Motivating patients to manage their chronic illness

Transcription

1 Motivating patients to manage their chronic illness Bruce G. Bender, Ph.D. Proportional Contribution to Premature Death Genetic predisposition Social circumstances Environmental exposure Health care Behaviors Schroeder S. N Engl J Med 2007;357:12.

2 Effective Therapies Effective Therapies Effective Disease Management Effective Therapies Patient Adherence Effective Disease Management

3 Adherence is Effective Therapies Effective Disease Management the extent to which a person s behavior taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations from a health care provider WHO. Adherence to long-term therapies. Evidence for action Nonadherence is a problem in the treatment of: Cancer COPD AIDS Depression Hypertension Diabetes Asthma Organ transplant Atopic dermatitis Hyperlipidemia Epilepsy Tuberculosis Osteoporosis Seizure disorder Nonadherence 1. How much of a problem is it? 2. Why don t patients take their medication? 3. What can healthcare providers do to improve adherence with medications?

4 Medication abandonment in 2.7 million patients % Asthma CV disease Diabetes/Pills Diabetes/Injections Statins Vanelli M. Clinical Therapeutics, 2009: How many patients persist in taking their medication? How many patients persist in taking their medication? RMAG, 2006 KT Kearney 2015 (

5 Adult Asthma ICS Adherence (%) Week of Study Onyirimba, F. Ann Allergy Asthma Immunol 2003; 90: 411

6 Adherence in the Childhood Asthma Management Program Adherence with ICS and OCS 2 weeks postdischarge in Patients Hospitalized for Asthma % of prescribed, mean (SE) Year 3 4 Self Report Objective Measurement P<.001 Krishnan J, Bender B et al. J Allergy, Asthma & Clin Immunol 2012; 129: Krishnan J, Am J Respir Crit Care Med. 2004;170: Multivariate Regression: Relationship Between Adherence and Probability of an Asthma ED Visit or Hospitalization All-Cause Mortality Increased Probability 0 each 25% improvement in adherence was associated with a 10% reduction in the odds of an ED visit or hospitalization Adherence Level Poor Moderate Good Excellent -0.1 Decreased Probability <25% 25 - <50% 50 - <75% % Adherence to Advair Delea TE et al., Current Medical Research and Opinion 2012;24(12): Time (years) Esposti, LD., Adherence to antihypertensive medications and health outcomes among newly treated hypertensive patients. ClinicoEconomics and Outcomes Resesarch, 2011:3:47-54 Epub 2011 Mar 7

7 Adherence and Inflammation Control in Rheumatoid Arthritis Diabetes-Related Healthcare Cost Total Cost ($) to to to to to 100 Adherence Level (%) Drug Cost Medical Cost Pascual-Ramos V. Arthritis Research & Therapy 2013 Sokol MC, Med Care 2005; 43: Why don t patients take their medication? Types of Nonadherence Unintentional Forgetting Misunderstood instructions Intentional Patient decided not to use medication

8 Ambivalence is at the heart of most nonadherence Reasons patients identify for not taking their medications Reasons patients identify for not taking their medications Fear of side effects Cost Belief that the medication is not helping Belief that only intermittent use is needed Inconvenience Bender B and Bender E. Immunol Allergy Clin N Am 2005;25:

9 How do we increase treatment adherence? How do we increase treatment adherence? Patient Centered Care The Institute of Medicine defines patient-centered care as: "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. arqh.gov va.gov healthcare.gov hhs.gov Shared Decision Making The Agency for Healthcare Research and Quality defines shared decision making as: a model of patient-centered care that enables and encourages people to play a role in the management of their own health. arqh.gov innovation.cms.gov pcori.org

10 Communication Strategies to Improve Adherence 1. Build a relationship 2. Focus on listening 3. Provide information 4. Collaborate on the treatment plan 5. Follow up Communication Strategies to Improve Adherence 1. Build a relationship Bender BG. Pediatric Allergy: Principles and Practice. D. Leung et al. (eds.) New York: Elsevier 2016; Bender BG. Pediatric Allergy: Principles and Practice. D. Leung et al. (eds.) New York: Elsevier 2016; Communication Strategies to Improve Adherence 1. Build a relationship 2. Focus on listening Bender BG. Pediatric Allergy: Principles and Practice. D. Leung et al. (eds.) New York: Elsevier 2016;

11 Communication Strategies to Improve Adherence 1. Build a relationship 2. Focus on listening open-ended question reflective listening Teach back Bender BG. Pediatric Allergy: Principles and Practice. D. Leung et al. (eds.) New York: Elsevier 2016; Communication Strategies to Improve Adherence 1. Build a relationship 2. Focus on listening 3. Provide information Bender BG. Pediatric Allergy: Principles and Practice. D. Leung et al. (eds.) New York: Elsevier 2016;

12 Communication Strategies to Improve Adherence 1. Build a relationship 2. Focus on listening 3. Provide information 4. Collaborate on the treatment plan Bender BG. Pediatric Allergy: Principles and Practice. D. Leung et al. (eds.) New York: Elsevier 2016; Communication Strategies to Improve Adherence 1. Build a relationship 2. Focus on listening 3. Provide information 4. Collaborate on the treatment plan 5. Follow up Bender BG. Pediatric Allergy: Principles and Practice. D. Leung et al. (eds.) New York: Elsevier 2016;

13 BOAT Study (Better Outcomes of Asthma Treatment) SDM (N= 204) Participants (N=613) MBG (N= 205) UC (N= 204) Wilson S. Am J Respir Crit Care Med 2010 Vol 181. pp ICS Medication Days Over 1 Year Other 12-month outcomes * * The SDM group also demonstrated Higher quality of life Better lung function Lower healthcare utilization 20 0 Usual Care Disease Management Training Shared Decision Making Training *P<.05 Wilson S et al Am J Respir Crit Care Med 2010; 181:566 Wilson S. Am J Respir Crit Care Med 2010 Vol 181. pp

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