Monthly Archives: March 2014

Patients’ Adherence Decision-Making: The Roles of Emotion and Logic

For patients, adherence decision-making is based on a mix of emotion and logic. Understanding where an individual patient’s balance point lies and responding appropriately could be a major key to better adherence.

Roles of Emotion and Logic in Decision-Making

If asked whether your decision-making processes leaned more on logic or emotion; what would you say? I’d guess most of us believe our decisions emerge from a rational and logical consideration of the options. You may be surprised to learn this does not appear to be the case.

There’s a growing body of opinion that decisions are emotional, not logical. A champion of this view is the USC neuroscientist, Antonio Damasio. He argues that emotion and feelings are not in opposition to reason. Instead, he proposes they provide essential support for the reasoning process (see here).

Damasio supports this view with the following observations (see here):

  • Patients with damage to the brain’s emotional center cannot make even simple decisions
  • Pure thought, free from emotion, is less useful than generally assumed
  • Personally beneficial decision-making needs emotion as well as reason
  • The brain ‘decides’ among choices by ‘marking’ one option as more emotionally important

So how does all this effect adherence decision-making?

The rest of this post examines this question from the patients’ perspective. While a future post will consider the other side of the coin; focusing on HCPs’ balance of logic and emotion when seeking to improve adherence decision-making.

Patients' adherence decision-making mixes emotion with logic. Responding appropriately to an individual patient's 'mix' may be a key to better adherence.Patients’ Adherence Decision-Making – Where Does the Balance Lie?

With respect to adherence decision-making, my starting assumption is it that patients act just like people. So – like all of us – they need to combine emotion with logic to make ‘good’ decisions.

However, patients treated for chronic illnesses often deal with exaggerated emotions, beyond the ‘normal’. For example, such a patient may:

  • Have an impaired self-image (eg, stigma of illness, restricted lifestyle)
  • Present irrational biases (eg, emphasize present treatment discomforts over future health benefits) – see here for more on biases
  • Feel a lack of motivation (eg, low feelings of treatment necessity, high perceptions of treatment concerns)

The emotions triggered by these factors may in part explain why levels of intentional non-adherence are so high. For instance, intentional non-adherence rates of 40%-80% have been reported (see here and here).

Patients treated for chronic illnesses are where non-adherence rates are the highest. And for these patients, it’s likely that emotion reasoning plays a greater role in adherence decision-making.

Implications for Improving Adherence Decision-Making

How does all this impact the way HCPs go about approaching the task of improving patient adherence? As chronically ill patients have more emotional reasoning behind their non-adherence, shouldn’t HCPs response in kind?

If emotions drive non-adherence, then logical arguments to improve adherence are unlikely to gain traction. Patients won’t make the ‘right’ decision because it is logical. They’ll make the decision to adhere because they feel it’s to their advantage to do so. The HCP’s role is to help them feel this way.

As an example, the aim of Motivational Interviewing (see here) is to help a patient discover their own internal motivation to adhere. Maybe that’s one route to consider?

How else might HCPs address emotional reasons for non-adherence?

Addressing Adherence: The Need to Prioritize

Is enough rigor put into identifying the causes of non-adherence? Or into prioritizing these causes? Addressing adherence issues in the right order could have a major impact on improving adherence.

Adherence and Diagnostic Rigor

HCPs make clinical diagnoses based on a defined, rational process. Typically the process involves an examination of different inputs, such as patient history, physical signs, symptoms, and diagnostic test results. These findings are matched against possible causes and a diagnosis is made.

So should a similar diagnostic rigor be applied to addressing adherence issues?

Given the huge impact non-adherence has on outcomes and costs (see here, opening paragraphs), there are strong reasons why the answer should be “yes”!

Challenges of Addressing Adherence

When dealing with clinical conditions, usually there’s a linear correlation between a specific set of inputs and a singular ultimate diagnosis. When addressing adherence issues, the situation is not so clear-cut. Here are a few reasons why:

  • A patient may have several different reasons for non-adherence
  • These  reasons may carry different ‘weights’ in terms of their importance
  • Reasons may be emotional as well as practical
  • Reasons may be irrational as well as rational
  • Patients may keep some reasons for non-adherence hidden

Plus, here are other important challenges associated with adherence:

  • Addressing adherence issues in the right order could impact adherence improvement. Greater focus is needed on prioritizing non-adherence reasons.Because a patient often has more than one reason for non-adherence, HCPs must also consider prioritizing these reasons
  • Because reasons can be emotional and irrational, they can be tough for HCPs to cope with or overcome
  • Innate patient lack of motivation could be a critical hidden reason for non-adherence that HCPs may need to ‘dig for’ – over 40% of non-adherence has been reported as intentional (see here)

So there are a few ‘twists and turns’ associated with addressing adherence. One thing is for sure, there are few simple, linear solutions. If there were, we’d be making faster progress than we are!

