Monthly Archives: October 2013

Nurses and NPs Can Do More to Improve Adherence

Efforts to improve patient adherence are making slow progress. Could nurses and NPs be key factors in accelerating adherence improvements? This post explores reasons why physician practices should look urgently at this option.

Nurses Are Well Qualified to Improve Adherence, But Are Underused

With over 3 million members, nurses are the largest group in the healthcare workforce. Nurses are increasingly well qualified (see here: “Focus on Education”), with 50% or more holding a bachelor’s degree or higher. They feature in almost every aspect of healthcare delivery, including hospitals, primary care practices, case management, and health plans. Depending on their scope of work, nurse practitioners (NPs) may also diagnose and treat patients.

Physicians are too overburdened with administrative tasks to effectively improve adherenceAs physicians are increasingly burdened by administrative tasks, they are spending less time with patients. This limits a doctor’s ability to effectively identify the motivations associated with medication non-adherence. It may also limit their ability to counsel patients on ways to improve adherence. Adding to this, there is the growing shortage of physicians, particularly in primary care.

These physician trends are leaving a large and important ‘gap’ in care. Specifically a gap in the ability of physician practices to adequately monitor patients’ adherence and to adequately manage and treat poor adherence.

Nurses and NPs are particularly well suited to fill these roles, yet at present they are underused. Making better use of nurses and NPs to improve adherence can improve patients’ health and also reduce healthcare costs.

Nurses Have the Skills to Improve Adherence

Nurses and NPs have the skills and aptitude to improve adherence through developing strong personal relationships with patients. Here’s a “5-for-Success” list of reasons why they should take more active roles in managing and improving medication adherence:

Patient trust and relationships – In Gallup surveys, nurses have consistently been rated highest for honesty among healthcare professionals. And of course honesty is a key factor in generating trust and building personal relationships. In turn, a trusting relationship is a big stepping stone towards better patient adherence.

Patient communication and engagement – Nurses spend time communicating with patients, because they care and because the patient comes first. They get to know the patient at a personal level — their fears, their thoughts, and their preferences (see here). This knowledge helps in tailoring treatment to an individual patient’s needs. Aside from further strengthening personal relationships, good communications and patient engagement are also strongly associated with better adherence.

Patient education – Nurses are often good patient educators. They have a good working understanding of medical conditions and treatments. Plus they can explain them in language easy for patients to understand. Understanding the right information helps build the right patient beliefs, which helps improve adherence.

Patient motivation – Motivating patients to adjust or make changes to their behavior is a common nursing challenge. Medication adherence is often a case in point. The validation of motivational interviewing (MI) to improve adherence provides nurses with a valuable tool to help achieve these behavioral changes. MI is easy for nurses to include into patient discussions as it typically takes only a brief time (eg, 10-to-15-minutes).

Nurse experiences – Studies have shown that nurses and NPs have successfully been able to improve adherence in a number of different situations. For example through:

  • Telephone follow-ups with patients
  • Implementing work site interventions
  • Home visits with patients
  • In-clinic discussions with patients
  • Education and counseling of patients prior to hospital discharge

All of which is neatly summarized in the following line from a recent article:

Nurses can make a significant difference in patients’ understanding about their medications and their willingness to take the drugs as directed.

Physicians are overburdened with administrative tasks, so the time is right for nurses and NPs to step up and help improve adherenceNurses and Adherence – the Time is Right

Three years ago the Institute of Medicine published their directional report: “The Future of Nursing: Leading Change, Advancing Health”. This report advocated that nurses and NPs should practice to the full extent of their education and training.

Nurses are ready and able to take on bigger roles in the battle to improve adherence. They should lobby hard for such roles. And if physicians have any sense, nurses should be granted these roles right now!

Your thoughts?

 

Improving Adherence – What Will It Take to Really Move the Dial?

Many recommendations for improving adherence focus on ‘policy’. But are these aimed at the healthcare providers (HCPs) who can make a day-to-day difference? Here are some thoughts on practical approaches that could make big advances in adherence.

Need for Practical Approaches to Improving Adherence

Numerous healthcare-related bodies have issued numerous reports on ‘policy recommendations’ for improving adherence. They are great documents and they contain many good ideas. However, I can’t help thinking there’s a burning need for more pragmatic approaches to the problem.

For example, something that suggests how busy HCPs can build better adherence practices into their daily activities. And also underlines why this is an important thing to do.

A document that takes a practical Why? What? Who? When? Where? And How? approach.

Payers and pharmacists are already very committed adherence improvements. So the suggestions below are more targeted towards physicians, where greater work is needed to get improvements in adherence really moving (see here).

