Monthly Archives: November 2013

Adherence Approaches: What If We Have the Wrong Focus?

Some adherence approaches aim to motivate patients by imposing opinions. Other approaches draw out motivations from within the patient. So which should be the more important focus?

Recipe for Improved Adherence Approaches?

A JAMA editorial appeared last week with the title of: Ingredients of Successful Interventions to Improve Medication Adherence”.  The article suggested that well-designed interventions should be based on four essential approaches – patient knowledge, counseling and accountability, self-monitoring, and cost.

I wasn’t sure why, but something about this article didn’t feel right to me. Don’t get me wrong, these approaches all improve adherence – albeit modestly. And all four approaches are regularly used. But are these really the best adherence approaches that doctors and pharmacists can offer patients?

Adherence and Behavioral Change

Adherence approaches that draw out patients' internal motivations have a greater chance of sustaining new adherence behaviors over the longer term.

Some adherence approaches draw out internal motivations.

When I thought about it some more, something else nagged at me. Moving patients to better adherence requires behavioral changes. And for adherence approaches to have sustainable effects patients must WANT to change their adherence behavior. So, shouldn’t interventions that foster a patient’s motivation to adhere better be a cornerstone of overall adherence approaches? As an example, motivational interviewing (MI) is designed exactly to do this (see here). It may be that the authors of the JAMA editorial included MI under their heading of “counseling”? However, MI is a highly patient-centric approach, whereas counseling may simply consist of healthcare providers (HCPs) handing down expert advice.

This distinction between evoking or drawing out thoughts and ideas from the patient (ie, MI) and HCPs imposing their perspectives on the patient (eg, delivering knowledge) is a key issue for physicians and pharmacists to consider.

Contrasting Perspectives on Adherence Approaches

Adherence approaches that impose external opinions often encounter internal resistance from unmotivated patients.

Other adherence approaches that impose opinions may encounter internal resistance.

It’s often quoted that 50% of patients treated for chronic conditions are non-adherent to their medications. However many proven interventions improve adherence by figures of less than 10%. While this may be statistically significant in a controlled study, its practical relevance is less certain. For instance, such interventions would only move adherence levels from 50% to less than 55%.

Why are adherence improvement figures so poor? One possible answer is that many patients intentionally do not take their tablets. Because such patients are not inclined towards taking their medications, externally driven adherence approaches have limited effect. By externally driven, I mean approaches that seek to impose thoughts and opinions on patients.

Contrast this with an approach such as MI, which draws out a patient’s own motivation and commitment to change their adherence behavior. It does not tell patients what to do. Nor does it focus on why they should do it. MI works on the principle that lasting change is more likely to occur when the patient discovers their own reasons and determination to change.

In Summary

The intervention types proposed in the JAMA editorial may be effective in controlled studies. However in the ‘real world’, their impact is blunted by lack of patient motivation to change their non-adherent behavior.

Internally focused adherence approaches, like MI, potentially offer better prospects for success. Because they draw motivation from within the patient, there’s also a greater chance that new adherence behaviors will be maintained in the long run.

Maybe there’s a need for a change of focus?

Adherence Initiatives – What Have Payers Done for Us Lately?

Health insurers can undoubtedly influence improvements in medication adherence. So what kinds of adherence initiatives are payers actually sponsoring? Read on for answers based on a sample of five leading payer organizations.

The short answer is “a lot”!

The five payers reviewed were Aetna, Humana, Kaiser Permanente, United Health, and WellPoint. Sources of information were either corporate websites or web search findings. The results were very interesting! Different approaches across the five payers are divided into three sections:

The Predictable – the kinds of adherence initiatives that are probably expected.

The Innovative – initiatives that break new ground and test new approaches.

The Future – based on a report summarizing future payer priorities.

There are major differences between individual payer activities. The sections below provide an overall summary of findings.

The kinds of adherence initiatives that you would probably expect to see.Payer Adherence Initiatives: The Predictable

It’s not surprising that two payers report using claims data to monitor adherence. Both follow up with patients to encourage adherence. One uses care managers for follow-up, the other does not specify.

It IS surprising though that only two payers report doing this. Health plans are unique in having broad access to hard evidence of non-adherence. I would have expected all five to make active use of this information.

All five payers provide patient reminder services to support adherence. Two of these services involve text messaging, two are by phone, and one uses letters (still?).

Patient education is also a common service, with four payers providing this. The importance of adherence is usually included in the educational content

Two payers have mail order pharmacies in their networks and claim better adherence through easier patient access to medications.

