3/6/2017. Grassroots Strategies for Improving Adherence. Learning Objectives

Transcription

1 Grassroots Strategies for Improving Adherence Amy Knight, PhD Director of Rehabilitation Psychology Department of Physical Medicine & Rehabilitation University of Alabama Birmingham Nothing to Disclose Learning Objectives Review the current data on program adherence in cardiac rehabilitation Use of behavioral change theory to embrace new models for program operations Present strategies for improvement of patient adherence in CR programs CR Program Efficacy Dose-response relationship in CR with higher attendance associated with lower morbidity/mortality Suaya et al 2009, J Am Coll Cardiol 54:25-3 1

2 Gap in CR Program Efficacy Cardiac Rehab drop-out rates >50% Martin et al 2012, Circulation (prospective cohort study CAD N=5886) Men <75 years Completed Non-Completed Completed Non-Completed Gap in CR Program Efficacy Women and older 2/3 rds drop-out Martin et al 2012, Circulation (prospective cohort study CAD N=5886) Women 75 years Non-completers were not different from Non-enrollers in characteristics and survival outcomes Completed Non-Completed Completed Non-Completed Predicting Adherence Cardiac Rehab Outcomes Registry Project Turk-Adwai et al 2013, J Am Heart Assoc (38 CR facilities in WI, N=4412) ADHERENCE: 21 exercise sessions (median # of cohort) Patient Characteristics Facility Characteristics Program Features 2

3 Patient Characteristics CR Facility Characteristics CR Services Group-based session advantage

4 Behavioral Health & Nutrition Lifestyle Change Strategies Incentives for Attendance Motivational Interviewing Self-Management Nutrition Measures Incorporating Dietitians Diabetes Education Program Weight Management Program Managing Depression and Anxiety Psychosocial Providers Support Groups Social Support Medication Adherence Stress Management Substance Abuse Gap in Program Execution Let s talks about adherence & self-efficacy Specifically: your program s self-efficacy and likelihood of non-adherence to R2R changes GROUP THERAPY TIME! Demonstration of self-efficacy and selfmanagement skills in relationship to CR program adoption of change strategies Self-Efficacy & Adherence Self-Efficacy: Judgment of capacity to perform specific actions - Bandura, 1997 Mastery of Skills Vicarious Experiences Verbal Persuasion Physiological State Self-Efficacy Judgments Behavior Belief in ability to carry out a specific activity like dietary changes, CR exercise or CR program modifications 4

5 Self-Efficacy & Adherence Self-efficacy determines the amount of effort invested and perseverance. People with selfdoubt are more inclined to anticipate failure scenarios, worry about deficiencies, and abort their attempts prematurely - Schwarzer, 2010 Self-Efficacy & Adherence People with an optimistic sense of self-efficacy visualize success scenarios that guide action and let them persevere in face of obstacles. When running into unforeseen difficulties they quickly recover - Schwarzer, 2010 Pessimism 5

6 Technically Self-Efficacy & Adherence Interventions for LOW Self-Efficacy Performance mastery = skills training Vicarious experiences = group setting, model Verbal persuasion = education, MI Physiological state = yoga, relaxation, mindfulness, exercise, CBT - Bandura, 1996 Self-Management & Adherence Behavioral change interventions most effective in increasing physical activity Goal setting and action planning Relapse planning and prevention Self-monitoring techniques - Ferrier et al, 2011 Barrier management Problem solving - Chase et al,

7 Medication Non-Adherence Medication is central to risk reduction after cardiac events Non-adherence = worse outcomes and re-hospitalizations STILL: many patients do not persistently adhere to their prescribed cardiovascular medications - (Osterberg & Blaschke, 2005) Meta-analysis estimates approximately 1/3 rd of patients after a cardiac event are non-adherent - (Naderi et al., 2012) Estimated that up to 70% of medication non-adherence is intentional - (McHorney & Spain, 2008) Why all the non-adherence? BELIEFS about Rx influence engagement and adherence. Medication beliefs Perceived necessity for and concerns about heart medications have been independently associated with adherence to beta blockers, ACEi/ARBs and lipid lowering drugs respectively - (LaPointe et al., 2011) Necessity score related to lower odds of non-adherence Concern score associated with a higher odds of non-adherence Assessment of medication beliefs may be useful to identify those at greatest risk of non-adherence Interventions to change beliefs (low necessity and high concerns) may be useful in improving adherence and clinical outcomes 7

8 Medication Adherence in CR Beliefs about cardiovascular medicines & adherence in patients attending Cardiac Rehabilitation (N=82) - J. Gallagher et al (2017) 14.6% at risk of non-adherence Beliefs about Medicines Multiple Regression R 2 = BMQ predicts 30.2% of the variance of MARS scores, p< % actual non-adherence Medication Adherence At Risk Good Poor adherence Good Anti-coagulants and statins noted as most cause for concern Medication adherence turnkey strategy Strategy centers on the idea that we can identify patients at a higher risk for non-adherence, address the specific beliefs which drive behaviors, and target interventions to promote change - Assessment, Process & Outcomes! METRICS measures that tap into Necessity (perception of personal need for treatment), Concerns (worry about potential adverse consequences), and Behaviors Beliefs about Medicines Questionnaire (BMQ) - Horne, Weinman, Hankins (1999) Medication Adherence Rating Scale (MARS) -Horne (2004) BMQ & MARS 8

9 Rx Adherence Strategy ASSESS BMQ & MARS administered at baseline Scores identify patients at risk of medication nonadherence BMQ concerns score minus necessity score 0; or anything less than a perfect score on MARS Rx Adherence Strategy PROCESS Results and medication list to pharmacist Will need someone to providing group-based CR educational session on RX Initiate intervention as early as possible Use answers to promote an adherence discussion normalizes medication non-adherence facilitates a no-blame approach to discussing medication beliefs. Rx Adherence Strategy PROCESS Check patient s understanding of treatment Address patient specific any concerns about their medications provide clear rationale for the necessity of the treatment identify any possible barriers. Utilization of motivational interviewing 9

10 Rx Adherence Strategy OUTCOMES Re-administer BMQ & MARS at CR discharge! Given the high incidence of non-adherence in patients presenting with 'resistant hypertension', it is recommended that particular attention be given to screening for nonadherence in this group - Gupta et al., 2016 Behavioral Health & Nutrition Lifestyle Change Strategies Turnkey strategies in support of lifestyle changes and improved program adherence Motivational interviewing to uncover hidden barriers to change and resistance to adherence Self-management techniques to encourage self-efficacy and promote health behavior changes Incentive-based reward strategy to improve attendance Emotional factors assess and connect patients with psychosocial providers Nutritional factors assess and incorporate dieticians to CR programs Questions? Amy Knight, PhD Director of Rehabilitation Psychology Department of Physical Medicine & Rehabilitation University of Alabama Birmingham Contact me at: ajk@uab.edu 10