To better set the scene though, here’s an extract from a recent article in Health Affairs (see here):

  • On Capitol Hill and among private payers the case can be made that better use of medicines and improved patient adherence are a pathway to better patient outcomes and appropriate cost control
  • Health care providers need to manage medicines well and improve adherence in order to achieve a new standard of performance (Total Medical Expenditure)

These are strong statements. Statements that reinforce the urgent need to get improving adherence moved higher up the healthcare agenda!

Activating Physicians on Adherence

Many of the 600,000+ physicians in the U.S. are currently ‘spectators’ on the issue of adherence. As the second largest group of HCPs (after nurses), this cannot continue. Without physician support, moving the dial on improving adherence will be significantly more difficult.

There's an urgent need for physicians to become more energized about improving adherence. Without strong MD support, advancing adherence will be difficult.There’s an urgent need to activate physicians, so they adopt adherence-supportive behaviors. However, they are currently ill-prepared to take on this challenge (see here). So here are a few ways to get physicians more energized about adherence:

  1. Payers and provider groups must establish improving adherence as a ‘clear-and-necessary’ physician priority. They should also stress that improving adherence is a critical stepping stone to achieve quality (outcomes) and cost-containment performance measures.
  2. Payers and provider groups must further support physicians by allowing them more time to devote to adherence activities. Perhaps reducing physician administrative duties might be a way of achieving this?
  3. Performance-based incentive payments must be a higher percentage of physicians’ remuneration. To emphasize the importance of better quality and better adherence, these incentive percentages have to be meaningful.
  4. Adherence must be a primary focus for physician training programs (particularly CME). Physicians need to be better informed about adherence matters. They also must be better skilled at assessing patient adherence behaviors and at engaging patients to improve these behaviors.
  5. A practical blueprint for ‘How Physicians Can Improve Adherence’ must be developed. This blueprint should set out:
      • Why adherence is an important factor for achieving quality and cost-containment performance goals
      • Clear, practical steps for integrating good adherence behaviors into physician practices
      • The roles that various practice staff can play to help introduce these adherence-supportive behaviors
      • Measures that can track progress towards inclusion of these new adherence-supportive behaviors into daily practice routines
      • A list of tools and resources that are available to support the blueprint
  6. Physician associations must show leadership and must more strongly advocate the need for a stronger focus on adherence. Currently such leadership is largely absent.
  7. Adherence training must be included into residency programs. This will further underline the importance of adherence to quality care. It will also provide a future flow of “adherence-enabled” physicians into the workplace to drive implementation of local actions.
  8. Lastly, but by no means least, there must be better care coordination and information sharing between physicians and other HCP groups. Through communication and shared information, different HCPs treating the same patient will be better informed. They can then better support that patient’s adherence plans and behaviors.

Implementation Anyone?

Hopefully there are a few decent thoughts here. But they’re still a long step away from moving any dial.

So what are the best routes to put these thoughts into action? Ideas anyone?

Pharmacists Working Hard to Improve Adherence

News & Comment about medication adherence

 

 

 

 

 

 

 

Poor medication adherence is a nationwide problem. So which healthcare professionals are working hardest to overcome this issue? The latest NCPA Digest report strengthens pharmacists’ claim to this tag.

Strong Pharmacist Support for Adherence

Pharmacy chains like Walgreens and CVS have shown strong commitment to improving adherence. Their respective WellTransitions and Pharmacy Advisor programs (see here and here) are examples of this. Now the National Community Pharmacists Association (NCPA) has released new information. Their 2012 Digest provides interesting new insights into how hard community pharmacies are also working to advance patient adherence.

Which healthcare professionals are working hardest to improve adherence? The latest NCPA Digest strengthens pharmacists’ claim to this tag.The NCPA Digest reviews the current status and activities of over 23,000 independent community pharmacies. Just considering activities to improve medication adherence, the Digest confirms how strongly these pharmacies are working to address this issue (see here and here):

  • 50% of independent community pharmacies offer programs to improve adherence
  • 48% offer adherence counseling services (up from 39% in 2011)
  • 39% offer phone or text reminder adherence reminders (up from 22% in 2011)

Another NCPA document (see here) lists several other ways in which independent pharmacies are tackling adherence. These include medication therapy management, compliance packaging, synchronized refills, and motivational interviewing.

The Digest also noted that community pharmacists helped reduce healthcare costs by dispensing a record number of lower-cost generic drugs (76%, up from 72%). They also on average consulted with physicians almost 8 times a day about drug therapies. This included advice on appropriate use of generics. Pharmacist recommendations were accepted by physicians 83% of the time.