Pharmacies in fact feature quite frequently in different adherence initiatives. In addition to the service already mentioned, two payers provide medication therapy management through their affiliated pharmacies. Drug reviews, adherence counseling, and pre-sorted medication packages delivered to patients’ homes are among the specific services mentioned.

Again, it’s surprising that only two payers offer medication therapy management. Though perhaps the others don’t have direct access to affiliated pharmacies?

Two other payer adherence initiatives are provision of free pill organizers and implementation of a health literacy program.

The types of adherence initiatives that break new ground and test new approaches.Payer Adherence Initiatives: The Innovative

Four out of five payers appear to offer value-based insurance design (VBID). I say “appear” as it’s not always easy to accurately interpret the language used in some web sites or articles. This 80% endorsement of VBID is encouraging.

Four payers are also investing in accountable care organizations (ACOs). The goals of ACOs include improving healthcare quality while also lowering healthcare costs. Once waste is teased out of the system, it’s to be hoped that improving adherence will play a pivotal role in achieving these goals. By the way, the fifth payer is Kaiser Permanente, which is effectively a huge ACO already! So, all five organizations are effectively supporting ACO initiatives. Again, this is very encouraging.

Three payers have specialty pharmacies in their networks, which focus on adherence. Specific programs mentioned include: adherence risk assessment, adherence monitoring, and adherence coaching.

Interestingly, three payers are sponsoring behavioral support initiatives. Of these, two programs specifically mention motivational interviewing (MI). Aetna, one of the companies majoring on MI, uses disease management nurses who are trained in the technique. These nurses elicit, rather than impose, motivation to change (see here). While MI has many possible applications to improve patient health, it has also been shown to be of significant value in improving adherence behaviors.

Special disease- or patient-focused programs are supported by three payers. These are:

  • A chronic care program, where care managers work with healthcare professionals to help improve patient’s adherence, using both phone calls and home visits
  • A diabetes control program, run by pharmacists who coach and counsel patients
  • A patient self-management and adherence program, where case management nurses trained in adherence work with pharmacists to build patient’s self-management skills, and improve patient-physician communication (see here)

To round this section off, here are a couple of additional programs that caught my eye.

Firstly, as Kaiser Permanente is an integrated health system, it’s EHR system truly links up physicians, pharmacists, and patients. Based on a large internal study, Kaiser credits their integrated EHR system for low levels of new script non-fulfillment (see here).

Lastly, Kaiser Permanente is unique (as far as I can see) in running an adherence training program for healthcare providers. Given poor physician capabilities with regards to adherence (see here), such training is much needed. Something the other four payers should perhaps consider?

Payer Adherence Initiatives: The Future

Overall, payers are working hard to include adherence initiatives – and through this improved quality – into everyday practice.

From a recent report, quality and cost (ie, value) are the major future payer priorities. Moving to value-based payment models is a major priority, and payers expect significant business impacts in getting there.

Interestingly, it’s likely that ACOs will become the most prevalent value-based payment model; possibly within the next 2 years.

In this new future, adherence initiatives – effectively implemented – will contribute to achieving value goals. They can also help healthcare providers achieve their value-based payment incentives.

A little extra motivation to move things along, perhaps?

Changing Patient Beliefs is Key to Better Adherence

To promote better adherence, should greater emphasis be placed on changing patients’ beliefs? This post explores why changing beliefs may be a key component in interventions to improve medication adherence.

Health Psychology as a Route to Better AdherenceUnhelpful patient beliefs contribute to nonadherence; modifying these beliefs can drive better adherence

A news release on adherence and patient beliefs recently caught my eye. It came from Atlantis Healthcare, a company that uses health psychology to encourage better adherence. The rationale for this approach goes like this:

  1. Non-adherence is often intentional – ie, patients deliberately choose not to take their medications.
  2. Frequently, this decision is driven by unhelpful beliefs – either about the patient’s condition, or their medication, or both.
  3. Psychology-based interventions can help overcome false, limiting, or unhelpful patient beliefs.
  4. Psychology-based approaches can also help motivate patients to change their behaviors and achieve better adherence.

Dr Scott Guerin of Atlantis Healthcare summarizes the rationale as follows:

“Patients need to be empowered to better self-manage their chronic illness – and successful programs need to go beyond support and simple reminders to shift patient beliefs to improve adherence behavior for the long-term.”

Comments on the Need for Psychology-based Interventions

So how strong is the need for psychology-based interventions? In part, the answer to this question lies in how often psychology-based reasons drive non-adherence. In this context, psychology-based reasons include not only patient beliefs, but also patient motivation, attitude, and self-efficacy.

