[Yellow Cohort] Module 3, 2018-19 – Patient Adherence

[Nabil Al-Kourainy]

Please enter your reflections for Module 3 here. Thank you.

[Nabil Al-Kourainy]

[Yellow Cohort] Module 3 – Patient Adherence

S: As we learned for the articles, non-compliant is more often associated with a negative connotation. In contrast, adherence takes into account the SDH that may lead to a patient either not taking a medication or going to a referral appointment altogether. Despite a doctor’s best efforts some patients remain non-adherent. This may be due to things like lack of understanding of the reasons for the prescribed treatment, financial considerations, prioritizing more pleasurable activities over the recommended treatment strategies, etc… As physicians we must seek to better understand the reasons for non-adherence.

O: As the articles pointed out, there are a number of reasons for non-adherence such as, a lack of rapport, mistrust in the healthcare system and doctors in particular, limited health literacy, financial considerations, concerns about potential side effects, non-peer reviewed literature on the internet, or negative anecdotal accounts from friends or family.
I recently encountered a VA patient who had been discharged from DMC after being treated for paroxysmal afib with RVR, on Rivaroxaban. The pt was again presenting with RVR, and had been non-adherent to his OAC. When I queried the pt as to the reason he had not filled his Rx, he stated that he did not understand what it was for, so he did “not want to put something in my body when I don’t even know what it is”. He also had not had follow-up with Cardiology, despite being discharged 3 months prior. I explained to him what his afib meant, how we could try to control it with beta blockers, how those helped control his heart rate, and then I explained to him how afib increases his risk of blood not moving forward, which increases his risk of clot and in turn stroke. He thanked me for taking the time to explain, stating “No one has ever explained it like that before”, and he agreed to fill and take his prescribed OAC at discharge.

A: For my patient, I believe it was taking the time to break down the pathophysiology of his disease and explain how an OAC could potentially protected him from a CVA/TIA that may have won him over. For the rest of his hospital admission he was adherent to the OAC. I can only hope that he will honor his promise to stick with it and to follow-up with his Cardiologist.

P: As physicians it is up to us to try to address potential care barriers. Some strategies that I have learned from readings include: collaboration, simplification of medications, communication – explaining key elements about a proposed treatment or examination, as well as providing behavioral support. As I continue to treat patients in residency, I must acknowledge some of the limitations in knowledge that these patients have. I will continue to take the time to explain complex processes in patient-friendly language and in turn build the rapport that I need to educate patients about their comorbidities, and hopefully break through a cycle of non-adherence. I must remember though, that some things are beyond my control, such as financial stressors, and I must be steadfast in my resolve to not judge patients when they are non-adherent, but to try my best to understand their reasons and to be patient with them.

[Shivani Agrawal]

This clinic week we had a good discussion about the articles and patient adherence. Several examples from clinic this week had me thinking about the articles and our discussion.
One patient was taking her BP medications “as needed” . I counseled her to take them daily but to continue to monitor her home BP. That way, we could see the trends and make appropriate changes. She may not have been counseled previously that BP medications are taken chronically and are not “as needed” pills.

I also had 3 patients this week who said they needed “refills on all their medications”. I reviewed each one medication with the patient, and every drug in question had refills. That way, the patient was reassured that he/she had enough of the drug. Also, too many unnecessary refills can reflect extra cost on the patient/system. There is also a risk of polypharmacy if patient continues to fill medications that may no longer be needed. There was a patient my intern year (I don’t recall all the details) who arrived with 40+ pill bottles and many, many duplicates to the hospital. I imagine my co-residents were being diligent with refills but this patient had a large polypharmacy issue. Therefore, I will be careful to make sure patients have appropriate refills both for their safety and to be cost conscious. I wish the call center could remind patients when they call for an appointment to bring pill bottles/medicines lists with them.

I will continue to use the ideas from the articles and our discussion when counseling patients about their medications.

[Deya Obaidat]

The medical world has changed in the last couple of decades where now we have a medication for every disease, and with the increase of the medications that patients are given it is expected that the adherence to such regimens would be challenging to both the patient and the physician, specially in the setting of polypharmacy when it comes to chronic diseases as patients will be taking medications for longer period of time which even makes it more challenging in a way.