In connection with this last point, it should be remembered that pharmacists are consistently ranked in the top 3 most trusted professionals (see here).

Adherence Solutions Aligned to Patient Needs

Among the more common reasons for patients not adhering properly to medication regimens are cost, forgetfulness, lack of understanding , and mistaken beliefs.

Based on this latest Digest information, community pharmacists are well-placed to address adherence issues relating to any of these four reasons. For example:

Cost can be addressed by use of less expensive generic alternatives.

Forgetfulness may be addressed through use of reminders or compliance packaging, both of which help patients take their medications according to plan.

Lack of understanding (eg, regarding the importance of therapy and adherence) can be improved through education – which is typically a part of medication therapy management – and through counseling.

Mistaken beliefs may also be addressed by counseling and education, for example focusing on the value of treatment and the importance of adherence. Motivational interviewing can also play a role in such situations.

The easy availability of pharmacists, their approachability, and their highly trusted status all add to the value community pharmacies can bring to improving adherence.

Comments

Two comments come readily to mind relating to this latest pharmacist report.

Firstly, it’s essential to correctly match adherence solutions with identified patient reasons for non-adherence. For example, reminders can be effective when patients intend to take their tablets, but just forget to follow through (eg, due to interruptions or schedule changes). If patients lack commitment (eg, because of poor understanding or mistaken beliefs) reminders are less likely to be effective answers.

Secondly, the reported frequency of pharmacist-physician discussions opens up further opportunities to enhance adherence. Poor adherence has proved a tough nut to crack. The more healthcare professionals (HCPs) can work together, the better the chances of success. Regular exchange of relevant information will help get pharmacists and physicians on the same page. Through this, patient-specific adherence actions can be reinforced by both HCPs, which can surely help to further improve adherence.

Additional comments welcomed!

Improving Adherence: Factors Affecting Progress

To speed up improvements in adherence, we need to focus on factors that most impact progress. But which are those factors? This post considers five potential blocks to improvement and assesses their relative effects. 

Barriers to Improving Adherence

A previous post (see here) suggested five factors that may be slowing advances in medication adherence. These are:

  1. Maybe some key adherence information pieces are still missing?
  2. Perhaps there’s poor understanding among key healthcare providers (HCPs) of what they can do improve adherence?
  3. It could be a shortage of commitment or of training among HCPs?
  4. Or possibly insufficient commitment or support from healthcare systems?
  5. Or difficulties including adherence efforts and actions into the everyday practice of medicine?

Below we assess the extent to which these factors contribute to delayed adherence progress.

Lack of Adherence Information?

Lack of adherence information is unlikely to delay adherence progress.

Lack of adherence information is unlikely to be a reason for delay in adherence progress.

Assessment of this factor is relatively simple. We know the predictors of non-adherence. We have good insights into why patients don’t adhere. We have a number of interventions that have been successful in improving adherence. We even have suggestions for how interventions can be matched up with specific reasons for non-adherence; across nine chronic condition types. And based on the WHO 2003 Report (see here), we’ve had all this for 10 years or more.

Poor HCP Understanding of What They  Can Do About Improving Adherence?

This seems to differ between the three main HCP groups.

Pharmacists have a clear role to be “responsible for providing patient care that ensures optimal medication therapy outcomes” (see here). Including adherence into medication management is a natural step. Pharmacists are also well-placed to recognize non-adherence (through refill information) and to counsel patients on adherence issues.

Physicians may delay progress because of poor understanding of what they can do about improving adherence.

Poor physician understanding of adherence issues is a likely delaying factor to progress.

Payers understand their role in improving value of care (see here). They also recognize that better adherence improves patients’ health status. Plus, they have launched programs to enhance patient adherence (see here).

Physicians in ACOs or PCMHs probably place a higher priority on adherence, as it’s built into their quality measures. In general however, physicians don’t appear to place much emphasis on adherence (see here). This may reflect a less than full understanding of what they could (or should!) be doing.

Lack of Adherence Commitment or Training among HCPs?

Again, this varies by HCP group.

Pharmacists’ commitment to improving adherence is led by major pharmacy and PBM groups (eg, CVS Caremark, Walgreens, Express Scripts). Commitment to adherence is also strongly advocated by professional pharmacy associations (eg, NCPA, APhA, AACP, NACDS, NAPB). Pharmacist tools and training on medication management and adherence are available (eg, APhA certificate training), and several third-party companies provide adherence support to pharmacies.

Payers are committed to improving value of care, including better adherence. For example, many payers now offer value-based insurance design (VBID) (see here). VBID enables drug costs for patients to be reduced or eliminated as an incentive to improve adherence. Payers are also introducing payment-for-performance for hospitals and for physicians to increase the focus on better outcomes (see here).