An analysis of non-adherence reasons appeared in a recent post (see here). Drawing on nine sources for reasons for non-adherence, it ranked our four ‘reasons-of-interest’ as follows:

Psychology-based ReasonMean % Impact on Non-adherenceOverall Reason Rank
Patient motivation27%2 nd
Patient beliefs12%Equal 6 th
Patient self-efficacy7%13 th
Patient attitude5%14 th

For further comparison, “forgetfulness” was the most common reason for non-adherence (31%), “cost” was 3rd (22%), “poor physician-patient relationship” was =6th (12%), and “medication complexity” was 12th (8%).

So psychological reasons for ARE important considerations when healthcare providers are seeking to achieve better adherence.

There’s another reason to put a priority tag on dealing with psychological reasons. Because the issues are all internal, patients cannot easily solve them on their own. Whether it’s false beliefs, or low motivation, or poor self-efficacy, patients need help to get themselves back on the right track.

So healthcare providers (HCPs) need to get involved!

Comments on Practical Implications Patient beliefs, attitudes, motivation, and self-efficacy may all be important factors for achieving better adherence

It’s now generally accepted that multi-component solutions are needed to drive better adherence. The specific elements within each multi-component solution should be customized to individual patient’s needs. And these needs will be strongly influenced by a patient’s reasons for non-adherence.

Given the percentage of patients reporting psychological reasons for non-adherence, it’s probable that psychology-based interventions should be a regular part of optimized multi-component solutions.

However, fulfilling such a vision has practical implications. Specifically, to be effective psychology-based interventions will require time and new skills:

Time: There’s no ‘5-minute-fix’ for improving a patient’s beliefs, motivation, and self-efficacy. Quite the reverse, this will take appreciable time investments. For instance, time will be needed to engage with patients, build relationships, and gain their trust. Time will also be needed to understand their psychological status – their beliefs and what guides them, plus the ‘holes’ in their motivation or self-efficacy. Finally, time will be needed to modify beliefs and change patient behaviors; with better adherence as the overall goal.

New skills: In addition to baseline skills such as an open, friendly, and engaging discussion style, HCPs may also need to learn specific techniques. For example, motivational interviewing could be a valuable technique to master.

So who can take on this role – say within a physician practice?

Doctors can certainly do the job. But do they have the time? They already have so many other demands on their time; it’s probably not realistic for them to personally take on such new, time-invasive workloads.

What about Nurse Practitioners (NPs), or Physician Assistants (PAs), or Nurses? They can also do the job. Typically they enjoy spending time with patients; while nurses are also held in high esteem for honesty and trust. All of which are valuable assets for the role in question.

So maybe now is a great time for physicians to delegate these critical adherence-improvement tasks to their NPs, PAs, or nurses? Working together they can help achieve better adherence, better outcomes, and better overall quality.

What do you think?

Improving Adherence – Aligning Interventions to Reasons, pt 2

Part 2 of this post examines proven interventions for improving adherence. Then it looks at how these interventions match up to with the ‘top ten’ reasons for non-adherence (see Part 1). Matching interventions to reasons is important, because approaches are then aligned with individual patient needs.

Every story needs a beginning, middle, and end. Part 1 of this post represented the beginning; proposing a top ten reasons why patients don’t adhere to their medications. This article now lays out the middle and the end of this particular story.

Compiling a list of interventions proven for improving adherence makes up the middle. While the end suggests how aligning interventions to reasons can:

  • Provide a useful framework to help healthcare providers (HCPs) in selecting appropriate interventions to fit an individual patient’s needs
  • Help drive better adherence, leading to better patient outcomes and reduced healthcare spend

Improving adherence requires alignment of proven interventions to individual patient reasons for nonadherenceProven Interventions for Improving Adherence

My primary sources for identifying proven interventions were the two most recent, US-based, systematic reviews on medication adherence (see here and here). One was published in 2008 and the other in 2012.

Looking at these two reviews, however, it seems that two areas of important HCP skills were not included. These areas are quality of physician-patient communications and patient trust in their physicians. Both these factors appear in the long list of non-adherence reasons mentioned in Part 1 (see here). Also studies have shown that both poor physician communications and poor physician trust are associated with lower adherence to medications (see here and here).

Also, since the 2012 review, an interesting meta-analysis of Cognitive-based Behavioral Change Techniques (CBCT) has been published (see here). This analysis concluded that these techniques can have significant impacts in improving adherence. Motivational interviewing is the most commonly used form of CBCT.