Addressing Adherence by Prioritizing Certain Reasons

When looking to improve adherence – the order in which HCPs address reasons for non-adherence can play an important role. Here’s an example.

In discussion with his/her HCP, a patient readily volunteers two reasons for non-adherence:

  • I don’t understand what good this medication is doing for me
  • My schedule is demanding, I find it hard to remember to take my tablets

Through further guided discussion with the patient, the HCP determines that:

  • The patient has very low motivation to adhere with prescribed medication

Here are two possible ways a HCP might go about addressing adherence with this patient.

Option #1 – Prioritize Education

The HCP prioritizes efforts to educate the patient about his/her condition, its consequences, and the importance of adherence. Through this education, the HCP expects the patient will feel more motivated to adhere.

The HCP also suggests aligning tablet taking with regular daily events (eg, taking breakfast or brushing teeth) and suggests use of a mobile phone app – both with the goal of overcoming forgetfulness.

Option #2 – Prioritize Motivation

The HCP prioritizes directly improving patient motivation through (say) use of Motivational Interviewing techniques. By first building stronger internal patient motivation, the HCP has a higher expectation that educational efforts will be effective in further strengthening motivation.

Similarly, because of stronger motivation, the HCP has a greater expectation that daily structure and the reminder app will overcoming the patient’s forgetfulness.

Which approach makes more sense?

In previous posts, I’ve made the case for patient motivation being a prime focus when addressing adherence (see here, and here). If motivation is of prime importance, then option #1 runs that risk the patient will not be motivated enough to follow through on either the education or reminder interventions.

On the other hand in option #2, motivation is addressed up front; creating a higher likelihood of success with the other two interventions.

I guess it’s clear where my sense of things lies. What about you? Which approach do you think makes more sense? And why?

Behavioral Economics: A Promising New Way to Improve Adherence

Behavioral economics describes and predicts how common biases influence our decision-making. An understanding of these biases opens up promising new ways to improve adherence. Read on to find out more.

Patient motivation is a key factor for improving adherence. My last post presented reasons for including Motivational Interviewing into any adherence improvement plan; to boost patients’ internal motivation to adhere. Now here’s another way to approach the motivation issue. An approach that combines behavioral economics with elements of gaming to engage and motivate patients.

Behavioral economics describes how common biases influence our decision-making. Understanding these biases opens new opportunities to improve adherence.The Value of Behavioral Economics to Adherence

Truth be told, we all make irrational decisions. It’s the way humans are built. When we’re deciding between options, we unconsciously combine logic with emotions, feelings, and past experiences to make our choice.

From studying the mistakes people make, behavioral economics concludes we’re predictably irrational in our decision-making. We show common and consistent biases in the ways we select and analyze information.

Here are a few examples of such biases (there are many, many more!). People tend to:

  • Overestimate small probabilities (overestimation bias)
  • Favor short-term gains over longer-term rewards (present bias)
  • Prefer avoiding loss over acquiring gain (loss aversion bias)
  • Favor information that’s most readily available (salience bias)
  • Opt for a supplied choice when decisions are complex (default bias)
  • Continue to do something, rather than change to something else (status quo bias)
  • Follow others in their decisions (herding bias)

From a deep understanding of the bias factors that influence our decisions, behavioral economics goes one stage further. It offers a systematic way to think about incentivizing behavior change. An approach that offers strong promise for improving adherence.

Here’s a great example! Follow this link and read the short case study on pages 43-44. Warfarin non-adherence was reduced dramatically using a combination of the first three biases described above (ie, overestimation, present, and loss aversion biases). This case study also uses gaming to enhance patient engagement and make it fun!

5 Reasons Behavioral Economics Offers Promise for Adherence

Behavioral economics is a newcomer to adherence, so there’s little data in the public domain. However, the two studies mentioned directly below were positive. Also, anecdotal reports from other programs are equally encouraging. Here are 5 reasons behavioral economics approaches could make big impacts on adherence.

1.   They appear to work!

The warfarin program cited earlier in this post reduced non-adherence from 36% to 3%-4% (see here, pages 43-44).  

Another 3-arm study examined adherence to weight loss interventions. Arm #1 received lottery-based incentives (overestimation bias), arm #2 had deposit contracts (loss aversion bias), while arm #3 received just information and advice (control group – no incentives). Further details can be found here, page 44. Here’s a summary of study results:

“Only 7% of participants in the control group achieved their weight loss goals, while 71% of those in the lottery incentive group and a very impressive 100% of those in the deposit contract group achieved their weight loss goals.

