Pediatric Adherence for the School Nurse
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1 Pediatric Adherence for the School Nurse Eve-Lynn Nelson, Ph.D. Assistant Director, Research KU Center for TeleMedicine (913) ;
2 Generously sponsored through a grant from the Health Care Foundation of Greater Kansas City Thanks also to the ongoing support of KU Center for TeleMedicine, the TeleKidcare program, and Connected Kansas Kids.
3 Compliance
4 Adherence Definition The extent to which a person s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice. (Haynes, 1979)
5 Types of Nonadherence Not knowing, health literacy Not following Choosing not to follow, rational nonadherence
6
7 Range of Recommendations Appointment keeping Vaccinations as example Medications How much? Timing, Continuation, Other recommendations with food, etc. Psychotherapy recommendations Psychotherapy homework Daily note from school and home Calendar monitoring attendance, mood, dry/wet, etc. Lifestyle changes Eating Sleeping Other
8 The Scope of Medication Nonadherence
9 Types of Medication Nonadherence Not filling prescription, Adderall example Not (or delays in) refilling prescription Omitting doses Drug holidays (no doses for several concurrent days) Toothbrush Effect or White-coat Adherence (increased adherence around visits) Overdosing or taking extra make-up doses
10 Medication Nonadherence Rates 1/3 of patients on short-term regimens 50-55% of patients on long-term regimens Adherence declines over course of illness
11 Nonadherence Rates by Disease (Drug) in Pediatrics Under and over use of medication Asthma (theophylline) = 34-88% Cancer (prednisone) = 19-42% JRA (salicylates) = 45% Epilepsy (anticonvulsants) = 21-56%
12 Other Areas Less data but adherence as bad or worse as medications Insurance challenges Long-term nature of recommendations Nonadherence to psychotherapy recommendation Nonadherence to lifestyle recommendation
13 Society-wide costs Cost of nonadherence in U.S. estimated at $100 billion per year (Berg et al.; Annals of pharmacotherapy: 27: 2-21.) Costs associated with drug resistant infectious diseases in U.S. estimated at $100-$200 million per year (Gibbons; Science: 257: ) Increases economic burden on families and society in general
14 Local costs related to clinical care Providers unaware of nonadherence may order more invasive, risky, and costly procedures and may prescribe more potent meds with greater side-effects. Providers may fail to make appropriate changes in regimens (e.g., adjusting insulin doses for adolescents in response to pubertal growth spurts) if they overattribute treatment failures to nonadherence.
15 Asthma-related Morbidity and Mortality More days with functional limitations and school absences. Increased ER visits and hospitalizations. Increase in asthma-related deaths (especially among African-American children with a rate 5x higher than Caucasian children).
16 Nonadherence Risk Factors
17 Overall adherence factors CANNOT REPRODUCE FOR POSTED SLIDE, SEE ARTICLE Osterberg & Blaschke (2005), Adherence to Medication, NEJM, 353 (5),
18 Patient Nonadherence Adolescent Male Factors Dissatisfaction with Medical Care Lack of Knowledge Poor Overall Adjustment & Coping Depression and risk taking RISK factors for generalized poor adherence
19 Family Nonadherence Factors Family Dysfunction Lack of Parental Knowledge Lower SES Lack of Parental Supervision
20 Disease Nonadherence Factors Patient Asymptomatic or in remission Increased number of symptoms Younger age at disease onset Disease not perceived as severe by family
21 Regimen Nonadherence Factors Complex, Demanding, and Costly regimens Delayed beneficial effects Limited Provider Supervision Negative regimen side effects
22 Adherence & Dose CANNOT REPRODUCE FOR POSTED SLIDE, SEE ARTICLE from Osterberg & Blaschke (2005), Adherence to Medication, NEJM, 353 (5),
23 Measuring Nonadherence
24 Methods of Measuring Adherence. CANNOT REPRODUCE FOR POSTED SLIDE, SEE ARTICLE Osterberg & Blaschke (2005), Adherence to Medication, NEJM, 353 (5),
25 Improving Self-Reported Adherence Directly evaluate adherence behaviors in an information-intensive approach ( Which medications are you taking? What dose? How often? Have you had any side-effects? ). Probe for nonadherence in a non-judgmental and non-threatening manner ( Many people have trouble remembering to take their medication. Do you ever forget to take yours? Do you ever stop taking your medication on purpose? )
26 Improving Self-Reported Adherence PRAISE HONESTY Time frame for questioning about adherence should be limited to the previous 7 to 10 days. Ask families about barriers to adherence (personal, financial, social & cultural).
27 RX for Improving Adherence
28 Adherence Enhancement Strategies Educational (about disease, treatments, and importance of adherence) Behavioral (cognitive and behavior change strategies to enhance adherence) Organizational (delivering health care in a way that facilitates adherence)
29 The What of Education (Content) The Disease (causes, course & prognosis) Treatments (what to do and why) Negative Side Effects (how to minimize) Adherence (importance and improvement strategies)
30 The How of Education (Strategies) As an ongoing process Developmental stage Each new school year Effective verbal communication (avoid jargon, stress instructions, repeat info., encourage questions) Translated material good start but not enough to address health literacy; also use of professional medical interpreting Written & other media Modeling and behavioral rehearsal
31 HOW CAN SCHOOL NURSE HELP? Liaison between school and healthcare, helping youth do work of childhood Repetition What family would like to or may need to ask provider? Triage Writing down questions Basics how do I use a thermometer? Etc. Assist family and colleagues to understand link between health and learning Link resources for information Resources about insurance, medication assistance, other
32 Behavioral Strategies Normalize need for continued monitoring with adolescence, especially with attention challenges Parent school Prompting adherence Adherence incentives Discipline strategies Self-management strategies (goal setting, selfmonitoring, self-administered consequences, problem-solving, & cognitive reframing)
33 Who, what, where, when, why Parent and child as partners in what really work within the day REHEARSAL
34 Organizational Strategies Central point of contact organizing different specialists Culture encourage asking questions Consumer-friendly clinical settings Simplify regimens Minimize negative side effects Technology/EMR
35 CANNOT REPRODUCE FOR POSTED SLIDE, SEE ARTICLE Osterberg & Blaschke (2005), Adherence to Medication, NEJM, 353 (5),
36 EXAMPLE 1: NOT KNOWING Renewal of medication
37 EXAMPLE 2: NOT FOLLOWING Pill swallowing example
38 EXAMPLE 3: RATIONAL NONADHERENCE Can t be sleepy before honors classes
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