There are a lot of factors that may lead into non-adherence, and despite what we mentioned earlier about the polypharmacy being one of the reasons, it might not be the biggest reason, as patients tend to forget to take their medications in most of the cases, and in other cases they might not know exactly why they are taking a certain medication and decide that they are better without it, and some other patients will stop certain medication to possible side-effects without contacting the physician. also it appears that the modern world formulization of the medical field has been having its share of the problem, as health insurance is not available unfortunately to everyone which might make it difficult to continue seeing physicians or get medications with high prices.

no matter what the reason is for the non-adherence there is always a way to tackle it, from putting a reminder on the cell phone of the patients to remind them about taking their pills to have a better healthcare system that insures patient’s continues care with physicians and RNs.

[Marvin Kajy]

​In the past, the physician would take the paternalistic/ authoritarian role in the doctor-patient relationship. The physician would order the patient to do something or prescribe a certain medication and it was assumed that the patient would follow the instructions without any resistance. The patient had little to no input in the formulation of the treatment plan. Then when the patient comes back during the next office visit, we find out that the patient was not following the instructions and we would label them as noncompliant. “Noncompliant” is doctor-shorthand for patients who don’t take their medications or follow medical recommendations. It is a term loaded with implications and stereotypes. I used to ask the patient if they were taking their medications and then I would write down “Yes” or ” No” in the chart. However based on the discussion we had, reducing a patient’s adherence to whether or not they are taking a pill is an immense (and wrong) oversimplification.

There are many factors at play that affect a patient’s adherence to a treatment regimen. Often times, we provide recommendations without thinking about the potential implications that these recommendations have on a person’s life. Obtaining a prescription for multiple medications and getting to the pharmacy to fill them (and that’s assuming that the patient actually has insurance and a ride to get the medications). On top of remembering to take the morning pills and then the evening pills each and every day. With our patient population, we also have to consider the costs of the medication. When faced with paying the bills/providing food for the family versus paying for the medication, patients will go for the former. Then, there is always a component of health literacy. Patients often say they feel well and say that they are asymptomatic and they question why the doctor is prescribing the medications (e.g. for HTN and diabetes). Numerous studies have been performed whereby patients were asked how much they remembered after their office visit and the results were abysmal at best. One study cited 14% of what a doctor tells a patient is remembered.

In the modern era of medicine, there has been a shift in relationship between the physician and the patient. What once was an authoritarian approach has now changed to a collaborative partnership between patient and physician that is based on shared goals and a mutual understanding of problems and their potential solutions. Whenever we prescribe a medication or give a recommendation, we should take a step back and ask ourselves a question and ask the patient the question if they can adhere to the recommendation. If they can, great. If they can’t for any reason, then it is our duty as physicians to try to find an alternative treatment approach. A team work approach between the patient and the physician appears to be the most important factor for promoting medication and lifestyle adherence. A plan that is in part crafted by the patient is more likely to encourage adherence.

[Jie Chi]

3 patient appearance
Subjective: This week’s topic is about the patient’s adherence. Patient adherence is integral to positive health outcomes, including taking medication correctly and on time, accepting vaccinations, make 2 appointments timely, which positively affects chronic disease management
Objective: as in Gmap patient always misses doctor’s appointment, which may seem minor, but this is a reflection of low patient adherence to health care which leads to negative health outcomes and increased to healthcare costs. Missed appointments means opportunities for disease detection and needed care are delayed. We often see a patient with a long medication list, when you ask him, he was saying I am not taking all of these, that is just too much. Or I only take it when I feel bad. Patient’s in this region 10 to have multiple comorbidities, polypharmacy is not uncommon. It creates confusion, inconvenience for patient. this is often due to in adequate education. Prioritizing medication is a very important part which we often omit. The significance of Brilinta in a CAD patient recently had a heart attack is way bigger than omeprazole in this patient. However patient will take omeprazole to reduce the heartburn symptoms without realizing the outcome of missing a dose of Brilinta.
Assessment and plan
In order to improve patient’s health Alcon and deliver how quality care, some intervention can be done to promote patient adherence. Such as with the increased S ability of smart phones and other communication technologies, patient can set reminders of the appointments they have to make, and schedule of medication when they need to take it. As simple as a click can resolve a main reason for missed appointments, decreased confusion of appointment date and time. It would be nice if in future we can develop some communication software through which the provider can administer follow-up with the patient’s effectively, contact patient by text messages or phone messages, communicate about medication side effect monitoring and dosing adjustment. Text messages make it easy for patient to follow-up with questions. Provider contact information such as the office phone number can be included to simplify the call back process if the patient had questions regarding her follow-up or need to reschedule appointment.

