Therapeutic Adherence_Key to successful therapeutics

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Therapeutic adherence is very crucial for making any therapy successful

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Pharmacotherapeutic Adherence: Key to Rational Therapeutics:

Pharmacotherapeutic Adherence: Key to Rational Therapeutics Prof. R. K. Dixit Pharmacology and Therapeutics K. G. M. U. Lucknow, Uttar Pradesh [email protected] King George’s Medical University Lucknow Indira Gandhi Institute of Medical Sciences Patna

Comment:

Comment

How many sticks are in this picture?:

How many sticks are in this picture?

Objectives:

Objectives The talk will focus on What is Compliance Concordance Adherence Persistence It’s importance for therapeutic benefits Strategies to measure adherence Strategies to improve adherence Take-home messages and audience inputs

Please Find The Missing Link:

Please Find The Missing Link

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Prescribing Adherence Dispensing Diagnosis / Follow-up

PHARMIONICS:

PHARMIONICS The term Pharmionics refers to the investigation of what the patient actually does with the drug after it has been prescribed .

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Acceptance : The first phase is whether the patient accepts the principle and regimen of the prescribed treatment If acceptance is forthcoming, the patient commences to engage with the drug dosing regimen

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Discontinuation: When the treatment ceases Prescriber called for it to cease, or the patient may have partially or wholly stopped

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Attendance Measurement of the frequency or timing of medical follow-up visits compared to the frequency or timing that should occur based on the physicians‘ plan.

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Compliance- Act of obeying an order, rule, advice or request Acting according to an agreement The degree of constancy with which a patient follows a prescribed regimen The attributes of compliance included Patient obedience (Passivity) Ability to implement medical advice Flexibility Responsibility Collaboration Participation Persistence in implementing the advices

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Adherence - Extent to which a persons behavior corresponds with agreed recommendations from a health care provider Preferred Different from compliance Patient obedience (Passivity) Ability to implement medical advice Responsibility, Collaboration and Participation Persistence in implementing the advices

Adherence:

Adherence Adherence to medication comprises of Initiation of prescribed therapy Implementation as prescribed Persistence

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Concordance- An agreement reached AFTER NEGOTIATION between a patient and a health care professional Respects the belief and wishes of the patient in determining the decision Less a measure more a Philosophical approach Shared agreement

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Medication  persistence   Act of continuing the treatment  for the prescribed duration Defined as "the duration of time from initiation to discontinuation of  therapy ."

Compliance Vs Persistence:

Compliance Vs Persistence Compliance is measured over a period of time and reported as a percentage whereas Persistence is reported as a continuous variable in terms of number of days for therapy Clinical outcomes are affected both by Compliance (how well patients take their medications) Persistence (how long they take them)

ADHERENCE Vs COMPLIANCE :

ADHERENCE (Concordance) TO …. partnership between doctor and patient , The patient’s conformance with the provider’s recommendation with respect to timing, dosage and frequency of medication taking COMPLIANCE WITH ….. you must, you have to take (one-way street ) , Patient’s passive following of provider’s orders A DHERENCE Vs COMPLIANCE

Consequences of nonadherence and Non-persistence:

Consequences of nonadherence and Non-persistence Negative outcomes Increased Mistrust with physician Risk of relapse of disease Mortality and morbidity Length of hospital stay Frequency of re-hospitalization Cost of management Burden on society

Primary Vs Secondary Nonadherence:

Primary Vs Secondary Nonadherence Primary nonadherence Patients fail to fill prescriptions when new medications are started so it is related to refilling initiation of the medication therapy Secondary nonadherence Medication being not taken as prescribed when prescriptions are filled

Medication Non-Adherence:

Medication Non-Adherence Ho, P., Bryson, C., , & Rumsfeld, J. (2009). Medication adherence: Its importance in Cardiovascular Outcomes. Circulation , 119 (23), 3031. 23 Intentional “ Active process whereby the patient chooses to deviate from the treatment regimen.” Unintentional “ Passive process in which the patient may be careless or forgetful about adhering to treatment regimen.”

