submit your SOAP Reflections below:

[Antonio Smith]

30 year old male with a pmh of HIV with a recent non detectable viral load which has since risen to 2100. The patient mentioned having a number of missed doses over the weekend. When asked why he mentioned on days in which he drinks alcohol he skipped doses because he heard it was dangerous to drink and have those medications in his system. We took time to discuss the importance of no skipped doses because of how important it is to suppress his viral load and to not miss doses if he decides to go on a single drug regimen (some of which has low barrier to resistance and can develop such in situations of non adherence). Just from including the patient in the conversation about risk, and how to take his medication even on days when the patient drinks, My patient was encouraged to take all of his doses to suppress his viral load.

My plan moving forward is to address the root causes of apparent non adherence and to tackle those issues head on and to make the experience inclusive so that the patient is able to empower themselves and feel welcomed in the process of choosing therapeutics and developing a plan of action that will improve adherence of chronic illnesses.

[Kendall Bell]

49 yo woman w/ pmh of poorly controlled Type 2 DM. Patient presented to clinic because her peripheral neuropathy had continually worsened over the past 6 months. Patient had previously received care from a different provider, and was presenting to DCC for evaluation of her peripheral neuropathy. Her point of care hga1c was approximately 13. Patient states she had been non-adherent with her, diet, and insulin however takes her metformin as prescribed. The patient was interested in options other than gapabentin to aid with her neuropathy. I asked the patient why she didn’t follow her diet, and insulin regimen and she states she was overwhelmed with taking care of her family, and working and she couldn’t find the time to eat healthy or check her blood sugar and inject her insulin throughout the day. That she took her long acting insulin at night, however doesn’t have time to take her short acting throughout the day. Also she states she wasn’t concerned with her overall blood sugar as much as her neuropathy. I then explained to her until her blood sugar is managed better her neuropathy would continue to get worse. She stated no health care provider had explained to her that the extent of her neuropathy was related to to how poorly the blood sugar was controlled. She had always thought of neuropathy as something that was inevitable with DM. Once I told her they were related she then became very motivated to manage her blood sugar better. We came to an agreement that should would work in the time to take her fasting blood sugar in the morning, as well as her pre and postprandial blood sugar for her lunch (which is her biggest meal of the day). My attending then suggested we increase the patient’s night time insulin as that is the insulin that the patient has the most success with using. This story reminded me of the journal article, because we worked together with the patient to come up with a plan that the patient would buy into and be able to follow.

[Carli Denholm]

I found it very interesting to learn just how big a problem adherence and compliance is and that it really is not related to any specific demographic. This week, I had a patient who was on over a dozen medications from multiple providers and was often noncompliant because she did not understand what several of her medications were for or how to take them. As a result, she was very unsatisfied with the results of her treatment. I went through her medications with her and explained what her medications were for and how to use them. I also addressed some concerns she had over side effects from her medications and tried to simplify her regimen where I could. Hopefully taking the time to do this will help to improve the sense of partnership with the patient and improve her adherence. As the articles pointed out, one of the most important things we can do as providers to improve adherence is to communicate clearly and involve patients in making decisions. However, it is difficult to take the time to do so, given the constraints of time that we often deal with. We need to be able to communicate clearly and concisely. It also helps if we have continuity with patients and address adherence across multiple visits. It will be my goal, going forward, to improve communication with my patients and maintain continuity with them as much as possible.

[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 to my thoughts, I share the following 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?

[Ahmed Yeddi]

In the present time, It is unfortunate that patients are not able to get the same quality of care based on their income/socioeconomic status. This can create a difficult situation for patients and physicians.
A patient has type diabetes mellitus and was not able to consistently come to the clinic. Unfortunaetely the patient cannot afford the medications (oral hypoglycemic) and the dietary modifications. We provide samples for the patient when he comes to clinic while his insurance covers only a portion of the payment. To effectively address patient’s issue it is necessary to gain knowledge about limitations that may alter course of patient care. These are serious discrepancies in social issues that also determine the a person’s health and future. As seen that living his poverty has a great impact on where you end up, the resources maybe available but may not be easily accessible for these individuals.

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