[James Bathe]

Medication non-adherence is an important determinant of health that we are all familiar with. Unfortunately, this can be incredibly frustrating, especially when the same patient can come in for multiple visits and have made no progress. However, while the first reaction a provider may have is frustration with the patient, we have to realize that often there are good reasons for non-adherence that are often outside of patient control.

For example, today I had a gentleman present looking for insulin refills. He said he usually uses up the insulin before the end of the month and the pharmacy refuses to refill early. Our order to the pharmacy requested 10 vials a refill. His blood sugar was 319 and A1C was 10.9% Come to find out, the pharmacy thought that the 10 was supposed to be a one. After clearing it up, my patient is back on track.

There can be many reasons to non-adherence so sitting and talking to the patient should reveal the truth. Sometimes, the patient just needs reassurance. Halons Razor comes to mind: Never attribute to malice what can be attributed to ignorance. Rather than be frustrated with our patients, we should seek out road blocks to their success. Apply that frustration to the real puzzle and everyone will benefit.

[Salina Faidhalla]

As we practice, we encounter the non-adherence issue daily, most of the time we blame it on the patient thinking that this patient is just not adherent or as we used to say not compliant. if we look in depth and try to understand the issue further, there are multiple factors that can affect the patient adherence. those can be patient related factors, but can also be physician related factors and health system related factors. so in order to address adherence problems, all these factors needs to be addressed simultaneously.
I had one of my patients this week in clinic, who has a history of HTN that is well controlled with medications, this patient is adherent to her medication, she shows up to her appointment despite the transportation difficulties. she was recently seen by a cardiologist who started her on (entresto) without explaining the reasoning behind it or why the patient needs it, the patient didn’t even know if she had heart failure or not, she actually thought it was another BP medication that was added to her regimen and she was surprised because her BP is always controlled. So if this patient decided to stop taking entresto thinking its for hypertension, not knowing she has HF (which was dx by cardiology), then her non-adherence is due to physician factors.
So I think we all need to take a moment and spend maybe little more time educating our patient and give them a chance to better understand their disease and the need for the treatment.

[John Dawdy]

The challenge of optimizing patient adherence has been a part of the art of medicine since its origins. Although treatment plan development is at face value the greatest part of what physicians were paid to do for many years, this is now an outdated train of thought with reimbursement and outcome measures focusing more on treatment outcomes than initial services rendered. Patient adherence is of particular importance in a primary care setting, where our outcomes are often longterm and not simply immediate results as seen in surgical or procedure heavy specialties. Our articles aimed to better tease out classifications of patient adherence and why we have moved from discussing patient compliance to adherence. Although there are many sorts of contributing factors that impact patient adherence, from a physician’s standpoint it comes down to communication with our patients. Not just our communicating to them treatment plans, but also taking the time to listen to their stories and asking the best questions to get them to open up about the barriers that they face. Whether it is about transportation, financial troubles, or understanding, these all contribute to being able to the overall picture of adherence.

Patient adherence takes more than a prescription and well-educated patient. Even the best laid plans go awry sometimes, but we must try our best to put our patients in the best place possible in order to carry out our plans. An awareness of and frequent reflection on the barriers that our patients face help make us more effective physicians and provide our patients with better outcomes. We often can not erase all of their barriers, but we can try our best to work around them with the patient. Moving away from our profession’s history of paternalistic instruction to collaborative planning helps with this. Knowing that they are listened to and have the change to actively participate in the plan has shown to increase patient adherence, as described in this week’s articles. Although this often takes more time in clinic, it is something that helps in the long run and can likely save time moving forward. As CCR this week I often found that the tasks that I was completing arose from some miscommunication or

[Aliza Rizwan]

