Monthly Archives: February 2014

How Can HCPs Improve Patient Motivation to Adhere?

Lack of patient motivation is a major barrier to adherence; one that may be under-recognized and under-addressed. Yet highly effective ways exist to both assess and improve motivation to adhere. This post explores the available tools to improve patient motivation.

Is Patient Motivation an Adherence Deal Breaker?

My last post explored the importance of patient motivation as an adherence factor. It concluded that lack of motivation to adhere can be a deal breaker; if unrecognized or not addressed by healthcare professionals (HCPs).

Patient motivation to adhere is an under-addressed issue. Use of motivational interviewing and behavioral economics can help HCPs tackle this problem.Why is that? Well consider this analogy.

When faced with non-adherence, HCPs develop plans for how to change a patient’s adherence behaviors. Such plans often have several different components. For example, a plan could comprise counseling, patient education, reminders, and cost reduction measures. Let’s say this plan is like an ‘adherence improvement engine’, where all the parts need to work together smoothly and effectively.

To continue this analogy ‒ engines need fuel, which is where patient motivation comes in. Motivation is the gas or electricity that makes the engine work. It’s tough for patients to change their adherence behaviors; they need to be very motivated. Without patient motivation to adhere, an HCP’s plan may never really get off the ground.

If patient motivation is such a deal breaker for adherence, should it not receive greater attention? Indeed the case can be made that assessing patient motivation should be front-of-mind for HCPs when faced with non-adherent patients. And if motivation is lacking, then HCPs need to address this before tackling other factors contributing to non-adherence.

Patient Motivation to Adhere Can Be Simply Assessed

As the overall goal is to change a patient’s adherence behaviors, a useful surrogate here is to assess ‘readiness to change’. An easy way to evaluate readiness to change can be found here.

The patient is asked to rate his or her willingness to change their adherence-related behaviors using a 0-to-10 scale. Zero on the scale equates to the patient being ‘not ready’. While 10 means the patient is ‘ready to change’.

Once the patient provides a ‘readiness score’, the authors then suggest how a conversation can progress. For example, if the patient score is a 3, a follow-up to emphasize positive progress might be: “Why did you choose 3 and not a 1?” Another question to promote stepwise progress could be: “What would need to happen for you to choose a score of 5?”

This simply approach can provide valuable insights on how to further strengthen a patient’s resolve to change their behaviors.

Just how important a factor is patient motivation? Here are some thoughts on why it's of primary importance to improving adherence.Two Ways to Enhance Patient Motivation to Adhere

So a patient’s willingness to change adherence behaviors can easily be measured. But what do HCPs do if motivation is lacking?  Well, there are at least two approaches that HCPs can use to improve a patient’s motivation to adhere. These approaches are summarized below.

1.      Motivational Interviewing

Motivational interviewing (MI) is a well-known, scientifically tested, counseling style that was first described in 1983. MI uses special techniques to facilitate collaborative conversations that strengthen a person’s own motivation for and commitment to change.

MI is an established approach for treating persons with substance use disorders. It has also been used successfully to address motivation-related adherence issues in several different disease areas.

The effectiveness of MI techniques in improving adherence is summarized in two separate meta-analyses publications (see here and here).

Some key characteristics of MI are:

  • It respects the patient’s autonomy
  • It involves directive and client-centered counseling
  • It identifies and mobilizes the patient’s intrinsic values and goals to foster behavior change
  • Motivation to change behavior is elicited from within the patient, not imposed by others

2.      Behavioral Economics

Behavioral economics (BE) is a newer field; though one that offers strong promise for improving patient motivation to adhere. BE is based on the proposition that while human decision-making is often irrational; people are in fact predictably irrational. For example people will tend to:

  • Be biased towards overestimating small probabilities
  • Favor short-term rewards over longer-term rewards (present bias)
  • Prefer avoiding loss over acquiring gain (loss aversion bias)

For an example of how such ‘predictable irrationalities’ can be used to enhance adherence, I’d strongly recommend you take a look here (see pages 43-44). In this case study, non-adherence of the blood thinner warfarin was reduced dramatically using a combination of the three biases described above.

In addition to the three listed above, many other biases have been described. And from an understanding of these behavioral cues, it’s possible to construct other incentives that enhance patient motivation to adhere.

So the tools to assess and improve motivation are available. What can be done to increase their use? I’ll go into this more in later posts.

What other approaches to improving patient motivation to adhere can you think of?