The challenge:

The challenge Often HIDDEN Undisclosed by patients Unrecognised by prescribers Haynes R, McDonald H, Garg A, Montague P. (2002). Interventions for helping patients to follow prescriptions for medications. The Cochrane Database of Systematic Reviews, 2, CD000011.

Non-adherence may lead to:

N on-adherence may lead to Underuse Overuse

Medication Non-Adherence Includes::

Medication Non-Adherence Includes: Fail to fill the first prescription Fail to refill prescription, as directed Skipping doses Taking more OR less of a medication than prescribed Stopping the medication too soon Taking dose at the wrong time

Medication Non-Adherence Includes::

Medication Non-Adherence Includes: Taking someone else’s medication Taking medication with foods, drinks, or other medications it shouldn’t be used with Taking expired medications Storing medications in the wrong place Using devices improperly (such as inhalers)

Highlights of Statistics of Nonadherence:

Highlights of Statistics of Nonadherence Nonadherence reported from 10 to 90% Overall 20 to 50% patients Elderly, Children and chronic ailments at risk Nonadherence results in Loss of billion of dollars / Rs 10 to 25% of hospital and nursing home admissions 6 times increased risk of premature death Millions of deaths

Highlights of Nonadherence:

Highlights of Nonadherence Adherence not exclusively responsibility of patient Increasing adherence may have a greater effect on health than improvements in specific medical therapy Medication-taking behavior is complex and involves patient, physician, and process components Identification of nonadherence is challenging and requires specific interviewing skills Don’t limit interventions to patients who are not compliant as patients once compliant often become nonadherent down the line

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9 Copyright © 2011 Capgemini Consulting. All rights reserved. 33 Source: (1) Andree Bates, “Ensuring Profitable Patient Adherence Programs”, Eularis, March 2010 (2) Source: Capgemini external interviews - Q2) What in your opinion is the current level of adherence in patients? Adherence rates of selected conditions

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9 Copyright © 2011 Capgemini Consulting. All rights reserved. 34 Adherence rates across the duration Source: (1) Andree Bates, “Ensuring Profitable Patient Adherence Programs”, Eularis, March 2010 (2) Source: Capgemini external interviews - Q2) What in your opinion is the current level of adherence in patients? Adherence rates of select conditions in US, 2008 1

Negative correlation between frequency of daily doses and compliance level:

Negative correlation between frequency of daily doses and compliance level

Adherence to Chronic Therapy:

Adherence to Chronic Therapy 0 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6 7 8 9 10 11 12 Patients (%) ACE-Inhibitor Statin Month

Combining 2 Antihypertensive Agents In 1 Pill Enhances Persistence:

Combining 2 Antihypertensive Agents In 1 Pill Enhances Persistence 19%* * P <0.05 vs. fixed-dose combination Dezii C. Managed Care . 2000;(Suppl 2):6-10. Lisinopril/HCTZ combination pill (n=1644) Lisinopril and diuretic in separate pills (n=624) 50 60 70 80 90 100 0 1 2 3 4 5 6 7 8 9 10 11 12 Months Persistence (%) 69% 58%

Persistence* with Diabetes Therapy Declines When Patients Are Prescribed 2 Pills Instead of 1:

Persistence * with Diabetes Therapy Declines When Patients Are Prescribed 2 Pills Instead of 1 55% 29%** 58% *Defined as continuous months of drug use. ** P <0.05 vs. monotherapies. Data on file. Bristol-Myers Squibb Company. Metformin alone Sulfonylurea alone Metformin and sulfonylurea in separate pills 0 25 50 75 100 1 2 3 4 5 6 7 8 9 10 11 12 Months Persistence (%)

Adherence Lowest When Therapy is Preventive:

Jackevicius CA et al. JAMA. 2002;288:462-467. Adherence Lowest When Therapy is Preventive 100 90 80 70 60 50 40 30 20 10 0 Patients taking statins (%) Cohort study using linked population-based administration data from Ontario, Canada (N=143,505).

