Adherence360 http://adherence360.com Exploring multiple viewpoints relating to improving medication adherence Wed, 09 Apr 2014 13:28:57 +0000 en-US hourly 1 https://wordpress.org/?v=4.4.10 7 Reasons HCPs Should Work Harder at Optimizing Adherence http://adherence360.com/2014/04/09/7-reasons-hcps-work-harder-optimizing-adherence/ Wed, 09 Apr 2014 13:28:57 +0000 http://adherence360.com/?p=827 Optimizing adherence has positive impacts on many aspects of healthcare, including outcomes, quality, and costs. When taken all together, these impacts provide clear incentives for HCPs to work harder to achieve better adherence. Optimizing Adherence and Outcomes of Care Many of you I’m sure are familiar with the ‘Physician Charter’, published in Annals of Internal Medicine in 2002 (see here). This multinational consensus drew on both European and U.S. expertise… Read More »

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Optimizing adherence has positive impacts on many aspects of healthcare, including outcomes, quality, and costs. When taken all together, these impacts provide clear incentives for HCPs to work harder to achieve better adherence.

Optimizing Adherence and Outcomes of Care

Many of you I’m sure are familiar with the ‘Physician Charter’, published in Annals of Internal Medicine in 2002 (see here). This multinational consensus drew on both European and U.S. expertise to create a set of 10 commitments. These commitments restate professional responsibilities in the context of challenges for the new millennium.

As a scene-setter for this post, I’ll focus on the commitment #5 from this ‘Charter’, which addresses quality of care. The essence of this commitment for physicians (and other HCPs) is as follows:

Work collaboratively with other professionals to reduce medical error, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care.”

(The emphasis above on outcomes of care is mine.)

There are many potential paths for achieving better outcomes. For the moment though, I’d like to address just one of them: to propose why HCPs should work harder at optimizing adherence.

7 Benefits of Extra Focus on Optimizing Adherence

Optimizing adherence has positive impacts on many aspects of healthcare; impacts that underline the importance of working harder to achieve better adherence.For patients with chronic conditions, optimizing adherence can significantly help in achievement improved care. Here are reasons why HCPs should focus more on this approach.

1.     Improved Treatment Success

When patients take medications as prescribed, the chances of treatment success (eg, lowering BP, reducing HbA1c levels) are markedly improved. This is not only good for the patient but also good for the HCP …

2.     Increased HCP Satisfaction

For HCPs, feelings of personal satisfaction can be elusive. Investing effort in optimizing adherence not only pays back in terms of improved treatment success. It can also pay back in terms of the increased sense of satisfaction HCPs may feel from a job well and fully done.

3.     Reduced Healthcare Costs

The pressures to control rising healthcare costs are huge. In a recent report (see here), the increased healthcare costs associated with non-adherence in the U.S. were estimated at $290 billion. Increased focus on optimizing adherence can help curb these extra costs, while also improving treatment success and increasing satisfaction. A win, win, win!

4.     Taking Responsibility for Adherence

It has been suggested (see here) that physicians see patients as being primarily responsible for adherence. In everyday practice though, patients need HCP help to get them on the right track. This is especially so when patients have motivational issues that undermine their intent to adhere. Optimizing adherence is shared responsibility between the patient and HCP. It’s vital however that the HCP steps up to take on his or her adherence responsibility to get things moving.

5.     Achieving HCP Rewards for Quality

As time moves forward, more emphasis will be placed on the ‘quality of care’ provided, as opposed to ‘quantity of care’. The exact measures of ‘quality’ will likely evolve over time, but will surely include components relating to outcomes and patient satisfaction. Outcomes are positively influenced by adherence. So there’s a direct relationship between adherence and quality; greater investment in the former can influence greater rewards through the latter.

6.     Adherence Tools Are Readily Available

To help HCPs in optimizing adherence, many different tools are available. These range from reminder apps for mobile phones, to web sites that engage and educate patients, to HCP training programs that help improve communication with patient and can also help in building patient motivation to adhere. These tools can work in concert with practice efforts to increase patient commitment to adhere.

7.     Better Treatment Outcomes

“Drugs don’t work in patients who don’t take them.”
C. Everett Koop

Physicians put a lot of effort and care into making the right diagnoses and prescribing the right treatments. But all that care is for nothing if patients don’t adhere. Investing a little more time to motivate and support the patient to adhere to treatment carries as much importance as the initial diagnosis and treatment choice. Only when medications are taken correctly and consistently over time will better patient outcomes be achieved.

The roles of physicians and other HCPs in fulfilling this vision are paramount.

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HCP Solutions to Poor Adherence: Should Logic or Emotion Be the Focus? http://adherence360.com/2014/04/02/hcp-solutions-poor-adherence-based-logic-emotion/ Wed, 02 Apr 2014 12:58:34 +0000 http://adherence360.com/?p=816 When HCPs address issues of poor adherence with their patients, where should their focus lie? Should it be more on logic or on emotion? Here are a few thoughts about why emotion should be front-of-mind. Two recent publications got me thinking again about the roles of emotion and logic in adherence-related decisions. This time from the HCP perspective. HCPs Show Poor Adherence to Treatment Guidelines A report from the Dartmouth… Read More »

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When HCPs address issues of poor adherence with their patients, where should their focus lie? Should it be more on logic or on emotion? Here are a few thoughts about why emotion should be front-of-mind.

