Improving Adherence – Aligning Interventions to Reasons, pt 2

By | November 8, 2013

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?