Adding these additional sources to the two major review papers generates the following list of effective interventions. The figures in each cell reflect the number of studies supporting the effectiveness of each intervention type.

Intervention TypeCR 2008AIM 2012AIM 2005MC 2009BMJO 2013
Compliance packaging 11
Case management 5
Patient education 166
Patient reminder calls and alerts22
Patient counseling 52
Patient follow-up by HCPs 93
Patient self-management 51
Shared decision making 1
Cost mitigation5
HCP access to patient adherence data 1
Motivational interviewing 1
Improved HCP communications quality 1
Poor patient-physician trust 1
Positive reinforcement for patient 2
Regimen simplification 1
Family education 2
Patient support groups2

Multi-component Solutions for Improving Adherence

In addition to the list above, the two main review papers also provided insight into usage of multi-component solutions. This is important information. Many articles have stressed that interventions used alone are less effective than when used in combination. This is because patients often have multiple reasons for non-adherence and require multiple interventions for improving adherence.

Here is a list of multi-component solutions taken from the two major reviews. Once again, the figures in the cells reflect the number of studies.

Multi-component SolutionsCR 2008AIM 2012
Patient education + Counseling + Patient follow-up + Reminders11
Patient education + Counseling + Patient follow-up1
Patient education + Patient follow-up + Adherence packaging1
Patient education + Patient self-management + Simplification1
Patient education + Patient self-management1
Patient education + Patient Follow-up31
Patient education + Counseling1
Counseling + Patient follow-up1
Patient self-management + Patient follow-up1
Patient follow-up + Positive reinforcement1

In terms of frequency of inclusion in multi-component solutions:

  • Patient education appears 7 times
  • Patient follow-up 7 times
  • Counseling 4 times
  • Patient self-management 3 times

Improving Adherence – Putting It All Together

So now the rubber hits the road! What happens when we try to align the above proven interventions with the top ten non-adherence reasons from Part 1?

Firstly, an explanatory comment. Studies that underlie the proven intervention list were carried out in general patient populations. Patients in these studies were not pre-identified as having non-adherence reasons that matched the interventions being tested. So there’s no direct “one-to-one” alignment. Assigning interventions to reasons therefore required a certain amount of personal judgment.

What follows is a first pass at what such an interventions-to-reasons alignment might look like.

Aggregated ReasonAligned Proven Interventions
ForgetfulnessReminder calls and alerts; Family education (to remind patients)
MotivationMotivational interviewing; Positive reinforcement; Patient education; Counseling; Follow-up
CostCost mitigation (eg, VBID)
LifestyleNone identified from recent major reviews
Communications qualityImproved HCP communications (eg, training)
Patient-HCP relationshipImproved physician-patient communications; Improved patient-physician trust; Shared decision making; Positive reinforcement
BeliefsPatient education; Improved patient-physician communications; Counseling
Side effectsCounseling; Patient education; Follow-up
Patient experiencesCounseling; Patient education; Follow-up
AccessCost mitigation (eg, VBID)
Understanding/KnowledgePatient education; Improved physician-patient communications; Counseling; Follow-up; Case management

So out of the top eleven reasons, we can line up matching interventions in all but one – lifestyle. Of course that’s not to say there are not possible answers to this issue out there somewhere. There’s just nothing contained in the two main adherence review papers.

So what do you think about this alignment? Does it make sense? Are there things you’d put in different places? I’d really like to get your comments.

Some Final Comments

I strongly believe this approach of aligning interventions to patient non-adherence reasons is a key way to move forward for improving adherence. It’s a patient-centric approach that boosts chances of better adherence, because efforts are tailored to individual patient needs. However, among all the 750+ adherence publications I’ve read in recent months, I’ve only come across ONE PAPER that included pre-identification of reasons for non-adherence into its methodology. What’s extremely encouraging though is that this study showed significant improvements in adherence. Improvements which are specially noteworthy, as prior studies of similar interventions – used in a non-tailored fashion – failed to show benefits.

I’m surprised that more adherence intervention studies have not been designed this way? (You may know of more, if so please let me know.) Using general patient populations for intervention studies must surely dilute prospects of getting a positive result? And it cannot be that difficult to pre-select subject populations? Or maybe I’ve wrong here?

In designing a practical blueprint on best practices for improving adherence (see here), guidance on how best to align interventions with reasons must play a central role. Of course, then HCPs would need to better ‘diagnose’ reasons for non-adherence. But that’s a topic for another day!

Hope you have found this useful?

