Adherence Approaches: What If We Have the Wrong Focus?

By | November 26, 2013

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?

One thought on “Adherence Approaches: What If We Have the Wrong Focus?

  1. AudibleRx

    Great analysis! Motivating patients to participate in their own pharmaceutical care is definiately the cornerstone to medication adherence. Patients with an increased Health Literacy will have a much better understanding of what they do and don’t know about their medical condidition so that they will be in a position to take educated questions back to their own health care providers. When a pateint understands their condition and their medications; they will also have a clear understaning of the consequences they may face if they do not treat their condition.
    Thanks for the post!
    Steve Leuck, Pharm.D.

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