Initial Therapy Choice Influenced Long-term Persistence:

Conlin PR et al. Clin Ther. 2001;23:1999-2010. Initial Therapy Choice Influenced Long-term Persistence Patients continuing therapy at 48-month follow-up (%) b -Blocker Retrospective, records-based, cohort study of patients on antihypertensive medication using the Merck-Medco Managed Care LLC Research Convenience Sample database (N=15,175).

More Frequent Physician Visits Improved Adherence:

Monane M et al. Am J Hypertens . 201 7;10:697-704. More Frequent Physician Visits Improved Adherence Adherence ≥80% (OR) Retrospective study of elderly (aged 65 to 99 years) members of the New Jersey Medicaid and Medicare populations (N=8643).

Number of Concurrent Medications Influenced Adherence:

Data on file. Pfizer Inc., New York, NY. Number of Concurrent Medications Influenced Adherence Adherence ≥80% (OR) P <.0001 P <.0001 P <.0001 P <.0002 Retrospective cohort study in a large managed care population (N=8406).

Using Multiple Pharmacies Negatively Affected Adherence:

Monane M et al. Am J Hypertens. 1997;10:697-704. Using Multiple Pharmacies Negatively Affected Adherence 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1 >1 Pharmacies used in last 120 days Adherence ≥80% (OR) Retrospective study of elderly (aged 65 to 99 years) members of the New Jersey Medicaid and Medicare populations (N=8643).

The way we ask matters:

The way we ask matters

Factors Associated with Nonadherence:

Factors Associated with Nonadherence

Factors Related to Nonadherence:

Factors Related to Nonadherence Social & Economic Limited language proficiency Low health literacy Unstable living conditions / Homelessness Lack of health insurance Medication cost High cost of transport Long distance to reach clinic

Factors Related to Nonadherence:

Factors Related to Nonadherence Health care system Patient provider relationship and uncomfortable visits Long wait time and Short consultation time Restricted formularies and Poor medication distribution Poor health services Overworked health care providers Inadequate training of providers Lack of incentives and feedback Lack of knowledge on adherence No system to educate patients Lack of community support

Factors Related to Nonadherence:

Condition related Lack of symptoms Severity of symptoms Depression Psychotic disorders Associated co-morbidities Factors Related to Nonadherence

Factors Related to Nonadherence:

Therapy related Lack of Immediate beneficial effects Complexity of medication regimen Duration of therapy Frequent changes Previous treatment failures Actual or perceived side effects Changes in pharmacy Cost of medicine Safety closure containers Factors Related to Nonadherence

Factors Related to Nonadherence:

Patient related Visual, hearing, cognitive impairment Forgetfulness No Knowledge about disease Perceived risk / susceptibility to disease Lack of Perceived benefits of treatment Lack of Motivation and confidence Lack of belief in therapy Lack of belief in clinician Lack of understanding Extreme of age Factors Related to Nonadherence

Measuring Adherence:

Measuring Adherence

Methods of Measuring Adherence :

Methods of Measuring Adherence Self-reporting Pill counts Pharmacy records Provider estimate Pill identification test Electronic devices—MEMS (medication events monitoring system) Biological markers—Viral load Measuring medicine levels—TDM

Methods of measuring Adherence:

Methods of measuring Adherence Test Advantages Disadvantages Direct Methods Directly observed therapy Most accurate Pt can hide pills in mouth , Impractical for routine use Measurement of level of medicine or metabolite in blood or urine etc Objective Variations in metabolism and WHITE COAT ADHERENCE can give false impression, expensive Biological markers Objective Expensive, Invasive

Methods of measuring adherence:

Methods of measuring adherence Indirect Methods Patient questionnaires, patient self reports Simple, inexpensive, most useful method in the clinical settings Susceptible to error with increases in time, easily distorted Pill counts Objective, quantifiable, easy Data easily altered by the patient Rates of prescription refills Objective, easy to obtain data Not equivalent to ingestion of medication, Assessment of patient’s clinical response Simple, generally easy to perform Other factors can affect

Methods of measuring adherence:

Methods of measuring adherence Indirect Methods Electronic medication monitors Precise, results are easily quantified, tracks patterns of taking medication Expensive, requires return visits and downloading data from vials Measurement of physiologic marker Easy to perform Marker may be absent for other reasons Patient diaries Help to correct for poor recall Easily altered Questionnaire for caregiver Simple, Susceptible to distortion

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Adherence scales are identified mostly in the last few years (2005-201 5 ). ( Lavsa et. al ) M edication adherence surveys/scales to gauge patient behaviours at the point of care.

