Patient Adherence Claire Neely, MD

Care of Mental, Physical, and Substance use Syndromes! The project described was supported by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 2

Objectives At the end of this session you will be able to: Describe implications of non-adherence Understand barriers to adherance Help overcome those barriers

Who has Been Non-Compliant? 4

When all else fails, blame the patient. 5

The Problem WHO estimates patients do not follow instructions 30-50% of the time Mismatch between patient s goals and professional s goals 33-69% of medication-related hospital admissions are due to poor adherence 6

Defiance or Reasoned Decision? Patients carry out a cost benefit analysis of each treatment, weighing the costs/risks of each treatment against perceived benefits Patients comply with medical advice when it makes sense to them, and seems effective, is accorded with their beliefs, and is possible to carry out within the constraints of their lives Soc Sci Med 34(5): 507-13; 1992 7

Predictors of Non-Adherence? 8

Predictors of Non-Adherence Psychological problems (depression) Cognitive impairment Asymptomatic disease Poor discharge planning/education Side-effects of medication Patient s lack of belief in benefit of treatment 9

Predictors of Non-Adherence Patient s lack of insight into the illness Poor provider: patient relationship Presence of barriers to care or medications Missed appointments Complexity of treatment Cost Osterberg & Blaschke NEJM 353:5;487 (2005) 10

Barriers to Adherence Relationship Problems Provider & Patient Patient & System Provider & System 11

Barriers to Adherence Poor provider:patient communication Patient has poor understanding of disease Patient disagrees about diagnosis Patient has poor understanding about benefits and risk of treatment Patient has poor understanding of proper use of medication Provider prescribes overly complex regimen 12

Barriers to Adherence Patient interaction with the healthcare system Poor appointment access or missed appointments Poor treatment by clinic staff Poor access to medication Formulary changes Poor pharmacy access High medication cost 13

Barriers to Adherence Physician s interaction with healthcare system Poor knowledge of drug costs Poor knowledge of insurance coverage Low level of job satisfaction 14

Strategies to Improve Adherence? 15

Strategies to Improve Med Adherence Identify poor adherence Ask in normalizing fashion Elicit patient s feelings about ability to adhere Simplify and clarify Customize according to patient wishes Enlist other caregivers 16

Strategies to Improve Med Adherence Build relationship safety Increase patient s willingness to be candid Recognize autonomy The care plan they create may not be the one we like Consider more forgiving medications 17

Increase Patient Engagement Meet where they are Health literacy Cognition Level of activation Encourage patient to express preferences Type of services Intensity Settings 18

Executing Directions Health literacy Executive cognitive functioning Activation 19

Executive Cognitive Functioning Complex functions Planning, problem-solving, working memory, anticipating consequences of actions, monitoring the effectiveness of one s own behavior There is decrement of executive cognition with age (starting in mid 50 s) 20

Screening for Cognitive Impairment Clock drawing test Mini mental status 21

Patients have Workflows We need to understand what they are and how well they are serving the patient s needs. 22

Minimally Disruptive Medicine Victor Montori, Mayo Clinic Minimally Disruptive Medicine 23