Physicians likely to delay adherence progress because of lack of commitment or training.

Lack of physician commitment to, or training on adherence is a likely delaying factor to progress.

Physicians – compared to pharmacists and payers, physicians have a low commitment to adherence. Physicians report a low sense of responsibility for adherence; seeing it as a patient problem (see here). Physicians also score poorly for key adherence-supportive behaviors; such as quality of communications (see here) and shared decision-making (see here). Physicians are poor at identifying non-adherence (see here). They generally have limited or no training on adherence-related topics (see here) and have few tools available to them.

Advocacy for adherence from professional physician organizations (eg, ACC, AHA, ADA) is either absent or only limited. Plus, physicians have made no clear attempts to ‘own’ elements of the adherence problem.

This sentence from a 2011 article in Mayo Clinic Proceedings sums things up:

Not only do physicians often fail to recognize medication non-adherence in their patients, they may also contribute to it by prescribing complex drug regimens, failing to explain the benefits and adverse effects of a medication effectively, and inadequately considering the financial burden to the patient.

Lack of Adherence Commitment or Support from the Healthcare System?

Once again this varies across HCP groups.

Pharmacy groups and professional organizations provide significant support and training for employees and members. Pharmacists are also reimbursed for carrying out medication management reviews with patients.

Payers are their own masters. They are testing new approaches (eg, ACOs, VBID, ‘gaming’) and quantifying impacts on adherence, value, and costs. Through these new approaches, payers are also directly influencing both physicians and pharmacists (eg, pay-for-performance programs).

Physicians likely to delay adherence progress because of lack of commitment or support from healthcare systems.

For physicians, lack of commitment or support from healthcare systems is a likely to delay adherence progress.

Physicians on the other hand are largely left to fend for themselves. To support physicians, healthcare systems need to:

  • Allow physicians the time to effectively engage patients on adherence topics (see here)
  • Provide appropriate incentives for HCPs to adopt new behaviors (see here)
  • Provide HCPs with appropriate adherence support and training (see here)

Sadly, the proposals below from the WHO Report in 2003 still hold true today:

Health providers can have a significant impact by assessing risk of non-adherence and delivering interventions to optimize adherence. To make this practice a reality, practitioners must have access to specific training in adherence management, and the systems in which they work must design and support delivery systems that respect this objective.

Difficulties Including Adherence Efforts into the Daily Practice of Medicine?

Physicians likely to delay adherence progress because of difficulties including adherence into daily practice of medicine.

For physicians, difficulties including adherence into the daily practice of medicine is a likely factor to delay progress.

This is a likely physician sticking point for a number of reasons. For instance:

  • There’s no single clear area for physicians to focus on where they can quickly improve adherence (unlike pharmacists and medication management)
  • Improving adherence will require physicians to sharpen up their skills (eg, communication, engagement, shared decision-making)
  • Physicians will need to create additional patient-facing time (eg, using nurses/NPs/PAs)
  • There’s no simple plan available for how physicians should incorporate adherence into their daily practice routine

Maybe a ‘blueprint’ for successfully introducing better adherence management into physician practices might look something like this.

What do you think?

Physicians who want to improve adherence efforts in their practices need a plan of action. This blueprint suggests some key areas to focus on.

 

 

Why So Little Progress in Improving Adherence?

How can we reenergize efforts to improve medication adherence? Figuring out what’s impeding progress would be a great start. Through looking back to the WHO 2003 report, this post suggests 5 key questions that need to be answered.

Learning from the past to create practical adherence solutions that fit into everyday medical practice.‘Back to the Future’?

It’s over 10 years since the WHO released its report “Adherence to Long-Term Therapies: Evidence for Action”. This critical, evidence-based review remains one of most relevant, most complete documents on the issue of medication adherence. If you read the 2-page summary entitled “Take-home messages”, the statements apply just as strongly today as when they were first written.

While this reflects the great job done by the report’s authors, there’s also a flip side. The fact these take-home statements are just as relevant today as they were 10 years ago is very worrying. It’s an indicator of how little has been achieved to improve medication adherence since January, 2003.

When you look more closely at the information contained in the WHO report, it pretty much covers all the bases. New data in the last 10 years has mostly added support for defined issues, rather than offer new perspectives. For example the key effects of non-adherence are still the same – poorer health outcomes for patients and higher healthcare costs.

What’s changed since 2003 is an even stronger recognition of how much costs associated with non-adherence contribute to overall spiraling healthcare spending. That’s around 12% at latest reckoning. A figure that should give everyone an extra incentive to solve the adherence problem!