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1 Medication Adherence Questionnaire (MAQ ) ( Morisky et al.) the shortest the easiest t he fastest wide range of diseases

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1 4 -item scale MMAS-4

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1 8-item scale MMAS-8

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Self-efficacy for Appropriate Medication Use Scale SEAMS 13-item scale had good internal consistency reliability a reliable and valid instrument that may provide a valuable assessment of medication self-efficacy in chronic disease management appropriate for use in patients with low literacy skills 2 Source Risser J, Jacobson TA, Kripalani S. Development and psychometric evaluation of the Self-efficacy for Appropriate Medication Use Scale (SEAMS) in low-literacy patients with chronic disease. J Nurs Meas . 2007;15(3):203-19.

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3 The Brief Medication Questionnaire BMQ a new self-report tool for screening adherence and barriers to adherence BMQ tool is: useful in identifying patients who need assistance with their medications , assessing patient concerns, and evaluating new programs . Svarstad BL, Chewning BA, Sleath BL, Claesson C. The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ Couns. 1999;37(2):113-24.

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3 The Brief Medication Questionnaire BMQ includes: 5-item Regimen Screen that asks patients how they took each medication in the past week, 2-item Belief Screen that asks about drug effects and bothersome features, and 2-item Recall Screen about potential difficulties remembering 2-item Access Screen about difficulties in buying and refilling

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3

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Regimen screen Belief screen Recall screen Access screen 3

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4 The Hill-Bone Compliance Scale assesses patient behaviors for three important behavioral domains of high blood pressure treatment: reduced sodium intake; appointment keeping, and medication taking. Hill-Bone Compliance Scale (For HT) Kim MT, Hill MN, Bone LR, Levine DM. Development and testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Prog Cardiovasc Nurs. 2000 Summer;15(3):90-6.

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HILL-BONE HIGH BLOOD PRESSURE COMPLIANCE SCALE (NA=not applicable / DK=don’t know) None of the time Some of the time Most of the time All the time NA DK 1. How often do you forget to take your HBP medicine? 1 2 3 4 8 9 2. How often do you decide not to take your HBP medicine? 1 2 3 4 8 9 3. How often do you eat salty food? 1 2 3 4 8 9 4. How often do you shake salt, fondor, or aromat on your food before you eat it? 1 2 3 4 8 9 5. How often do you eat fast food? (KFC, McDonalds, fat cook, fish and chips) 1 2 3 4 8 9 6. How often do you get the next appointment before you leave the clinic? 1 2 3 4 8 9 7. How often do you miss scheduled appointments? 1 2 3 4 8 9 8. How often do you leave the dispensary without obtaining your prescribed pills? (due to long line, closure of clinic, forgot) 1 2 3 4 8 9 9. How often do you run out of HBP pills? 1 2 3 4 8 9 10. How often do you skip your HBP medicine 1–3 days before you go to the clinic? 1 2 3 4 8 9 11. How often do you miss taking your HBP pills when you feel better? 1 2 3 4 8 9 12. How often do you miss taking your HBP pills when you feel sick? 1 2 3 4 8 9 13. How often do you take someone else’s HBP pills? 1 2 3 4 8 9 14. How often do you miss taking your HBP pills when you care less? 1 2 3 4 8 9 4

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5 Medication Adherence Rating Scale MARS 10-item scale includes : a valid and reliable measure of compliancy for psychoactive medications diagnosed with schizophrenia Thompson K, Kulkarni J, Sergejew AA. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophr Res. 2000 May 5;42(3):241-7.