5 Reasons Why Patient Motivation Is Vital for Adherence

It’s widely accepted that patient motivation is a factor in non-adherence. But just how much of a factor is it? And how does it rank vs other factors? Here are some thoughts on why patient motivation is of primary importance to improving adherence.

Improving Adherence Behaviors Isn’t Easy

I’d guess we’re all familiar with the old joke about psychiatrists and light bulbs. It goes something like this:

Q. How many psychiatrists does it take to change a light bulb?
A. Only one, but the light bulb really has to WANT to change.

The point at issue here is that getting people to change behaviors is not easy. Behavioral change only works if people really want to do it. And patients need to be strongly motivated to make a change happen.

Many articles on adherence focus on practical measures, such as:

  • Patient education
  • Cost reduction
  • Patient reminders

These measures may work fine … if patient motivation is strong. But what about the large numbers of patients who intentionally don’t adhere? If anything, such patients are motivated NOT to adhere. And these may account for over 40% of the non-adherence population (see here).

Even among more positive patients, it’s generally accepted that just telling people what to do isn’t always enough. Simply loading patients up with education, copay cards, and reminders doesn’t predict adherence (see here). These measures only work well when patients are motivated.

Whichever way you look at it, patient motivation looks like a critical factor.

Reasons to Think About Patient Motivation First

Just how important a factor is patient motivation? Here are some thoughts on why it's of primary importance to improving adherence.So here are 5 reasons for putting patient motivation at the top of the list for things for HCPs to consider, assess, and act upon:

1.      Patient motivation is essential to behavior change

Improving patient adherence means changing patient behaviors, which can be tough. Improvements in adherence behaviors are unlikely to occur unless patients are highly motivated and have a strong intent to make the necessary changes. Motivation is cited as a pivotal element for changing adherence behavior (see here).

2.      Patients need help to find their motivation(s)

To acquire and sustain new adherence behaviors, patients must find their motivation(s) from within themselves. And often this is not be easy for them to do. By having motivation front-of-mind and by using available motivational techniques (more about these in a later post), HCPs can play a key role in unlocking an individual patient’s commitment to change.

3.      Motivational techniques are effective in improving adherence!

Here are a few publications that underline this point.

  • See here for a 26 study meta-analysis that found a statistically significant (p<0.001) benefit, with an effect size of up to 0.34
  • See here for benefit in patient weight reduction
  • See here for benefit in patients with high cholesterol
  • See here for benefits in patients with asthma

4.      Patient motivation is widely applicable

Indeed an argument could be made that motivational improvement is universally applicable, based on a report that suggested:

“For many people there is a negative psychological overlay to taking medication.”

Certainly, motivation can be an important factor for improving adherence across wide ranges of both patient types and conditions, irrespective of non-adherence reasons. This contrasts strongly with many other intervention types that are narrowly focused and associated with specific reasons.

5.      Motivation enhances effectiveness of other adherence interventions

Lastly – though by no means least – improving patient motivation can improve the effectiveness of other adherence solutions (see here).

Patient Motivation – The Bottom Line

So in summary, motivation looks like a BIG factor in adherence. And there are compelling reasons why improving patient motivation should be front-and-center for managing adherence across a wide variety of patient types and conditions.

Any other reasons you’d like to add?

Simplify Adherence by Identifying Patient Intentions

Progress to improve adherence has been frustratingly slow. Maybe there are just too many options and too much information; making understanding and interpretation difficult? We need to simplify adherence in order to make the breakthroughs needed. Identifying patient intentions can help achieve this.

Too Many Pieces in the Adherence Puzzle?

Improvements in adherence have been difficult to achieve and progress has been frustratingly slow. To what extent is this lack of progress a product of too much information? That’s a question I’ve been exploring in recent posts.

There are so many ‘moving parts’ in the adherence puzzle, it’s hard to make sense of it all. Plus, it’s tough to translate all the data into practical actions relevant to day-to-day clinical practice. In short, maybe there’s just too much ‘adherence clutter’ (see here)?

To make better progress we must simplify adherence. This can be done by reducing the number of ‘moving parts’. Say for example, we separate out the ‘necessary’ pieces from the ‘unnecessary’ (ie, the ‘clutter’). That’s a common approach to solving complex problems.

A previous post (see here) suggested how this may be done for HCPs; by aligning selected adherence interventions with their priority needs. Now in this post, we’ll take a similar approach with patients.

