The Vital Road Ahead: Addressing Barriers to Treatment Adherence

1
The Vital Road Ahead Addressing Barriers to
Treatment Adherence

• Cynthia L. Russell, PhD, RN, APRN, BC
• Assistant Professor
• University of Missouri
• Sinclair School of Nursing
• Columbia, Missouri , USA

2
Adherence Behaviors

• Appointment keeping
• Self-monitoring
• blood pressure, weight
• Diet
• Exercise
• Not smoking
• Avoiding alcohol and illegal drugs

• Skin cancer monitoring
• Screening for other cancers
• self-breast exam, mammography, colonoscopy
• Medication taking

3
Definition of Adherence

• The extent to which a persons and/or caregivers
  behavior coincides with a health-promoting or
  therapeutic plan agreed upon by the person
  (family or community) and healthcare professional

Carpenito-Moyet, LJ. Handbook of Nursing
Diagnoses. Philadelphia Lippincott Williams
Wilkins2006.
4
Medication Non-Adherence Behaviors

• Not having the prescription filled
• Taking too much or not enough medication (dosing)
• Failure to follow dosing intervals (timing)
• Stopping the medication for a day or longer (drug
  holiday)
• Not taking the medication for the duration of
  treatment (non-persistence or stopping treatment)

Bosworth, H. Patient treatment adherence. Mahwah,
New Jersey Lawrence Erlbaum Associates 2006.
5
Prevalence of Medication Non-Adherence in
Transplantation
Percent Non-Adherence
Adults
1. Matthees et al. Heart Lung, 2001 30258-268
2. Teichman et al. Progress in Transplantation,
200010 113-121. 3. De Geest S, et al.
Transplantation. 199559340-347. 4. Dew MA et
al. J Heart Lung Transplant, 1996 15631-645.
5. De Geest S et al. J Heart Lung Transplant,
199817854-863. 6. Desmyttere A et al. Acta
Gastroenterol Belg. 2005 68 347-352. 7. Drent
G, et al. Transplant Int. 200518960
6
Prevalence of Medication Non-Adherence in
Pediatric Transplantation
Percent Non-Adherence
Pediatrics
Dobbels F et al. Ped Trans. 20059381-390.
7
Outcomes of Medication Non-Adherence in Adult
Transplantation
Desmyttere A et al. Acta Gastroenterol Belg.
200568347-352.
8
Degree of Non-Adherence
De Geest S et al. J Heart Lung Transplant.
199817854-863.
9
Changes in Medication Non-Adherence Over Time

• Mixed findings
• Increases with longer graft survival time
• RT1,3, and HT2
• Stable-HT4 and RT5

1. Frazier PA, et al. Clin Transplant.
19948550-557. 2. Dew MA, et al. J Heart Lung
Transplant. 199615631-645. 3. Sketeris I et al.
Transplant Proc. 1994 262538-2541. 4. Grady KL,
et al. J Heart Lung Transplant. 199817383-394.
5. Russell CL. Research in Nursing Health.
2006 29521-532.
10
Patient Demographic Predictors of Medication
Non-Adherence

• Small impact1
• Consistent association
• Adolescent age2

• Inconsistent association
• Gender
• Age (middle or older)
• Education
• Race
• Living arrangements
• Marital status
• Socioeconomic status

1. DiMatteo M. Med Care. 2004 42 200-209. 2.
Denhaerynck K et al., Transplant International.
18 1121-1133.
11
Psychosocial Predictors

• Inability to afford medicationsHT1
• Poorer quality family relationshipsHT2, RT3
• Less spousal supportHT4
• Greater inability to care for selfHT5,6
• Less confidence in relationship with health care
  providerRT7

1. Sisson S, et al. J Heart Lung Transplant,
199413930. 2. Dew MA, et al. J Heart Lung
Transplant. 199615631-645. 3. Lopez SJ, et al.
Paper presented at The First European Symposium
on Non-compliance in Transplantation Feb. 1999
Salzburg, Austria. 4. Bunzel B, Laederach-Hofman
K. Transplantation. 200070711-716. 5. De Geest
S, et al. Transplantation. 199559340-347. 6.
Grady KL, et al. J Heart Lung Transplant.
199817383-394. 7. Kiley DJ, et al.
Transplantation. 19935551-56.
12
Psychological Predictors

• Negative subjective transplant experienceHT1 and
  RT2,3
• Anxiety-HT1
• Avoidance style of copingHT1 and RT4
• HostilityHT1 and RT5

1. Dew MA, et al. J Heart Lung Transplant.
199615631-645. 2. Raiz LR, et al.
Transplantation. 19996851-55. 3. Rovelli M, et
al. Transplantation Proc. 1989213979-3981. 4.
Frazier PA, et al. Clin Transplant.
19948550-557. 5. 7. Sketris I et al. Transplant
Proc. 1994 262538-2541.
13
Psychological Predictors

• External locus of controlRT1,2,3
• StressRT2,5 and HT4
• Less satisfaction with health4
• Lower perceived self-efficacyRT5 and HT6,7