Back to the WHO 2003 Report on Adherence

The WHO report identifies improving medication adherence as a means of increasing health system effectiveness. It proposes that improving adherence is a good healthcare investment. And it sets out several important areas where health care professionals can contribute to adherence improvements. For instance:

  • Supporting patients to achieve better adherence; not blaming them for adherence lapses
  • Understanding and identifying the factors and barriers that affect medication adherence
  • Recognizing that an individual patient may have more than one factor or barrier affecting his or her adherence
  • Matching specific adherence-improving interventions with identified patient factors and barriers
  • Using multiple interventions to target several factors or barriers at the same time
    (multi-component solutions)

All of these points are still good today. The report goes on to outline:

  • The wide variety of different factors or barriers that can affect adherence – a comprehensive list divided across 5 categories
  • Thoughts on the most common factors/barriers for each of 9 different chronic disease or treatment areas – asthma, cancer, depression, diabetes, epilepsy, HIV/AIDS, hypertension, smoking cessation, and tuberculosis
  • Suggestions across each of these 9 areas for interventions that match up with the most common factors/barriers

In addition, the document says health systems must evolve to allow physicians, pharmacists, and other healthcare professionals the time, resources, and incentives needed to properly tackle adherence problems.

All this sounds good. So where’s the problem?

The WHO 2003 report provides a great framework around which to build a solid program of adherence improvements. Why has so little progress been made over the past 10 years?

Learning from past lessons to create practical adherence solutions that fit into everyday medical practice.Implications for Future Efforts to Improve Medication Adherence

To succeed in broadly improving adherence we must better understand why efforts to date have been so unsuccessful. Here are a few initial thoughts:

  1. Maybe some key information pieces are still missing?
  2. Perhaps there’s a lack of awareness or understanding among key healthcare stakeholders of what all this information means?
  3. It could be a shortage of commitment or of training among healthcare professionals?
  4. Or possibly insufficient commitment or support from the healthcare system?
  5. It may be due to difficulties in including adherence efforts and actions into the everyday practice of medicine?

What do you think are the reasons for adherence improvement efforts to date not being more effective? Is it one or more of the above? Or are there other factors involved?

What are your views on the reasons why progress has been so slow?

Please share your thoughts!

 

Physicians and Adherence: the Bad, and the Ugly

Physicians are very well placed to drive improvements in medication adherence. But are they fully engaged in the task? This is the second in a two-part post exploring this question. Part one, ‘the Good’, is here. This second part focuses on: ‘the Bad and the Ugly’.

The Story So Far

Physicians are a critical cog in the adherence machine. With the focus of healthcare moving to ‘value’, doctors have clear incentives to improve adherence. Because improving adherence helps achieve better outcomes.

In ‘the Good’, we identified five behaviors that physicians should adopt to promote better adherence among their patients. These are:

  • Prioritize the quality of their communications
  • Devote appropriate time to talking with their patients
  • Engage patients and activate them to self-manage
  • Commit to shared decision-making
  • Build trusting relationships

In this post we’ll review how doctors are currently doing in each of these areas, based on available information.

Physicians and Adherence: the Bad

Before we get into the five areas, I’ll lead off with three more general findings about doctors’ views on medication adherence.

Physicians’ have a low overall sense of responsibility for adherence

Physician views on their adherence responsibilities were reported in a 2012 paper (see here). Findings were that physicians feel responsible for assessing medication adherence and for addressing factors underlying non-adherence.

However physicians believe that patients were ultimately responsible for taking medications.

Undoubtedly, adherence is a shared, physician-patient responsibility. However to adhere better, patients need help and support. For example, physicians can provide information on the importance of adherence, guidance on tools that can assist adherence, and counseling to address misconceptions.

Placing the ultimate responsibility on patients hints at assignment of blame, something that should be avoided.

A weak sense of responsibility for adherence among physicians potentially weakens their resolve to adopt the five behavior changes described above.

Physicians are poor at actively identifying non-adherence

Physicians say they feel responsible for assessing medication adherence (see here). In the same paper however the authors found that in-depth inquiries about medication use were made in only 4.3% of patient discussions.

Physicians feel responsible for assessing adherence. But the words don't carry through to actions. Physicians ask indepth questions about adherence less than 5% of the time.

These two findings are clearly at odds. However, they say “actions speak louder than words”.

It is self-evident that if physicians don’t actively look for non-adherence, they’ll miss much of it. So that raises the question: how much non-adherence is out there, but unrecognized?