Two recent publications got me thinking again about the roles of emotion and logic in adherence-related decisions. This time from the HCP perspective.

HCPs Show Poor Adherence to Treatment Guidelines

A report from the Dartmouth Institute (see here) examined variations in prescription use for Part D patients across the U.S.A. Data for the report came from a 40% random patient sample for years 2006 to 2010. For analysis, the authors divided medications into three classes:

  • Effective – those with evidence of benefit
  • Discretionary – those of uncertain benefit
  • Harmful – those where risks outweighed benefit

In summary, the analysis found wide regional variations in prescription use. It also found:

  • Lower than optimal use of effective meds
  • Common use of discretionary meds
  • Higher than expected use of harmful meds

These wide regional variations together with sub-optimal usage of medications suggest poor adherence by prescribers to guidelines. But what causes this poor adherence?

When deciding how to address issues of poor adherence, should HCPs focus more on logic or emotion? Here's why emotion should take priority.What Drives Poor Adherence by HCPs?

Some answers to this question can be found in a Medscape article (see here).

The article commented that despite efforts to promote evidence-based guidelines, often these are not applied. Some 30%-40% of patients do not do receive care according to present scientific evidence, while 20%–25% of care provided is not needed or potentially harmful.

The paper concluded that poor adherence to guidelines was associated with doctors’ subjective characteristics. Doctor attitudes, beliefs, experiences, knowledge, skills, and values were all cited as playing fundamental roles.

So doctors tend to go with what they feel, not what someone else tells them. Perhaps sounds familiar? It’s just like patient reasons for non-adherence to medications – driven more by emotion (ie, feelings, experiences, and beliefs) than by logic.

Which leads me back to my last post (see here) and the roles of emotion and logic in decision-making. This suggested that:

  • Emotion has a major role in decisions
  • Emotion tends to take the lead in decision-making
  • Logic is then used as post hoc rationalization

So if emotion leads, how does this affect the way HCPs should go about improving poor adherence?

Applying Emotional Approaches to Poor Adherence

We’ve all been in situations where we’ve delivered a bulletproof, rational proposal. One that was so solid, there was no way it could be turned down. But then the other person says “no” and rejects our arguments. He or she just wasn’t swayed by our logic.

That’s because decision-making isn’t logical, it’s emotional.

A major slice of patient non-adherence is intentional. They choose to be non-adherent. These patients override rational arguments with emotional feelings, beliefs, and personal experiences. Just as doctors may do when choosing not to follow treatment guidelines.

Bombarding these patients with more facts and more logic is unlikely to win the day. HCPs need to communicate at a more personal, emotive level.

Spend a little time. Engage with these patients. All with the aim of discovering internal motivators that can be used to improve adherence. Maybe something they care a lot about, or something they want to achieve? Or maybe something “fun” that gets them away from negative thoughts associated with their condition?

Something they care enough about that they’re prepared to adhere to treatment to get there.

There are approaches available that can help HCPs do this (see here and here).

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Patients’ Adherence Decision-Making: The Roles of Emotion and Logic http://adherence360.com/2014/03/26/adherence-decision-making-patients-emotion-vs-logic/ Wed, 26 Mar 2014 13:06:04 +0000 http://adherence360.com/?p=807 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… Read More »

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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?

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Addressing Adherence: The Need to Prioritize http://adherence360.com/2014/03/19/addressing-adherence-need-prioritization/ Wed, 19 Mar 2014 13:46:20 +0000 http://adherence360.com/?p=790 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… Read More »

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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?

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Behavioral Economics: A Promising New Way to Improve Adherence http://adherence360.com/2014/03/12/behavioral-economics-promising-new-way-improve-adherence/ Wed, 12 Mar 2014 17:17:25 +0000 http://adherence360.com/?p=783 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… Read More »

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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?

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Motivational Interviewing: 6 Reasons It’s Key to Adherence http://adherence360.com/2014/03/05/motivational-interviewing-6-reasons-key-adherence/ Wed, 05 Mar 2014 19:14:32 +0000 http://adherence360.com/?p=768 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… Read More »

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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.

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How Can HCPs Improve Patient Motivation to Adhere? http://adherence360.com/2014/02/26/can-hcps-improve-patient-motivation-adhere/ Wed, 26 Feb 2014 18:19:12 +0000 http://adherence360.com/?p=758 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… Read More »

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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?

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5 Reasons Why Patient Motivation Is Vital for Adherence http://adherence360.com/2014/02/19/5-reasons-why-patient-motivation-can-improve-adherence/ Wed, 19 Feb 2014 16:36:47 +0000 http://adherence360.com/?p=746 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… Read More »

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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?

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Simplify Adherence by Identifying Patient Intentions http://adherence360.com/2014/02/12/simplify-adherence-identify-patient-intentions/ Wed, 12 Feb 2014 15:22:29 +0000 http://adherence360.com/?p=740 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… Read More »

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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?

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How to Simplify Adherence Choices for HCPs http://adherence360.com/2014/02/05/simplify-adherence-choices/ Wed, 05 Feb 2014 18:43:58 +0000 http://adherence360.com/?p=725 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… Read More »

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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.

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