Improving Adherence – Aligning Interventions to Reasons, pt1

Improving adherence depends on identifying specific patient reasons for non-adherence, then choosing the right intervention(s) to address them. This is part one of a two-part post that explores how this can be achieved in everyday practice.

Some posts are easy to write. You get an idea – often sparked by a new piece of information – and away you go! This two-part post is different. It has taken research time and taken still more time to think through. Even now it’s a “work in progress”. However, I would like to share these early ideas with you, to get comments and feedback.

To be most effective, interventions for improving adherence must align with individual patient reasons for nonadherence.Practical Thoughts about Improving Adherence

Firstly, let me lay out the key points on which these ideas are built. Also, as a general note, the term “reasons” is used below as a catch-all for any factor, barrier, reason, or cause that influences non-adherence.

  1. To be most effective, interventions for improving adherence must align with individual patient reasons for non-adherence
  2. The current, most comprehensive list of non-adherence reasons is so long (55 items) it’s difficult to use
  3. The five ‘Dimensions’ in this list reflect reason sources and don’t relate to solutions
  4. The literature currently does not offer any comprehensive guidance for aligning reasons with solutions

In short, there’s very little out there that offers healthcare providers (HCPs) practical guidance for aligning interventions to reasons. Developing such guidance can help HCPs choose the right interventions for improving adherence. Availability of such guidance can also be a big help to HCPs looking to set up or improve adherence-related processes in their day-to-day work.

Aggregating and Prioritizing Adherence Reasons

This posts focuses on reasons, with two main aims:

  1. To look for ways to simplify the current long list of reasons (eg, aggregation). We need a shorter list than 55!
  2. To look for hard data on the most common reasons for non-adherence (ie, prioritize). If we know the ‘top ten’, then we can check we’ve got good interventions to address them.

Web searches produced over 60 ‘hits’ for reasons influencing non-adherence. Of these, nine publications provided quantitative data. All sources were considered in developing the “aggregated reasons” list shown in the table below. A combined analysis of the eight hard data sources produced the “mean % impact” figures and ranking.

A list of the nine data studies appears at the foot of this post. If you have suggestions to add to this list of studies/surveys, please let me know!

Based on these analyses, here’s a ranked ‘top ten’ reasons for medication non-adherence:

'Top Ten' Aggregated ReasonsMean % Impact on Nonadherence
Forgetfulness31%
Motivation27%
Cost22%
Lifestyle21%
Communications quality19%
Patient-HCP relationship12%
Beliefs12%
Side effects11%
Patient experiences10%
Access10%
Understanding/Knowledge8%

OK, so you’ve probably noticed there are 11 items in the list! The reason for including the 11th is to offer an important comment. At first sight, the 8% figure for ‘Understanding/Knowledge’ looks low. Particularly if you consider that patient education is one of the most commonly used interventions for improving adherence (more about this in Part 2). Poor ‘Understanding/Knowledge’, though, is a key contributing factor to poor motivation, mistaken beliefs, and poor attitude. Combining all these reasons might easily make ‘Understanding/Knowledge’ the most common factor influencing adherence. However, interventions to address understanding, motivation, beliefs, and attitude will most likely be different. So for the list above, I’ve kept them separate.

Hope this makes sense?

If you would like to get a copy of how I arrived at the list and percentages above, send me an email request at: steve.morris@adherence360.com. I’ll be happy to share with you the Excel spreadsheet file of my workings.

Improving Adherence – ‘Work in Progress’

So that’s the first part of this two-part post.

I’d appreciate your thoughts on the approach? Also what are your thoughts on the list above? Does it ‘look right’? Is it what you would have expected? Is anything ‘obvious’ missing? Please let me know. Any other comments welcomed too!

In part 2 of the post, I’ll focus more on the interventions side of the equation. Plus, I’ll look at matching up reasons to interventions.

 

Links to Source References for Quantitative Data

AARP Survey, 2004
Improving Medication Adherence in Older Adults

BCG/Harris Survey, 2002
Patient nonadherence: Tools for Combating Persistence and Compliance

HealthPrize Survey, 2013
Improving Adherence Requires Addressing Psychological Barriers

NCPA Survey, 2013
Adherence in America – A National Report Card

N Engl J Med Review, 2005
Adherence in Medication

Am J Pharm Benefits Study, 2013
Barriers to and Facilitators of Medication Adherence

JAMA Intern Med Study, 2013
Communication and Medication Adherence: The Diabetes Study of Northern California

United Health Survey, date uncertain
Adherence Barriers Survey

Medical Care Meta-analysis, 2009
Physician Communication and Patient Adherence to Treatment: A Meta-analysis