Physicians overestimate patient adherence

Hard data on a patient’s adherence may be difficult to get. In its absence, physicians tend to overestimate how well patients are adhering to their medications’ regimens. For example, in a 2010 study (see here) doctors overestimated adherence in 67% of patients.

The study compared physicians’ assessment of adherence with that found using MMAS-8. Agreement between physician perception and MMAS-8 was 95% for high adherers but only 33% for low adherers. Overall, physicians underestimated adherence in 5% of patients, while overestimation occurred in 67% of patients.

A tendency to significantly overestimate patients’ adherence levels may adversely affect doctors’ views on the importance of dealing with non-adherence. Perhaps this over-optimistic view of true adherence levels also contributes to their low sense of responsibility as well? This overestimation maybe also explain why physicians so rarely question patients about their tablet-taking habits.

That deals with the three general areas. The next few points get us back to the behavioral areas flagged earlier in ‘the Good’ post. Here goes …

Quality Communications

It seems there’s quite some room for improvement in physician-patient communications. For instance, the headline from a recent infographic (see here) caught my eye:

 “50% of patients walk out of the physician’s office not knowing what they were told or are supposed to do.”

Perhaps sounds excessive? Maybe not so much. This number is within the range from an earlier 2003 paper (see here), which noted that:

“40–80% of medical information provided by healthcare practitioners is forgotten immediately.”

Of further relevance is the advice from the infographic that:

  • Telling patients once is usually not enough to get the patient’s attention or buy-in
  • Patients filter what they hear from their doctor in a variety of ways that physicians know nothing about, ie the patient’s health beliefs, values, previous experience, and illness explanation models

This clearly remains an area for further physician improvement.

Investing time with patients to help improve their medication adherence is time well invested.Appropriate time for patients

Physicians are pressed for time. Administrative duties, management tasks, dealing with insurance queries, and many other demands all threaten the time available for patients.

A survey by AHRQ carried out in 2012 (see here) found that almost 70% of respondents felt “rushed when taking care of patients”. And a 2013 paper (see here) found that 81% of physicians perceived a lack of time as the largest barrier to practicing shared decision-making.

So time is a problem and the problem has consequences.

To address this, better time management by physicians could be one solution. Another answer might be better sharing of workload among practice staff. For instance, relationship-building could be a shared task, as could communication and patient education.

In support of this approach, a recent survey (see here) reported the nurse practitioners are taking on key adherence-related activities, such as:

  • Providing patients with adherence resources
  • Spending time on patient education
  • Referred patients to adherence tools

Patient engagement and shared decision-making

Shared decision-making (SDM) is a prime example of patient engagement. And when successfully carried out it can boost patient activation too. So how well have physicians adopted SDM?

A 2013 paper on prostate cancer screening (see here) reported only 8% implementation of full SDM. This figure is extremely close to 9% that met the criteria for informed decision making in a 1999 study (see here).

These are disappointing numbers; both because of their lowness and because it’s possible that implementation of SDM hasn’t improved a lot in nearly 14 years.

Once again, with SDM there’s massive room for improvement.

Trusting patient relationships

In a 2013 paper (see here, Table 2) patient trust in doctors was very high. To the question: “Have you felt confidence and trust in your personal physician”, 78% of respondents said “usually” or “always”.

Questions about the continuation of such high levels may depend on possible changes to future patient expectations of their doctors. If patients begin to look for better communications, for more time, or improved engagement and participation in treatment decisions, then based on the findings above trust levels could be endangered.

Physicians and adherence, it's ugly. The low levels of doctor contributions to adherence topics just does not look good.Physicians and Adherence: the Ugly

This section addresses several more qualitative impressions relating to physicians and adherence. The term “ugly” is applied because the low levels or even absence of physicians contributing to these matters just does not look good.

Adherence – Leadership

Among leading healthcare professional groups, physicians appear to be a poor third in terms of active involvement in, and leadership of, adherence activities. Pharmacists currently lead the charge, with payers second.

Adherence – Visibility and Support

Similarly in terms of the number of general articles or reports written about adherence and its importance, physicians are not among the leaders.

Adherence – Sharing

Even when it comes to groups like ACOs or PCMHs, who are most likely to support improving adherence as a major goal, little has been shared or published from their experiences (impacts, best practices, etc). Perhaps it’s early to expect this?

Physicians and Adherence: Summary

Better adherence is of major benefit to patients because it improves outcomes and health status. It’s of major benefit to society because it can reduce healthcare costs – exactly what the economy needs. And it’s of major benefit to physicians because it improves ‘value of care’ – an increasingly important performance measure for doctors. A win-win-win!

To fulfill this vision will require physician behavioral changes. The practical dimensions of these changes are covered above.