1. Raiz LR, et al. Transplantation.
19996851-55. 2. Frazier PA, et al. Clin
Transplant. 19948550-557. 3. Kiley DJ, et al.
Transplantation. 19935551-56. 4. Grady KL, et
al. J Heart Lung Transplant. 199817383-394. 5.
Rosenberger J, et al. Transplant International.
181072-1078. 5. De Geest S, et al.
Transplantation. 199559340-347. 6. De Geest S,
et al. J Heart Lung Transplant. 199817854-863.
7. De Geest S, et al. J Cardiovasc Nurs.
2001161-14.
14
Psychological Predictors

• Depression1,2,3
• HT4 and RT5
• Anxiety/personality disorders-HT6

1. DiMatteo et al., Arch Intern Med.
1602101-2107. 2. Paris W, et al. J Heart Lung
Transplant. 199413424-430. 3. Phipps L. J
Psychiatry. 199136565-568. 4. De Geest S, et
al. J Cardiovasc Nurs. 2001161-14. 5. Kiley DJ,
et al. Transplantation. 19935551-56. 6. Dew MA
et al. J Heart Lung Transplant.1999 18549-62.
15
Other Predictors

• Physical
• More complicationsHT1 and RT2
• Greater symptom distress3,4
• Cognitive
• Lower knowledgespecifically situation
  operational 5

1. Grady KL, et al. J Heart Lung Transplant.
199817383-394. 2. Sketris I, et al. Transplant
Proc. 1994262538-2541. 3. De Geest S, et al. J
Cardiovasc Nurs. 2001161-14. 4. Moons P, et al.
Heart Lung. 1998 27315-325. 5. De Geest S, et
al. Transplantation. 199559340-347.
16
Preoperative Predictors of Non-Adherence

• Pre-op non-adherence is a good predictor of
  post-op non-adherence1 in HT2 and RT3
• Significant relationship between pre-transplant
  non-adherence and post-transplant graft
  lossRT3,4
• Appointment non-adherence (strong
  association)RT5 and HT6

1. Hathaway D, et al. Paper presented at The
First European Symposium on Non-compliance in
Transplantation February 1999 Salzburg,
Austria. 2. Paris W, et al. J Heart Lung
Transplant. 199413424-430. 3. Douglas S, et al.
J Transplant Coordination. 1996653-58. 4.
DeLone P, et al. Transplant Proc.
1989213982-3984. 5 Schweizer RT, et al.
Transplantation. 199049374-377. 6. De Geest S,
et al. J Heart Lung Transplant. 199817854-863
17

• What evidence-based strategies can be implemented
  to overcome these barriers?

18
Transplant Interventions
19
Meta-analysis

• 153 studies
• Acute and chronic illness
• Cognitive
• Individual or group education and teaching,
  audiovisual, telephone, mail, email delivery
• Behavioral
• Targeting, shaping, or reinforcing specific
  behaviors
• Affective
• Individuals feelings, emotions or social
  linkages such as counseling, support to family,
  or home visits

Roter et al. Med Care. 1998361138-61.
20
Effectiveness of Interventions
Effect Size
Intervention Type
Roter et al. Med Care. 1998361138-61.
21
Systematic Review

• 57 randomized controlled trials
• Acute and chronic illness
• 50 (18 of 36) of interventions improved
  medication adherence, but only slightly
• Effective interventions
• Complex
• More convenient care, information, reminders,
  self-monitoring, reinforcement, counseling,
  family therapy, supervision, attention

Haynes RB et al. The Cochran Database of
Systematic Review. 2005 Art.No. CD000011.
pub000012.
22
Meta-analysis
Type of Interventions Used

• 16 studies of randomized trials
• Hypertensive patients
• Behavioral interventions overall effect size of
  0.04 (95 CI -0.01 to -0.09)

58
29
13
Behavioral
Behavioral/ Educational
Educational
23
Systematic Review

• 33 RCTs
• 49 (19/39) statistically significant
  improvements in medication adherence
• 44 (17/39) statistically significant
  improvements outcomes
• Overall modest effects
• Complex, convenient care, information,
  counseling, reminders, self-monitoring,
  reinforcement, family therapy, supervision,
  attention

McDonald HP et al. JAMA. 2002. 2882868-2879.
24
Systematic Review

• 57 randomized controlled trials
• 65 years of age and older
• 54 (31 of 57) of interventions improved
  medication adherence
• Effective interventions
• Self-medication programs in hospital
• Decreasing dosing frequency

Russell CL et al. , American Journal of
Behavioral Health. 200630636-650.
25
Randomized Controlled Trial

• RCT N 24 adult renal transplant recipients
• 12 months
• Clinical pharmacy services (med history, review
  of meds, recommendations to nephrologist) vs.
  routine clinical services
• Non-adherence improved in intervention group (p lt
  0.001) for longer time (p lt 0.05) with better
  target blood levels (p lt 0.05)

Chisholm MA et al., Clin Transplant.
200115330-336.
26
Randomized Controlled Trial

• RCT N 18 adult renal transplant recipients
  identified as non-adherent
• Clinical Nurse Specialist interventionist
• Educational-behavioral intervention vs. enhanced
  usual care
• 3 months-1 home visit and 3 telephone contacts
• Non-adherence improved in both groups (p 0.06)
  No difference between groups (p 0.31)