Our topic for social health determinant for this week was on patient adherence, which indeed is an important component of health care. Adherence relates to how each individual thinks, behaves, and engages with their therapy and medication. There are several factors involved in patient adherence including patient’s knowledge and understanding of the regimen, clear and effective communication between health professionals and their patients, and the nurturance of trust in patient-physician relationship. One such factor that I came across this clinic week in regards to patients nonadherence was patients’ ability to remember the details of the recommendations made to them. My patient who had a moderate persistent asthma who was on maintenance and rescue inhaler came to the clinic with not much difference in her asthma symptoms although was put on maintenance inhaler last clinic visit. On asking regarding her use of inhalers found out that she was using rescue inhaler as her maintenance inhaler and vice versa, therefore she was not able to achieve the goal expected in terms of symptom relieve with her current treatment regimen. Which made me think regarding the gap in communication that could have been overcome by optimal verbal communication.
Forgetting to take (or how to take) medications is a major contributor to nonadherence, much of what is conveyed during the medical visit is forgotten within moments of leaving the doctor’s office. Since the verbal communication between physicians and patients is often filled with technical terms and “medical jargon” that impedes patients’ comprehension and retention of information. Also in the interest of time efficiency, details of the prescribed treatment may not be thoroughly explained and/or rehearsed with patients, but such clarification is necessary. These seems to be small factors but can have major impact in patient’s adherence that can be handled by a physician. If each of us take a little time and effort to make our communication between our patients optimal and empathic, we can at least can overcome one of the several factors of patient non adherence.

[Sahrish Ilyas]

We are all aware that patients’ adherence to treatment plans is integral to quality healthcare outcomes and non-adherence can pose a significant threat to overall health. I think one of the key reasons we witness patient non-adherence is due to lack of understanding of both the disease process and treatment plan requirement. It is imperative that physicians educate patients on what it means to have a certain disease and what interventions are being undertaken to treat that process and why. Many patients simply chose not to take their prescribed medications because 1. They do not feel that they need to (often times because they don’t feel unwell especially in cases of chronic noncommunicable illnesses such as DM and hypertension) 2. They do not understand why they take the medication and what effect it truly has
There are a few strategies that physicians can and should be practicing to help improve patient adherence. This includes explaining what a new medication is for, how it works, and the risks or side effects of use. Additionally some patients are on multiple medications, often times a few of these are unnecessary and so helping to simplify patient medication lists would help alleviate the burden of taking so many medications.
Sometimes we need to do a better job of explaining disease processes in better detail to our patients. One of the new patients I saw this week has a known history of hypertension but self discontinued his medications because he never felt “bad” and assumed his pressures were fine. He came into clinic and his BP was 200/100. He still felt pretty good despite the elevated BP and so it was important to explain to him that he may not always feel unwell when BP is high and it is important to check it daily at home and continue medications until a physician discontinues them. He simply said no one has ever put it to me this way and now he has a better understanding. We as physicians need to do a better job on our part to help improve patient adherence.

[Leslie Kao]

This week’s discussion revolved around patient adherence.

This was especially precedent with a patient I saw in clinic today who has fibromyalgia. She presented to us for the first time 3 months ago with a supposed diagnosis of Rheumatoid arthritis, despite being serologically negative and symptoms that were more in line with fibromyalgia. At that time, we had given the patient a prescription for a TCA and sent her to follow-up with Rheumatology. In her follow-up appointment with me this week, the patient stated her symptoms were worse then ever, however on questioning her, she did not adhere to any of the medications that our clinic or rheumatology prescribed due to perceived side-effects. On further questioning, the patient did not attempt to try the medication long enough (<1 week) to obtain any benefits. In the end, through discussion in regards to the patient’s circumstances including inability to afford a new prescription, the patient was convinced to try the medication again. This time however, she was warned in regards to the side-effects and duration of trial of treatment before discontinuing the medication.

I think we as physicians sometimes do a very poor job of education our patients in regards to the medications we are prescribing and our thought process behind changing medications. When our patients are better educated in regards to physician’s motivations, in what side effects to expect, how long to trial a medication and what goals of therapy are they are more willing to adhere to the therapies prescribed to them and our patient-physician interaction becomes a collaboration.

[Justin Gatt]

Patient adherence is one of the most critical aspects of quality medical care. It is our duty to ensure each and every patient is given the best chance to manage and/or overcome their illnesses. However, oftentimes this becomes lost in the shuffle of the ever-more complicated patient visit process.

In my opinion, medication non-adherence is often borne from patients’ lack of understanding and education about their specific illnesses. This can be broken down to multiple issues in the American health care and education systems, but for our part physicians can do a much better job of thoroughly educating each patient about their medical conditions. Not only the treatment for the condition, but, importantly, what the disease really means for them. One vital way to achieve better understanding is to use the teach-back method. Having patients verbally explain the condition followed by the treatment regimen recommended by the physician will help cement the importance of adherence in their minds. When someone has a true understanding of the risks they’re assuming if they choose the non-adherence route then they will be less likely to divert from the path recommended by the physician.