At an ethereal level, the changes needed were nicely summarized in an article earlier in 2013 (see here). Speaking about medical practice changes the author wrote:

“This will require renewed attention to the character of the clinical practitioner, to the quality of the practitioner-patient relationship, and to the source of those values that sustain humanistic medical care. Above all, it will require exploration of what it might mean to view medicine as a spiritual vocation.”

Physicians and Adherence: What Does ‘Good’ Look Like?

Physicians are very well placed to drive improvements in medication adherence. But are they fully engaged in the task? This is the first in a two-part post – “Physicians and Adherence: the Good, the Bad, and the Ugly” – that will explore this question. This part focuses on: What does ‘good’ look like?

‘Volume’-to-‘Value’ and the Role of Adherence

With healthcare emphasis shifting to ‘value of care’ and away from ‘volume’, there are clear incentives for physicians to look at medication adherence in a fresh light.

‘Volume’ placed emphasis on the number of tests carried out and prescriptions written. As the focus moves to ‘value’, health outcomes will become the dominant measure. For example, patients’ health status or efficient use of health resources will become much more important measures.

In making the change to ‘value’, medication adherence is a vital mediator. This is explained in the visual below. Treatments (representing ‘volume’) will only work when taken according to prescribing instructions. If patients don’t take medications as instructed, desired outcomes (‘value’) will not be achieved. And physicians’ performance may be downgraded.

Healthcare focus is shifting from 'volume' to 'value'. Medication adherence is a key mediator in achieving health outcomes and 'value of care' goals.

Improving adherence becomes a critical factor
in helping doctors achieve their intended treatment value.

Physicians Can Strongly Influence Medication Adherence

Physicians are very well positioned to influence good medication adherence.

It’s well documented that patients being treated for chronic conditions have the highest risk of non-adherence. Such patients see their physicians regularly for routine follow-ups and examinations. These frequent contacts are helpful, as they create opportunities to foster good doctor-patient relationships.

To translate patient relationships into a springboard for improved adherence, doctors need to adopt patient-centered approaches that address five vital areas:

  1. Focus on high quality communication
  2. Invest appropriate time to spent with patients
  3. Achieve patient engagement and activation
  4. Support shared decision-making
  5. Gain patient trust

Nurturing patient relationships in these five ways opens the door to productive two-way conversations; sets the table for patient engagement and collaborative working; and begins the process of gaining patient trust.

Rationale for the Five Key Areas

High Quality Communications

“What is unique about our study is that we found that medication adherence is better if the physician has established a trusting relationship with the patient and prioritizes the quality of communication, …”

This comment was by Dr Ratanawongsa (see here), an author of: “Communication and Medication Adherence: The Diabetes Study of Northern California” (see here). The study showed when patients give their physicians high marks for communication, they are more likely to fill their prescriptions. This association of good communication and better patient adherence confirmed earlier meta-analysis findings.

The main meta-analysis (see here) was based on 106 studies and found a 19% higher risk of non-adherence among patients whose physician communicated poorly than among patients whose physician communicated well.

A second part to the meta-analysis, involving 21 studies, looked at adherence as an outcome of physician communication skills training. This analysis found a 12% higher risk of non-adherence among patients whose physicians had not been trained in communication skills than among patients whose physicians had been trained.

Communication, activation, time, shared decision-making and all trust drive adherence, which helps physicians achieve quality and value of care goals.

“Adherence Doc”

Investing Time

Time physicians invest with patients is both a necessity and a challenge. Time is required to build patient relationships, engagement, and trust; and to have quality conversations. Given their many administrative demands, time has become a precious commodity for physicians,

In a recent AHRQ survey (see here), almost 70% of respondents felt rushed when taking care of patients. To maintain the quality of interactions needed to improve adherence, physicians and their practices will need to find new ways to achieve necessary face time with patients*.

Engagement, with the Aim of Patient Activation

To explain patient engagement, I like the words of a Mayo Clinic physician (see here), with a few extra thoughts from here.

In brief, engagement is described as:

  • Giving relevant information
  • Helping patients understand their options
  • Listening to their priorities
  • Understanding their beliefs and behaviors
  • Helping them choose the best solution for their lifestyle
  • ALL BEFORE WRITING A SCRIPT

The patient is central. And the dynamic shifts from treating a disease to allowing the patient to be the person he/she wants to be.

Engagement promotes patient activation and self-management through collaborative goal-setting and planning, which improves self-care, adherence, and outcomes.

Shared Decision-making

Shared decision-making is now widely accepted as a way to combine physician expertise with a patient’s right to be fully informed of care options, harms, and benefits. This process provides patients with the support they need to make the best individualized care decisions, while allowing providers to feel confident in the care they prescribe.