Simplify Adherence by Focusing on Patient Intents

Simplify Adherence by Cutting Through the Clutter

Simplify Adherence by Cutting Through the Clutter

“Patients are all different.” That seems to be the current governing theory. They have different reasons for non-adherence, which require different adherence interventions. As a theory, this may be true. However in practice such an approach may be just too complicated to work. The many pressures on HCPs’ time limit their ability to handle multiple different intervention types.

So is there another way to look at the patient side of things that can help simplify adherence interventions? How about if we distinguish between “verbalized” and “hidden” reasons for non-adherence?

By “verbalized”, I mean all the reasons that patients willingly offer for why they don’t adhere to treatment. These reasons are too many to list out here, but include things like: I don’t understand; too expensive; too complicated; I forgot; etc.

By “hidden”, I’m referring the reasons for non-adherence that patients most often don’t willingly share. Examples of such reasons may include: I choose not to adhere; I’m not motivated; etc.

This second category describes intentional non-adherence, which has been reported in over 40% of chronic medication patients (see here). It occurs frequently and deserves special attention. Especially as “not being motivated” to adhere likely has major knock-on effects on compliance with interventions for verbalized reasons too!

Here is one large group of non-adherent patients with a common issue – lack of motivation. A prime target for adherence simpification.

Simplify Adherence through Improving Patient Motivation

When patients aren’t motivated to change their behavior, they are much less likely to respond to standard adherence interventions such as simplification, education, cost reduction, or reminders. So for non-adherent patients, perhaps motivation should be the first thing to assess? Also, maybe improving motivation should be the first intervention to consider?

There are proven interventions for improving adherence motivation; for example motivational interviewing and gaming/behavioral economics. Can using such interventions first help simplify adherence? And more importantly help achieve that elusive goal of improving adherence.

Addressing motivation may be one broadly applicable approach to help simplify adherence. What about others? Any thoughts?

How to Simplify Adherence Choices for HCPs

Adherence ‘clutter’ – the sheer volume of data on the topic – can be overwhelming. Breaking through this ‘clutter’ to simplify adherence choices is vital to developing practical, everyday solutions that HCPs can use.

Breaking through the Adherence Clutter

My last post introduced the concept of “adherence clutter”. A term coined to describe the overload of information that surrounds the topic of medication adherence. This wealth of data can be so overwhelming; it’s hard to separate ‘the worthy’ from ‘the weak’.

So how can we break through this “clutter” and simplify adherence choices? A famous quote by the expressionist Hans Hofmann maybe offers one way to address this problem:

“The ability to simplify means to eliminate the unnecessary
so that the necessary may speak.”

Why It’s Necessary to Simplify Adherence for HCPs

Breaking through the ‘clutter’ to simplify adherence choices for HCPs is vital to developing practical, everyday solutions

Simplify Adherence to Overcome the Clutter

How can we separate the ‘necessary’ from the ‘unnecessary’? To address this requires a deeper dive into the needs of the two key parties involved ‒ the healthcare professional (HCP) and the patient.

For this post I’ll focus on the HCP and will follow-up on the patient at a later date.

HCPs are busy. They have many demands on their time. Perhaps too many? Administrative tasks, such as charting, ordering, filling out forms, and dictating, can take up a third of a physician’s workday (see here). All of which puts pressure on face-to-face time with patients.

What HCPs need is for someone to simplify adherence for them. Dare I suggest an ‘adherence for dummies’ type of approach?

Few HCPs have time to wade through all the data for all the many available adherence interventions. They need simple and effective adherence solutions. And ideally these should be solutions that work across a broad range of patient types (eg, different reasons for non-adherence and different diseases).

As an analogy, how many drugs does a doctor regularly use to treat a given chronic condition? My guess is probably somewhere in the range of 2-to-4? Should this become the guiding light to simplify adherence for HCPs? To focus on 2-to-4 relevant and effective adherence interventions?

Typically relevance (eg, high efficacy, good tolerability) is a key factor that influences choice of drugs an HCP will regularly use.  It’s likely that relevance (eg, efficacy and ease of use) will be a key factor in choice of adherence options too?

Practical Ways to Simplify Adherence for HCPs

Let the necessary speak!

Referring back to Hans Hoffman’s quote above, the ‘necessary’ factors to simplify adherence for HCPs could well be:

  • Identifying just 2-to-4 key adherence intervention types
  • That have broad patient applicability (eg, different non-adherence reasons, different conditions)
  • And are relevant (ie, have above average impact on adherence improvement and are easy to use)

That’s not to say that all other interventions are ‘unnecessary’. But perhaps they are ‘less necessary’ than these key interventions.

There will be more on the topic of broad patient applicability in a later post.