Adherence Compliance Concordance:
             p
       Difficulties following medical advice




  Alex J Mitchell

  Ack...
“Adherence”

The extent to which the patients
 behaviour coincide with the clinical
 prescription/advice [ Haynes et al 19...
At Risk
                           Population

Does not attend / delays asymptomatic screening (if offered)


            ...
Types of Medication difficulty
Ladder of Discontinuation

                                   Full discontinuation
                                   Is u...
Poor Compliance is Normal (Barber et al)
 N Barber et al Patients’ problems with new medication for chronic Patients’ cond...
Types of Adherence Problems

 Initial vs follow up
   Refusal vs discontinuation
   Non-attendance vs drop out


 Partial ...
Overview
                               Medication Course Started                                Initial Treatment
       ...
Medication Course Started                                        Initial Treatment
                                       ...
Medication Course Started                                                          Initial Treatment
                     ...
Medication Course Started                                                          Initial Treatment
                     ...
Examples of Medication difficulty
Compliance: Rheumatoid Arthritis

       45
                                                      40.3
                   ...
Compliance: Hypertension

50%                                         44%

40%
                                           ...
The problem of poor compliance


      Patients not                                        90
      adhering by           ...
Medication Problems in Mental Health
Percentage of Patients Discontinuing Antipsychotics in
                     18month CATIE Trial


80
                     ...
Compliance challenges affect almost ALL
    patients*
                 Continuous Medication
                 ANY Days Wit...
Partial compliance increases with time
  % of Patients Partially Compliant




                                      80
  ...
Adherence in general clinical practice is poor

         Antipsychotics
         (3–24 months)
            (24 studies)
  ...
Predicting Medication difficulty
Why Do Patients Have Difficulty?

 With medication?

 With appointments?
          i t   t ?
Predictors of Difficulty with Medication


 Medication not working (efficacy)
 Medication harming (side effects)
 M di ti ...
Predictors of Difficulty with Appointments?

 Clinician not helping (efficacy)
 Clinician harming (criticism/hostile)
 App...
Perceived Benefits of Care             Perceived Costs of Care             Barriers to Care           Doctor-Patient Facto...
Adherence and Satisfaction

 Audience: what is the relationship?

   Higher rated treatment success => drop-out
          ...
Measuring Medication difficulty
Measurement of adherence


INDIRECT
Clinicians enquiry
Patient or relative report

DIRECT
Measurement of the medication
Me...
Different Ratings Different Results
          Ratings,

                             Two separate studies found that both ...
Consequences of Medication Difficulty
Poor Compliance Affects Rehospitalisation
Rates
                            Percentage of patients with a psychiatric admi...
Continuous vs intermittent maintenance: 1
year relapse rates

                                                  33
Carpent...
Relapse in 1st episode patients over
1 year: according to compliance

35
30
25
20                                         ...
Helping with Medication difficulty
4 Steps

 1 Basic communication
   Establish a therapeutic relationship and trust
   Identify the patient’s concerns
   Ta...
2 Strategy-specific interventions
  Strategy specific
  Adjust medication timing and dosage for least
  intrusion
  Minimi...
3 Reminders
 Consider adherence aids such as pill boxes
 and alarms
 Consider reminders via mail, email or
 telephone
    ...
4 Evaluating adherence
           g
  Ask about problems with medication
  Ask specifically about missed doses
        p  ...
Extras
Potential to Improve Relapse Rates
With Depot vs Oral Antipsychotics

                                                    ...
Degree of difficulty to produce adherence sufficient
for therapeutic effect

     Weight Reduction

         Schizophrenia...
Oral medication Tips

[ Churchill et al] proposed the following
   improvement strategies ;
   i            t t t i
Keepin...
Interventions to improve adherence

Osterberg et al 2005 grouped intervention in
  to four categories;
Patient education
 ...
Contd - 2

Further interventions studied include ;
Providing more information [ both written and oral
  material and progr...
Contd - 6

Other interventions ;
In a systematic review [ Bennett & Glaziou 2003 ]
  which included 26 RCTs of computer ge...
Conclusion

In a systematic review [ McDonald et al 2005 ] of
  RCTs f i t
  RCT of interventions to assist patient
      ...
Conclusion

Evidence for any single intervention to
 improve adherence is weak however a
 combination of educational, cogn...
LPT - Adherence To Medication And Appointments (Sept07)
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LPT - Adherence To Medication And Appointments (Sept07)

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This is an academic talk on the evidence base behind adherence (difficulty taking) prescribed medication. I gave this as a small talk from the local NHS trust in 2007.