Shared decision-making with diabetic patients has been shown to improve HbA1c and LDL levels, by improving patient activation and improving medication adherence (see here).

Gaining Trust

As might be expected, patient trust is linked to the length of relationship with a physician (see here). The good news is that patient trust in doctors is quite high (see here, Table 2). To the question: “Have you felt confidence and trust in your personal physician?” 78% of respondents said “usually” or “always”.

Studies have shown that patient trust in physicians is associated with better adherence (see here and here).

In Summary

Physicians are a critical cog in the ‘adherence machine’. A paragraph from a recent brief by NEHI summarized this nicely:

“It seems unlikely that significant and lasting improvements in patient medication adherence will occur unless community-based providers and the daily practice of medicine support good adherence behavior among patients.”

Patient-centered communication is a core strategy by which physicians can create patient trust. In addition to prioritizing the quality of their communications with patients, doctors can further exert strong influences over patients’ adherence to medications, by:

  • Devoting appropriate time to talking with their patients
  • Activating patients to self-manage and self-care
  • Committing to shared decision-making
  • Building trusting relationships with their patients

 

* More about this in part 2 of this post.

Are We Looking at Medication Adherence Through the Right Lens?

Are the adherence solutions we’re currently testing too simple for a highly complex problem?

If solving the issue of medication adherence were easy, it would have been fixed years ago. The fact there’s still a way to go underlines just how complex a problem it is. Many articles on adherence echo this point.

Adherence is a complex problem with many moving parts.

Adherence is a complex problem with many moving parts.

Adherence – A Complex Problem

Take for example the reasons, causes, factors, or barriers that underlie non-adherence (I’ll just call them “reasons” from here on). There are over 60 sites on the Web that deal with this topic. The fullest single list can be found on page 13 of this report. It offers 55 different reasons organized under five categories:

  • Social and economic
  • Health care system
  • Condition-related
  • Therapy-related
  • Patient-related

Once an individual is identified as non-adherent to his or her medications, the next step should be to carry out a differential diagnosis – to determine which of the 55 reasons apply for this particular patient. Maybe not so simple?

But wait, a person may often have multiple reasons for non-adherence (an individual “reason-set”). And these reasons may change over time (see page XIV of this report and page 12 of this report). Now the complexities begin to mount up.

Lastly, one more complication must be added in. An individual patient’s reason-set is typically unique (see page 21 of this report). And reason-sets for non-adherence may differ widely from one person to the next.

At the end of the day, there’s no simple ‘one-size-fits-all’ solution to improving medication adherence. Because as a senior director for Aetna commented in a recent interview:

“[There’s] not just one thing that keeps a group of patients or even one patient from taking their medications as prescribed.”

Are Current Approaches to Improving Adherence Too Simple?

Many studies have assessed the effectiveness of different approaches to improve adherence. For example, the authors of a review in Annals of Internal Medicine found 758 publications that addressed this topic. Interestingly, 685 of these articles were excluded from the final review based on not meeting pre-set review criteria (eg, geography, study design, and bias). Perhaps this – at least in part – may be a comment on the general quality of adherence studies?

The remaining studies reported on 36 different ways that adherence might be improved. The majority of these were single-component approaches. That is to say they examined just one single intervention type.

Of the 36 approaches reviewed, less than 10% (3/36) looked at multi-component approaches.

Let’s take a moment to think about this finding in the context of two earlier statements:

  • There are around 55 possible reasons for non-adherence
  • An individual patient may have multiple reasons for non-adherence
Look at Adherence through a Difference Lens.

Look at Adherence through a Difference Lens.

Is it possible that current approaches are looking at the adherence issue through the wrong lens? That present approaches are too simple? Adherence presents as a complex problem, for which singular, standalone solutions are ill-suited. Instead, the search should be for multi-component answers.

The authors of a review in Advanced Therapeutics had the right idea when they said:

Multifaceted interventions that target specific barriers to adherence are most effective …”

Combinations of Solutions Are Needed to Improve Adherence

In a continuation his interview, the senior Aetna director commented that it’s necessary, “to find the combination of solutions that work best.” This goal of identifying multifaceted solutions to non-adherence – potentially coordinated through multidisciplinary care teams – is widely echoed by other experts in the field.

Defining multi-component solutions tailored to specific reasons for non-adherence will require changes to current approaches and thinking.

Looking to the future, I strongly feel that greater emphasis on multifaceted solutions must surely become the norm when addressing the adherence problem.

Would you agree?

I’d love to hear your thoughts and views on the best ways to put together effective, multi-component solutions?