De Geest et al. Clin Transplant. 200620359-368
27
Randomized Controlled Trial

• Prospective case control N24 heart transplant
  patients and N20 family caregivers compared to
  matched control N20
• 4 months
• Multifaceted web-based internet program
• Medication non-adherence was not different
  between groups

Dew MA et al. J Heart Lung Trans. 200423735-58.
28
Timing Patterns of Medication Taking

• 44 adult renal transplant recipients
• 6 months
• Electronic monitoring
• Four distinct groups
• Adherers who were on time almost all the time
• Adherers who were late or missed infrequently
• Non-adherers who were late or missed frequently
• Non-adherers who missed very frequently
• Interventions should be tailored to each patient
  group

Russell CL et al. Research in Nursing Health.
200629521-532.
29
Pediatric Intervention Study

• Pre-test post-test design N21 pediatric renal
  transplant patients 3-20 years of age
• 6 months
• Physician and clinical pharmacist interventionist
• Education-verbal and written, med changes, med
  calendars, schedules, pamphlets
• Med regimen simplified
• Non-adherence reduced from 43 to 19

Beck DE et al. J Pediatrics. 1980961094-1097.
30
Cognitive Interventions

• Coordination of patient teaching in hospital
• Transplant patient teaching protocol1,2
• Assess barriers to learning, primary learner,
  preferred learning styles, and patient learning
  priorities
• Reinforcement of key topics (verbal and written)3
• Explain disease/condition, name of each med, how
  meds work, how to take (dosage, timing)
• Have patient explain how s/he is taking meds to
  assess comprehension
• Assess recall

1. Messina, C. et al. Progress in
Transplantation 10169-176. 2. Russell, C. et
al. Clinical Nurse Specialist.17249-257. 3.
Chisholm, M. Managed Care Interface.
20041744-48.
31
Cognitive Interventions

• Stress the importance of taking medication as
  prescribed to help treat the disease/condition1
• Continue to assess the patients cognitive model
  of illness (beliefs) which may be inconsistent
  with medication prescription2
• Assess and honor cultural perspectives

1. Chisholm, M. Managed Care Interface.
20041744-48. 2. Di Matteo, M. Med Care. 2004
42200-209.
32
Cultural Sensitivity

• Patient education information should be written
  and/or reviewed by individuals from the cultural
  group for which is targeted
• Photos in the patient education information
  should be of individuals from the cultural group
• Patient and providers from same culture is ideal
  situation
• Integrate support groups (e.g. church)

Russell, C. Progress in Transplantation.
20061687-196.
33
Low Literacy Levels

• Pictures enhance written and spoken message and
  increase attention and recall
• Pictures improve comprehension
• Simple wording and reminder pictures can help

Houts, PS et al. Patient Education and
Counseling. 2006 61173-190.
34
Affective Interventions

• Appeal to patients beliefs and goals and how
  being healthy contributes to these goals1
• Social support systems
• Family member
• Consider medication coach
• Daily contact via phone or email
• Problem solver
• Increase medication taking self-efficacy
  (confidence)
• Transplant support groups

1. Chisholm, M. Managed Care Interface.
20041744-48. 2. Di Matteo, M. Med Care. 2004
42200-209.
35
Behavioral Interventions

• Foster medication self-management during
  hospitalization1 and long-term follow up
• Self-monitoring and documentation
• Encourage use of cues and reminders
• Foster organization of medication taking
• Keep track of medication changes on med list
• Associate medication taking with routines and
  habits
• Keep extra medications on hand
• Use refill reminders

1. Russell CL, et al. American Journal of Health
Behavior. 2006 30636-650.
36
Patient Provider Relationship

• Establish rapport and trust with the patient and
  caregiver1,2
• Discuss health care professional and teams
  expertise with treating patients
• Use consistent provider
• Check comprehension and behaviors frequently
• Demonstrate supportive body language

1. Chisholm, M. Managed Care Interface.
20041744-48. 2. Di Matteo, M. Med Care. 2004
42200-209.
37
Medication Regimen

• Decrease number and frequency of medications1,2
• Assess medication palatability, e.g. large pill
  size3
• Offer options, e.g. liquid3
• Conduct Brown bag review4

• Russell, C et al. American Journal of Health
  Behavior. 2006 30636-650. 2. Di Matteo, M. Med
  Care. 2004 42200-209. 3. Russell C et al.
  Clinical Nurse Specialist. 200317200-208.
• 4. Fillit H et al. Am J Man Care. 19995587-594.

38
Impact of Technology and Innovations

• Computer-assisted education
• Web-based systems for self-management
• Chronic disease management
• Motivational interviewing

39
Summary

• Focus multi-faceted interventions on specific
  patient beliefs and needs
• Initiate and maintain cognitive and behavioral
  changes using culturally appropriate approach
• Foster affective changes including social support
  and medication coach
• Nurture long-term medication self-management
  behavior
• Integrate cues, reminders, and organization
  skills that meet patients specific
  medication-taking patterns
• Address medication regimen factors
• Integrate technology and innovations