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LPT - Adherence To Medication And Appointments (Sept07)

  1. 1. Adherence Compliance Concordance: p Difficulties following medical advice Alex J Mitchell Ack. Dr Shoka, Dr Shanka, Dr Selmes
  2. 2. “Adherence” The extent to which the patients behaviour coincide with the clinical prescription/advice [ Haynes et al 1979 ]. What Wh t if medical advice i wrong, di l d i is inadequate or missing? Sometimes, does the patient know best?
  3. 3. At Risk Population Does not attend / delays asymptomatic screening (if offered) Symptoms Delays Dela s or does not seek help (where available) Adherence and attendance Diagnosis are linked R l Reluctant to accept di diagnosis (if told) i Early Treatment Reluctant to start treatment (if offered) Follow Up Does not attend further appointments (if offered) Continuation Treatment Does not follow course as prescribed
  4. 4. Types of Medication difficulty
  5. 5. Ladder of Discontinuation Full discontinuation Is unmonitored Full Discontinuation 4 Trial discontinuation Is harmless Trial Di T i l Discontinuation ti ti 3 Missing odd doses has no adverse effects Partial non-adherence 2 Benefits are unclear Or hazards are clear Thoughts of stopping g pp g 1 Medication is costly or a hassle or linked with stigma 0 Concordant
  6. 6. Poor Compliance is Normal (Barber et al) N Barber et al Patients’ problems with new medication for chronic Patients’ conditions. Qual Saf Health Care 2004;13:172–175. Taking All Medication As Prescribed & Problem Free & with sufficient information 10% Taking some Medication As Prescribed & Problem Free Taking some Medication As Prescribed with Issues g Stopped taking medication against medical advice 10%
  7. 7. Types of Adherence Problems Initial vs follow up Refusal vs discontinuation Non-attendance vs drop out Partial vs Full vs Over Partial attender, takes some medication, takes too much medication
  8. 8. Overview Medication Course Started Initial Treatment N Refusal Y Course interrupted Discontinuation Missed Doses Extra Doses Conversion to discontinuation Full non-adherence u o ad e e ce Partial non-adherence a t a o ad e e ce
  9. 9. Medication Course Started Initial Treatment N Refusal Y Course interrupted Discontinuation Missed Doses Extra Doses Conversion to discontinuation Full non-adherence Partial non-adherence Patient i h d to t P ti t wished t stop t ki taking medication? di ti ? P ti t wished t adjust medication d Patient i h d to dj t di ti dose? ? Y Y N N intentional Non intentional Intentional Non-Intentional External Internal External Internal Explanation
  10. 10. Medication Course Started Initial Treatment N Refusal Y Course interrupted Discontinuation Missed Doses Extra Doses Full non-adherence Partial non-adherence Patient wished to adjust medication dose? Patient wished to stop taking medication? Y Y N N intentional Non intentional Intentional Non-Intentional With medical advice?* External Internal External Internal With medical advice?* Barrier Lapse or Slip Barrier Lapse or Slip Y N Y N Collaborative Self Directed Self-Directed Collaborative Self Directed Self-Directed Based on adequate information? Based on adequate information? N Y N Y High Risk of Harm Low Risk of Harm High Risk of Harm Low Risk of Harm * Advice implies consultation and discussion of risk and benefits not necessary sanction to act
  11. 11. Medication Course Started Initial Treatment N Refusal Y Course interrupted Discontinuation Missed Doses Extra Doses Conversion to discontinuation Full non-adherence Partial non-adherence Patient wished to adjust medication dose? Patient wished to stop taking medication? Y Y N N intentional Non intentional Intentional Non-Intentional With medical advice?* External Internal External Internal With medical advice?* Barrier Lapse or Slip Barrier Lapse or Slip Y N Y N Collaborative Self Directed Self-Directed Collaborative Self Directed Self-Directed Based on adequate information? Based on adequate information? N Y N Y High Risk of Harm Low Risk of Harm High Risk of Harm Low Risk of Harm * Advice implies consultation and discussion of risk and benefits not necessary sanction to act