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Item Compliant Non-compliant 1 Do you ever forget to take your medication? 2 Are you careless at times at taking medication? 3 When you feel better do you sometimes stop taking your medication? 4 Sometimes if you feel worse when you take the medication do you stop taking it? 5 I take my medication only when I am sick 6 It is unnatural for my mind and body to be controlled by medication 7 My thoughts are clearer on medication 8 By staying on medication, I can prevent getting sick 9 I feel weird, like a zombie, on medication 10 Medication makes me feel tired and sluggish Compliant = ‘No’ response for questions 1-6, 9–10. ‘Yes’ response for questions 7 and 8. 5

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6 Adherence to Refills and Medications Scale ARMS 14 and 12-item scale : chronic disease . low-literacy patients Kripalani S, Risser J, Gatti ME, Jacobson TA. Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease. 2009;12(1):118-23.

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Choosing a suitable Scales No Scale 1 2 3 4 5 6 7 8 1. Morisky-Green + + + 2. SEAMS + + + 3. BMQ + + + 4. Hill-Bone + 5. MARS + 6. ARMS + 1 – Chronic disease 2 – Arterial hypertension 3 – Coronary heart disease 4 – Diabetes 5 – Psychosis 6 – AIDS/HIV 7 – Osteoporosis 8 – Smoking cessation

Measures Involving Secondary Database Analysis:

Measures Involving Secondary Database Analysis Multiple Interval Measure of Medication Acquisition (CMA ) Continuous Multiple Interval Measure of Oversupply (CMOS) Medication Refill Adherence ( MRA), Continuous, Multiple Interval Measure of Medication Gaps (CMG ) Continuous, Single Interval Measure of Medication Acquisition ( CSA ) Measures Involving Electronic Medication Packaging (EMP) Medication Events Monitoring System (MEMS) is the most commonly used EMP device in medication adherence studies.

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Medication Events Monitoring System (MEMS ) Basic principle of this system is that whenever the medication is removed from the container, a microprocessor embedded would record the time and date, assuming that the patient has taken that specific dose at that particular time It helps identify whether the nonadherence is sporadic or consistent or any other abnormal medication-taking pattern and it is able to detail the number of daily doses on any partial adherence situation It is always used as a reference standard f or validating other adherence measures .

There is a wide gap between writing a prescription and actual medication use:

There is a wide gap between writing a prescription and actual medication use “Medication don’t work in patients who don’t take them”

Adherence enhancing interventions:

Adherence enhancing interventions Coordination of healthcare (improved linkages between primary care physicians, clinicians and other health professionals) Live consultation and education Changes to the therapy, dose, dosage and packaging Patient education materials Disease management programs by clinicians Reminders, medication, refill reminders, delivered by mail and telephone Self monitoring Social support programs

Strategies to improve adherence:

Strategies to improve adherence Trust building Identification of achievable goals and explaining them Simplifying regimens Patient education counseling and motivation Ask patients to bring pill box at every visit (Brown Bag) Help from family members Clarifying inaccurate beliefs Informing importance of taking medications Instructions Verbal Written Demonstration

Strategies to improve adherence:

Strategies to improve adherence R 3 Review Reinforcement and Reminders Rewards Keep track of medicines and Calendar schedule Organize pills and Plan ahead of refills Manage side effects in time Keep follow-up visits Use of technology

Understand the patient’s perspective:

Patients sometimes make decisions about medicines based on their understanding of their condition and possible treatments, their view of their need for the medicine and their concerns. Asking patients: - What they know, believe and understand about their medicines and need for a particular treatment - About any general or specific concerns whenever prescribe, dispense or review medicines Understand the patient’s perspective

Strategies to Improve Med. Adherence:

Strategies to Improve Med. Adherence The SIMPLE approach S – Simplify the regimen I – Impart knowledge M – Modify patient beliefs and behavior P – Provide communication and trust L – Leave the bias E – Evaluate adherence

S—Simplify the Regimen:

S—Simplify the Regimen Encourage use of adherence aids. Investigate customized packaging for patients Adjust timing, frequency, amount, and dosage Match regimen to patient’s activities of daily living Consider changing the situation vs. changing the patient Avoid prescribing medications with special requirements Recommend taking all medications at the same time of day (whenever possible)

I—Impart Knowledge:

I—Impart Knowledge Focus on patient-provider shared decision making Involve patient’s family or caregiver if appropriate Keep the team informed (physicians, nurses, pharmacists) Provide all prescription instructions clearly in writing and verbally Reinforce all discussions often, especially for low-literacy patients Suggest additional information from Internet for interested patients

M—Modify Patient Beliefs and Behavior:

M—Modify Patient Beliefs and Behavior Address fears and concerns Provide rewards for adherence Empower patients to self-manage their condition Ask patients about the consequences of not taking their medications Restate positive benefits of taking medications Ensure that patients understand their risks if they don’t take their medications

P—Provide Communication and Trust:

P—Provide Communication and Trust Use plain language Practice active listening Provide emotional support Improve interviewing skills Elicit patient’s input in treatment decisions

L—Leave the Bias:

L—Leave the Bias Develop patient-centered communication style Acknowledge biases in medical decision making Understand health literacy and how it affects outcomes Address dissonance of patient-provider, race-ethnicity, and language Examine self-efficacy regarding care of racial, ethnic, and social minority populations

E—Evaluating Adherence:

E—Evaluating Adherence Self-report Ask about adherence behavior at every visit Periodically review patient’s medication containers, noting renewal dates Use biochemical tests—measure serum or urine medication levels as needed Use medication adherence scales— e.g. Morisky-8 (MMAS-8), Medication Possession Ratio (MPR), Proportion of Days Covered (PDC)

Strategies and Tools to Enhance Adherence:

Strategies and Tools to Enhance Adherence Pretreatment strategies— Identify the potentially nonadherent client/patient and address the barriers to adherence during counseling before first prescription. Identify an adherence partner or buddy, or a peer educator. Ask the client/patient to demonstrate adherence ability. Identify reminders or tools to help in taking pills.

Strategies and Tools to Enhance Adherence :

Strategies and Tools to Enhance Adherence Ongoing treatment strategies— Generate daily-due review and refill list, and “flag” absent clients/patients. Refer to community-based health care workers and NGOs. Use incentives and enablers (e.g., having income-generating projects for caregivers, providing transport on clinic days, or providing food).

Adherence Counseling: Multidisciplinary Team:

Adherence Counseling: Multidisciplinary Team Same message from all! Adherence message for the client/patient Doctors Adherence nurse Pharmacist Family and friends Counselor Social worker Source: Horizons/Population Council, International Centre for Reproductive Health, and Coast Provincial General Hospital, Mombasa, Kenya. 2004. Adherence to Antiretroviral Therapy in Adults: A Guide for Trainers . Nairobi: Population Council.

Adherence Counseling:

Adherence Counseling Needs to occur before and be ongoing throughout treatment period sessions. Involves highly personal and intimate matters and behavior. Requires recognition of barriers to and challenges of adherence. Needs reinforcement or constructive intervention as appropriate. Avoids negative-messaging, judgmental attitudes Encourages participation by family and friends.

Implications for Adherence Intervention Programs:

Implications for Adherence Intervention Programs Intervene EARLY in therapy Interact OFTEN KNOW your patient TARGET interventions EDUCATE patients PRESCRIBE regimens with a high probability of adherence ENCOURAGE close relationships

STEPS TO IMPROVE ADHERENCE:

STEPS TO IMPROVE ADHERENCE Give clear and simple instructions Better doctor-patient communication and interaction Simplify the regimen if possible Prescribe cheaper generic drugs in place of expensive, branded drugs Inform patient about possible side effects Change the medication if severe side effects Explain about taking antibiotics properly Get family members to monitor adherence Doctor can also monitor adherence Deal with food taboos and beliefs

STEPS TO IMPROVE ADHERENCE:

STEPS TO IMPROVE ADHERENCE Slow down — speak slowly and spend a small amount of extra time with each patient Use plain, nonmedical language Show or draw pictures Limit the amount of information provided, and repeat it Use the teach-back or show-me technique Create a shame-free environment

STEPS TO IMPROVE ADHERENCE:

STEPS TO IMPROVE ADHERENCE Before prescribing, offer patients clear, relevant information on their condition and the possible treatments Discuss information rather than just presenting it Check patients have any information they wish when medicines are dispensed Do not assume that PILs will meet each patient’s needs Offer individualised information that is easy to understand and free from jargon

STEPS TO IMPROVE ADHERENCE:

STEPS TO IMPROVE ADHERENCE Routinely assess adherence in a non-judgemental way whenever you prescribe, dispense and review medicines Make it easier for patients to report non‑ adherence Consider using records to identify potential non‑ adherence and patients needing support Use of ASK-TELL-ASK

REMEMBER!:

REMEMBER! Partial adherence is better than total nonadherence

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Demonstrating new skills Praise & Feedback

Self-Management:

Self-Management

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Electronic devices which includes alerting system

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Community Education Promoting Informed Medicine Use

Photonovelas (or fotonovelas) :

Photonovelas (or fotonovelas ) Like comic books, but they are compiled using photographs and captions They are a highly visual and creative form of getting a message across to a diverse population Allows learners to define the content and outcome of their own learning by creating a story line about an important topic or theme

Photonovelas (or fotonovelas) :

Photonovelas (or fotonovelas )

Smartphone app medication reminders:

Smartphone app medication reminders Dosecast medication reminder Drug.com Medication Guide MedCoach Medication Reminder Med Helper Pill Reminder MediSafe Meds & Pill Reminder Pill Monitor Free-Medication Reminders and Logs Pill Reminder by Drugs.com PocketNurse RXmindMe Prescription

The perfect patient :

The perfect patient Makes appointments Keeps appointments Has payment resources Listens Ask questions Plan ahead Follows instructions Gets better

Beware of Complex Patients, Complex Regimens:

Beware of Complex Patients, Complex Regimens Mansur et al 2012. Am J Geriatr Pharmacother 10;223-229 Wilson et al 2014. Ann Pharmacother 48(1);26-32

How healthy is your Patient’s Medication Adherence? :

How healthy is your Patient’s Medication Adherence?

Conclusions:

Conclusions Adherence is critical to patient outcomes Consistent adherence is hard to achieve Nonadherence is a multidimensional problem Every type of providers have a role in improving it SIMPLE approach to enhance adherence Simplifying the regimen, Imparting knowledge, Modifying patient beliefs, Providing communication and building trust, Leaving bias behind, and Evaluating adherence

Conclusions:

Conclusions Communication skills, ( cultural sensitivity, and patient centred) Improving adherence is a complex and variable Multidisciplinary efforts are needed Poor adherence to medication regimens is common, contributing to substantial worsening of disease, death, and increased health care costs Practitioners should always look for poor adherence and to implement measures to enhance adherence

Conclusions:

Conclusions Emphasize value of a patient’s regimen Make regimen simple, and customizing to the patient’s lifestyle Asking patients nonjudgmentally Use of new technologies ( cell phones and personal digital assistants and pillboxes etc. ) Medications are dispensed with the expectation that they will be taken exactly as prescribed While patient nonadherence remains one of the most important health care concerns, it is surprising that research in this area is sorely lacking

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“It is more important to know what kind of a patient has a disease than what kind of a disease a patient has” (William Osler) “Drugs don’t work in patients who don’t take them.” (Everett Koop)

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Hippocrates’ exhortation to the physician to “not only be prepared to do what is right himself, but also to make the patient…cooperate” Hippocrates, Decorum Increasing adherence may have a greater effect on health than any improvement in specific medical treatments WHO

Don’t we already know who isn’t taking their medications?:

Don’t we already know who isn’t taking their medications?

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Medication Adherence Promotes Safe and Effective Therapeutics Thanks Comments/Suggestions at [email protected]

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