ADHERENCE TO TREATMENT

Transcription

1 ADHERENCE TO TREATMENT Understanding and supporting patients John Weinman & Zoe Moon King s College London

2 OVERVIEW OF TALK - The Adherence problem and its effects - Adherence issues in cancer treatment - Understanding non-adherence - Supporting patients

3 The extent to which patients follow medical treatment and advice 3 distinct phases (i) UPTAKE (ii) IMPLEMENTATION (iii) PERSISTENCE/DISCONTINUATION Although majority of work focuses on medicines use, non-adherence is an even greater problem for other types of recommended medical advice ( eg diet; exercise etc )

4 The problem of non-adherence WHO report on non-adherence Estimated that over 30-50% medicines prescribed for long term illnesses are not taken as directed Higher levels of non-adherence to behavioural advice (eg exercise; diet and alcohol etc) If treatment is evidence- based, then this represents a loss for patients and for the health care system

5 Adherence to anticancer medications Adjuvant Endocrine Therapy 15-73% Oral Chemotherapy Other anticancer agents % 69% - 100%

6 OECD HEALTH WORKING PAPER (2018) EXECUTIVE SUMMARY Poor adherence contributes to 200,000 premature deaths in Europe per year Estimated cost : EUR 125 billion in Europe ; USD 105 billion in US per year 4-31% never fill first prescription Of those that get meds, only 50-70% take meds regularly Less than half of these persist for two years

7 THE COST OF NON-ADHERENCE New England HealthCare Institute (2009)

8 WHY? Traditional view Current evidence

9 WHAT ARE THE REASONS FOR NON-ADHERENCE? 1.Drivers of patient behaviour 2. Health care professional behaviour 3. Health care system factors

10 Early explanations of non-adherence Early theories (and interventions) based on idea that non-adherence was result of poor communication & subsequent effects on patient understanding and memory Pioneering studies of Ley et al. (1970 s) Early interventions mainly based on info provision, reminders etc Emphasis on HCP communication RCUKACTE01244d April 2015

11 ADHERENCE INTERVENTIONS Cochrane review: Haynes et al (2008; 2014) Current methods of improving adherence are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term disorders

12 WHAT NEEDS TO BE DONE? Need to understand the different types of non-adherence Need to understand the different causes of non-adherence Need to develop tailored/personalised interventions

13 Stages of adherence 1. Initiation 2. Implementation 3. Persistence/Discontinuation

14 More recent explanations of non-adherence Over last years, many measures and studies make a distinction between UNINTENTIONAL and INTENTIONAL non-adherence Although useful, this distinction is often problematic Now huge number of studies, which have identified a very large number of potentially modifiable factors which can affect adherence (eg Kardas et al, 2013; Mathes et al, 2014) HOW TO CLASSIFY THESE?

15 A new approach to classifying causes of nonadherence CAPABILITY Psychological e.g. understanding, planning, memory Physical e.g dexterity, swallowing MOTIVATION Reflective e.g. treatment beliefs self-efficacy Automatic e.g emotions; habits; cues OPPORTUNITY Physical e.g. access, cost ; regimen complexity; Psychological e.g. HCP communication, social support BEHAVIOUR (Adherence) Jackson, Eliasson, Barber & Weinman (2014). Applying COM- B to medication adherence: a suggested framework for research and interventions. The European Health Psychologist.

16 Applying COM-B framework to adherence in oral anticancer medications CAPABILITY Poor knowledge of cancer / treatment Less satisfaction with information about treatment OPPORTUNITY Low social support Increased prescriptions Less frequent communication with HCP Receive treatment from nonspecialist Greater out of pocket costs MOTIVATION Beliefs about cancer Beliefs in necessity of medication Concerns about medication / side effects Low self-efficacy beliefs Depression / anxiety Adherence to oral anticancer medications

17 Predictors of non-adherence: Overview of evidence (McHorney et al 2008) Weak evidence Moderate evidence Strong evidence Gender Income Cognitive ability, depression, social support, coping skills Number of medicines, disease seriousness beliefs Concerns about treatment (fear of side effects etc.) Beliefs about illness (case, timeline) Age Health literacy, locus of control Cost of therapy Race Self efficacy, trust in HCP, HCPpatient concordance Necessity (perceived need) for treatment Personality Symptom experience Perceived drug efficacy McHorney et al. Health Expectations 2011;14(3):

18 Key learnings from patient studies Very many factors have been found to influence adherence (Mathes et al, 2014) These can mostly be classified within COM-B Large variation in the causes of non-adherence between patients and within patients over time Importance of identifying the reasons for each patient and tailoring interventions to these

19 WHAT ARE THE REASONS FOR NON-ADHERENCE? 1. Drivers of patient behaviour 2.Health care professional behaviour 3. Health care system factors

20 Research on HCPs LACK OF AWARENESS OF EXTENT OF THE PROBLEM AT AN INDIVIDUAL AND SYSTEM LEVEL (OECD, 2018). CLINICIANS : often do not check adherence (when treatment is not working) if adherence is checked then question is asked in way which results in false patient response (eg Engel et al, 2017) no better than chance at rating individual patient adherence have an optimistic bias lack of ownership in dealing with the problem

21 LEVELS OF NON-ADHERENCE (COPD Preventer medication) % Nonadherent % 40% 60% 80%

22 CLINICIANS RATINGS OF NATIONAL LEVELS of non-adherence (COPD) Clinician rating of national % NA % 40% 60% 80%

23 CLINICIANS RATINGS OF NON -ADHERENCE IN OWN COPD PATIENTS Clinician rating of % of own NA patients % 40% 60% 80%

24 Key learnings from HCP studies Need to increase awareness of the extent and effect of nonadherence to medicines and other advice (OECD (2018) a major public health problem ) Need to use patient friendly/collaborative ways of asking about adherence in consultations Need to be able to identify specific reasons for each patient and tailor appropriate BC interventions to these Need TRAINING and TOOLS : CARE mission 1

25 CONCLUSIONS Non-adherence is quite widespread and determined by a range of factors Interventions need to focus on the individual drivers of nonadherence over the different phases of adherence Greater recognition and skill is needed on the part of the HCP Increasingly adherence support will be digital THANK YOU