  12. 12. Examples of Medication difficulty
  13. 13. Compliance: Rheumatoid Arthritis 45 40.3 40 3 40 35.7 35 Consistently 30 Compliant 23.8 25 Consistently Non- % 20 compliant 15 Other - ?partial compliance 10 5 0 •556 pts with RA followed for 3 years •Compliance assessed annually by interview Viller F et al. J Rheumatol. 1999;26:2114-2122.
  14. 14. Compliance: Hypertension 50% 44% 40% Very Regular 30% 25% Regular 20% 20% Irregular Forgetful 10% 2% 0% Mallion et al, J Hypertension, 1998
  15. 15. The problem of poor compliance Patients not 90 adhering by 80 disease area Arthritis (%) 55 Epilepsy Hypertension 40 40 Diabetes 35 Asthma Contraception p Whitney HAK et al. Annals of Pharmacotherapy 1993.
  16. 16. Medication Problems in Mental Health
  17. 17. Percentage of Patients Discontinuing Antipsychotics in 18month CATIE Trial 80 74 70 60 50 40 29.9 30 23.7 20 14.9 14 9 10 5.5 0 Other Intolerability Lack of Efficacy Patient Decision Total Discontinuations
  18. 18. Compliance challenges affect almost ALL patients* Continuous Medication ANY Days Without Medication Mean Number of Days Without Medication 100 5.2% 7.1% 94.8% 350 92.9% 80 300 250 60 nts s Days 200 Patien (%)) 40 150 110.2 125.0 100 20 50 0 0 Atypical Conventional Atypical Conventional n = 349 n = 326 n = 349 n = 326 Mahmoud et al, 2004. Clin Drug Invest:24(5):1
  19. 19. Partial compliance increases with time % of Patients Partially Compliant 80 70 75% C 60 50 40 Up to 25% p 50% 30 20 10 o 0 7-10 Days* 1 Year † 2 Years † Time From Discharge Keith & Kane. J Clin Psychiatry 64:11; 2003
  20. 20. Adherence in general clinical practice is poor Antipsychotics (3–24 months) (24 studies) Antidepressants p (1.5–12 months) (10 studies) Non-psychiatric (0.25–10 months) (12 studies) 0 20 40 60 80 100 Adherence (%) Wide range of estimates across studies may reflect difficulty of assessing covert non adherence non-adherence Data shown are mean and range Cramer & Rosenheck. Psychiatr Serv 1998;49:196–201
  21. 21. Predicting Medication difficulty
  22. 22. Why Do Patients Have Difficulty? With medication? With appointments? i t t ?
  23. 23. Predictors of Difficulty with Medication Medication not working (efficacy) Medication harming (side effects) M di ti stigma Medication ti Medication costs Medication availability Medication has helped (now not needed)
  24. 24. Predictors of Difficulty with Appointments? Clinician not helping (efficacy) Clinician harming (criticism/hostile) Appointment stigma A i t t ti Appointment travel (costs) Appointment availability Clinician has helped (now not needed)
  25. 25. Perceived Benefits of Care Perceived Costs of Care Barriers to Care Doctor-Patient Factors Lack of transportation Therapeutic alliance Previous bad experiences Reduced symptoms Financial inequalities Perceived helpfulness Feared adverse events F d d t Prevention of complications Infrequent appointments Communication style Financial costs Enhanced therapeutic relationship Inconvenient appointments Adequacy of explanation Dislike of medical model Improved Health Related QoL Inconvenience Stigmatization Adequacy of monitoring Self-Medication Behaviour Attendance Behaviour Ideal Concordance Disengagement (drop-out) Good Concordance Low Attendance Partial Concordance Partial Attendance Desire to continue Low Concordance medical care Good Attendance Desire to stop + Encouragement Discontinuation medical care Ideal Attendance + Distracters Cues to Act Illness Factors Non-intentional Intentional Reminders Insight into current symptoms Flexible booking / Open access Perceived risk of future decline May Not be Disclosed Likely to be Disclosed Delivery or collection of medication Previous treatment responsiveness Reasons incoherent Reasons coherent Encouragement / support by others Likelihood of treatment benefits No alternatives Alternatives discussed considered