2.   They’re fun!

It’s no fun having a chronic condition. Nor is it fun taking treatments on a daily basis. There is nothing inherently positive about these things. For many people, taking medication is a dreaded act (see here). Behavioral economics provides immediate rewards, gaming, and social contact. All of which bring fun and motivation to the act of adherence. 

3.   They strengthen perceived value

Along with rewards for taking their medication and refilling prescriptions, patients also get rewards for taking educational quizzes. These quizzes are designed to help patients get smarter about their disease. They also help patients better appreciate the value of medications and the value of adherence.

4.   They minimally consume HCPs’ time

HCPs are overworked nowadays. They lack the time to invest in counseling patients to improve their adherence. HCPs need solutions that can relieve the pressure on them. Which is what behavioral economics approaches can provide. As an example, take a look here for the benefits that one company provides to physicians.

5.   They’re broadly applicable

Because of the way they are constructed, there are very few inherent restrictions on the patient types for which behavioral economics approaches are applicable. They can be effective irrespective of reason(s) for non-adherence.

Behavioral economics: What are your thoughts about its role in adherence?

Motivational Interviewing: 6 Reasons It’s Key to Adherence

Patient motivation is a critical to the success of any adherence intervention. Without it, patients lack the energy or desire to follow through on recommended solutions. Here are 6 reasons to make Motivational Interviewing a cornerstone of adherence improvement.

Patient Motivation Is Pivotal

My last post described patient motivation as the ‘fuel’ needed to drive an ‘adherence improvement engine’ (see here for the full story). Without this ‘fuel’, adherence improvement plans may never really have a chance.

Lack of motivation has always been recognized as a factor in non-adherence. However, the ‘fuel’ analogy throws into sharper focus just how important a factor motivation can be. It’s like a veto, with the power to negate any plan a HCP puts together to improve adherence.

So patient motivation should always be a front-of-mind for concern in non-adherent patients. And if motivation is poor, it needs to be addressed before tackling any other factors contributing to non-adherence.

And one way to build motivation is through the use of the Motivational Interviewing.

Building patient motivation is vital to improving adherence. Here are 6 reasons why Motivational Interviewing should be the first step.Motivational Interviewing: The Headlines

As a quick introduction, Motivational Interviewing is a collaborative counseling style that uses special techniques to strengthen a person’s own motivation and commitment for changing their behavior. It’s an established approach for addressing substance use disorders and has successfully been used to address motivation-related adherence issues.

Further information about Motivational Interviewing can be found here.

Motivational Interviewing: Reasons to Make It an Adherence Cornerstone

Here are 6 reasons for HCPs to use Motivational Interviewing (MI) as an early and fundamental part of plans to address non-adherence.

1. MI Works!

Motivational Interviewing has been the subject of two meta-analysis/review publications (see here and here). The first reviewed and analyzed results from 72 randomized, controlled trials and found MI had a significant and clinically relevant effect in 74% of these studies. The second publication focused just on the impact of MI on medication adherence. It reviewed and analyzed results from 26 studies (5216 patients) and found an effect size of 0.34 (p<0.001).

2. MI Is Widely Applicable

The techniques of Motivational Interviewing are broadly applicable across different patient types and different conditions. Unlike other narrower, more focused adherence solutions, its effectiveness is not tied to specific patient reasons for non-adherence.

3. MI Helps Assess Patient Motivation

Motivational Interviewing techniques allow HCPs to quickly assess a patient’s motivation level. If poor, MI-based conversation helps the patient discover internal motivations to adopt adherent behaviors. These internal motivations may then make the patient more willing to follow the HCP’s recommendations for other adherence support solutions.

4. MI Has Sustainable Effects

Motivational Interviewing elicits a patient’s own motivation to adhere. Because motivation comes from within, it has a higher prospect of being sustained by the patient. Especially if MI techniques continue to be the centerpiece of regular doctor-patient conversations.

5. MI Can Be Delivered in Small Bites

Motivational Interviewing techniques can be easily included into routine patient conversations. Indeed, several studies have shown adherence benefits based on individual MI-based discussions lasting between 5 to 15 minutes (see here, here, and here).

6. Bonus Reason: MI Provides a Long-Term Skill Enhancements

Motivational Interviewing has wider applications than just adherence improvement. Clinical interviewing competency has for the longest time been a key HCP skill. With the increasing move to patient-centered care and shared decision-making, the need to improve and expand these skills has grown ever more important. Training in MI provides HCPs with significant additional skills that will help them better navigate the new requirements of patient conversations. Skills that will remain of value over the longer-term. Indeed, MI is increasingly recognized as a valuable skills asset (see here for an article on Aetna’s investment in MI).

Disclaimer: Just in case you’re wondering; no, I don’t have any vested interest in MI. All of the above is simply based on my extensive reading of adherence-related subject matter.