Educational training and counseling courses for specific illnesses (much like is currently done with diabetes) would provide patients with the opportunity to grow their knowledge base and help reduce re-admissions. In addition to in-person training courses, I think it would be beneficial to have a mobile and/or desktop application capable of initiating reminders for medication administration times. I know there are some pilot programs underway testing this in Europe and look forward to seeing the results of the trials.

[Syed Umer Mohsin]

Non adherence is one of the many issues in our healthcare system which comes across as a barrier to quality of care. I believe patients stop taking medications due to a number of reasons, 1) There are just too many medications to take and especially if they are elderly they are more prone to miss medications for this very reason. We need to simply medication regimens, do a medication reconciliation every visit and involve these patients by asking them why they think they are on a particular medication and then address to see what they are doing both from a life style (exercise, altering diet) and health monitoring (BP checks, glucose checks) standpoint in helping us titrate the medications off. 2) The other reason I think patients find difficult to adhere to medications is cost. Some patients are unfortunately unable to afford the copays. These are the ones that are lost to follow up the most. Our role here is to get a good understanding of patient’s social’s background and what would some of their barriers be. Our case workers have strong resources that can help and we should educate our patients with their options. Sometimes all it takes is connecting them to patient assistance programs for a particular drug. Being considerate of our prescriptions where we write for generics only instead of brands is another simple way to make it easier for our patients. 3) Discussing side effects. Patients often experience side effects from medications that have simple solutions (such as NSAIDs with food, bisphosphonates with a full glass of water and staying up) can help prevent many reasons to avoid use of a perfectly good drug before switching to other classes. These are all effortless measures that one can adopt as physician as a step towards perfecting the care we strive to give to our patients.

[Dana Kabbani]

I recent study that I read discussed that there was an average nonadherence rate of 25% to medications. Adherence to medications is highest in patients patients with HIB, arthritis, gastrointestinal disorders, and cancer, and lowest in patient with pulmonary disease, diabetes, or sleep disorders. Nonadherence has a number of impacts for our patients, particularly increased morbidity and mortality. During every clinic visit, I review medications with all patients, and advise them to keep all their medications written on a piece of paper, and to bring this to their doctor’s visits. I also like to go over what medication is/does, and explain the necessity of continuing adherence, and the risks of not taking their medication. Recently, I had patient with HIV and depression who did not take her antidepressants for two months. I explained to her the impact of her not taking her medication on not only her HIV, but her daily life as well. Counseling our patients and providing them with the educational tools and support system that they need will create the best opportunity for them for their health.

[Dana Kabbani]

Here is the article for those interested:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711878/

[Eskara Pervez]

I had a patient in my last rotation who presented with breakthrough seizures. He was adamant that he was taking his medications as prescribed. When further investigated it was found out that he WAS taking his Keppra as prescribed but not valproic acid as he did not realize that Valproic acid was for his seizures too.
It is well known that patient adherence to appropriately prescribed medications is essential for treatment efficacy and positive therapeutic outcomes. It is also understood that patients who are prescribed medications do not necessarily take them as prescribed. Providers need to do better at educating patients about prescribed medications. Nothing beats a physician taking a moment to sit with his/her patient and talking them through all their medications and making sure they understand. This extra effort to educate patients can improve adherence and reduce adherence related complications.

[Mahvish Khalid]

The mains reasons for patient non-adherence are lack of understanding of the disease process, inadequate comprehension of the treatment plan and inability to cover the cost of medications. Most patients do not feel the need to treat a condition which is not causing any acute symptoms, not realizing, that chronic illnesses have long term effects. They also do not understand why they are prescribed different medications or why the frequency with which they must take these medications is important. Lastly, patients experiencing economic hardship are more likely to drop expensive medications.

It is important for physicians to understand these challenges. Their role in treating patients should not only be to diagnose an illness and formulate a treatment plan but to make sure that their patients have a thorough understanding of both. Physicians must take time out to go over the medications with their patients. During this time, they must ensure that the patient realizes the important role their medications play in the successful treatment of their condition.

[wsumed]

A is for America by Devin Scillian — 9781585360154

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