Monthly Archives: December 2013

Adherence Issues: Can Behavior Change Be a Game-Changer?

When physicians talk with patients about adherence issues, attitudes and behaviors should be important topics of discussion. Understanding the best ways to change attitudes and behaviors may be a vital step in improving adherence.

Attitudes, Behaviors, and Adherence Discussions

Discussions about adherence issues are rarely simple and straightforward.

Patients typically have many beliefs and attitudes that influence their adherence behaviors. Some of these may be openly shared. Others may be deeply buried and not so easy to get at.

The way a doctor – or other healthcare professional – feels about a patient may also influence his or her behaviors. For instance, here are possible back-stories to a doctor-patient discussion on adherence:

The patient struggles to come to terms with having a chronic illness. Being “permanently sick” affects their self-image. The patient worries the condition may restrict his lifestyle and fears possible social stigma. Sometimes it’s easier to just avoid the whole issue of being ill – particularly the burden of taking daily medications. The patient isn’t motivated and doesn’t take his medications. With the doctor, he is guarded and evasive. 

The doctor isn’t seeing the expected improvement in symptoms and suspects lack of adherence to prescribed medications. The doctor believes it’s the patient’s responsibility to take their medications and has negative feelings towards non-adherence. As a result, the doctor tends to be blunt and prescriptive with the patient.

Of course, this is a constructed scenario. However it illustrates how tricky adherence issues can be, when you factor in the individual attitudes and behaviors involved. In the situation painted above, how easy do you think it would be to get patient engagement? Let alone achieve better adherence?

Techniques like Motivational Interviewing are designed to change patient behaviors, so they directly address key adherence issues.Attitudes, Behaviors, and Solving Adherence Issues

It’s important to recognize that attitudes and behaviors are forces for both bad and good. The scenario above suggests how they may negatively influence discussion. Now let’s turn it around and look at how addressing patient attitudes and behaviors can help to solve adherence issues.

Non-adherence is a behavioral issue. In fact, more correctly it’s a behavioral change issue; the goal being to get patients to adopt adherent behaviors. Which begs the question: why hasn’t there been greater focus on behavior change approaches to improving adherence?

Effective methodologies are available and effective in increasing adherence.

Earlier this year, for example a meta-analysis of cognitive-based behavior change techniques (CBCTs) was published in the BMJ (see here).

The analysis was based on 26 studies, covering 7 medical conditions, and involving 5216 participants – mainly from the USA. In terms of impact on improving adherence, an effect size of 0.34 was calculated, which was statistically significant (p < 0.001). The authors concluded that:

“Cognitive-based behavior change techniques are effective interventions eliciting improvements in medication adherence that are likely to be greater than the behavioral and educational interventions largely used in current practice.”

Within this meta-analysis, the CBCT technique most commonly used was Motivational Interviewing.

Motivation to adhere, when evoked from within a patient, is more likely to result in sustained, durable behavioral change.Behavior Change Techniques: A Potential Answer to Adherence Issues?

Current interventions produce only limited improvements in adherence and/or are applicable only in specific situations. The bigger aim is to find interventions that provide substantial adherence improvements across multiple patient types and situations. CBCTs offer significant promise in this regard.

  • CBCTs change behaviors – a critical step in addressing adherence issues
  • CBCTs are effective independent of patient reasons for non-adherence
  • CBCTs are therefore broadly applicable to many different patient types
  • CBCTs can produce substantial and significant adherence improvements
  • Because solutions are drawn from the patient, CBCTs may foster more durable improvements in adherence

Motivational Interviewing is one of the most widely recognized CBCTs. It is designed to facilitate behavior change by resolving patient ambivalence about change. As a relevant footnote, Aetna has some 1800 clinicians and clinical support staff, who use Motivational Interviewing to help patients achieve better health (see here).

Maybe Aetna are setting a trend here. Should others pay heed to it?

Are We Ignoring Important Adherence Information?

What if all barriers to adherence are not created equal? The immensity of available adherence information may obscure core ‘veto’ barriers that negate common types of intervention. Exploring this idea opens up major new adherence insight opportunities.

Hidden Gems of Adherence Information

The immensity of available adherence information may obscure core ‘veto’ barriers that negate common types of intervention.It’s a common enough phrase, but how about if it applies to medication adherence? After years of research, have we gotten to the point where we can’t see the forest for the trees?

Here’s a simple example. If you type “medication adherence” into Google, you get around 4.25 million hits. As a crude estimate, it might take about 80 years to browse through this number of hits! That’s plenty enough space to ‘hide’ a few critical pieces of overlooked adherence information.

We still struggle to find effective interventions to improve adherence. So perhaps it’s time to look anew at what we know; to see if some approaches are much more important than was originally thought?

‘Veto’ Barriers and Where to Look for Them

Do ‘veto’ barriers exist? Some key pieces of adherence information suggest they might. For example, take a look at improvements in adherence rates seen with the following common interventions.

Patient education (with telephone and mail support): 6% in hypertension patients; 4%-6% in myocardial infarction patients (see here for both).

Cost mitigation/reduced patient copays: 4%-6% in post-myocardial infarction patients (see here), 2%-5% in diabetes, hypertension, hyperlipidemia, or congestive heart failure patients (see here).

As patient understanding and medication costs both feature regularly in reasons for non-adherence, surely we’d expect better than single digit improvements? Maybe not if there are higher, ‘veto’ barriers in play.

The concept of a ‘veto’ barrier is simple. It’s a barrier that is so important and so influential that it negates other adherence interventions. To effectively inhibit other interventions, it has to be present in broad patient populations. Which suggests such ‘veto’ barriers might be driven by the human mindset or psychology?

That seems like a good place to start.

A Fresh Look at Patient-focused Adherence Information

Adherence information suggests there may be higher, ‘veto’ barriers that negate many different types of interventions.So what can patient-centric adherence information tell us?

There’s plenty of evidence that patients often intentionally choose not to adhere to their medication regimens. It’s a conscious decision they make, for a variety of different reasons. For such patients, lack of motivation to adhere is a unifying factor.

I also guess we’d all agree that non-adherence is a behavioral issue. More specifically, it’s a behavioral change issue – involving the change from non-adherence to adherence. And health behavior changes are very difficult to achieve, which readily places them in a ‘veto’ barrier role.

Patient Motivation a Possible ‘Veto’ Barrier

So lack of patient motivation to change their adherence behavior may well be one ‘veto’ barrier. In which case, interventions to increase a patient’s motivation take on a critically important role. Indeed, the value of other types of interventions will be limited unless this – or any other – ‘veto’ barrier is not addressed first.

What about other potential ‘veto’ barriers?  Does different adherence information lead us to other ‘vetoes’? Any thoughts?