Addressing Adherence: The Need to Prioritize

By | March 19, 2014

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?