  26. 26. Adherence and Satisfaction Audience: what is the relationship? Higher rated treatment success => drop-out drop out Low rated clinician => drop-out Rossi, A., Amaddeo, F., Bisoffi, G., et al (2002) Dropping out of care: inappropriate terminations of contact with community based psychiatric services. British Journal of Psychiatry 181 services Psychiatry, 181, 33 –338.
  27. 27. Measuring Medication difficulty
  28. 28. Measurement of adherence INDIRECT Clinicians enquiry Patient or relative report DIRECT Measurement of the medication Measurement of a biological marker
  29. 29. Different Ratings Different Results Ratings, Two separate studies found that both patients* and clinicians† overestimate compliance Rated as Compliant rcentage of Patients 100 94.7 80 67.5 60 o 38.1 40 20 10.3 Per 0 Pill Count Patient MEMS Cap Clinician *Criterion: ”took all pills.” †Criteria: >70% of days (MEMS cap); score >4 on clinician rating scale. *Lam YWF et al. Poster presented at: Biennial Meeting of ICOSR; March 29 – April 2, 2003; Colorado Springs, Colorado. †Byerly M et al. Poster presented at: Annual Meeting of APA; May 17-22, 2003; San Francisco, California.
  30. 30. Consequences of Medication Difficulty
  31. 31. Poor Compliance Affects Rehospitalisation Rates Percentage of patients with a psychiatric admission 40 35 30 25 20 P Percent t 15 10 5 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% 130% Medication Possession Ratio Valenstein M, et al. Medical Care. 2002;40:630-639.
  32. 32. Continuous vs intermittent maintenance: 1 year relapse rates 33 Carpenter, et al. 55 10 Herz, et al. 29 Continuous therapy 7 Jolley, et al. 30 Intermittent therapy I t itt t th 15 Pietzcker, et al. 35 20 Schooler, S h l et al. l 32 0 10 20 30 40 50 60 Rates of Relapse (%) Kane et al, 1996. N Engl J Med;334:34-41.
  33. 33. Relapse in 1st episode patients over 1 year: according to compliance 35 30 25 20 Relapse 15 Well 10 5 0 Compliant Non-compliant Novak-Grubic & Tavcar P. Eur Psychiatry 2002;17:148-54
  34. 34. Helping with Medication difficulty
  35. 35. 4 Steps 1 Basic communication Establish a therapeutic relationship and trust Identify the patient’s concerns Take into account the patient’s preferences Explain the benefits and hazards of treatment options Involve patients in decisions Don t Don’t force medication as “one size fits all” one all
  36. 36. 2 Strategy-specific interventions Strategy specific Adjust medication timing and dosage for least intrusion Minimise adverse effects Maximise effectiveness Provide support, encouragement and follow- up
  37. 37. 3 Reminders Consider adherence aids such as pill boxes and alarms Consider reminders via mail, email or telephone p Home visits, family support, encouragment
  38. 38. 4 Evaluating adherence g Ask about problems with medication Ask specifically about missed doses p y Ask about thoughts of discontinuation With the patient’s consent, consider direct methods: pill counting, measuring serum Liaise with GP & pharmacists re prescriptions Offer lt Off alternatives ti
  39. 39. Extras
  40. 40. Potential to Improve Relapse Rates With Depot vs Oral Antipsychotics Difference in Relapse Rates Number of Study Relapsed (%) (oral minus Study subjects duration Oral Depot depot) (%) Crawford and Forest 29 40 weeks k 27 0 27 (1974) del Guidice et al (1975) 82 1 year 91 43 48 Rifkin et al (1977) 51 1 year 11 9 2 Falloon et al (1978) 41 1 year 24 40 -16 Hogarty et al (1979) 105 2 years 65 40 24 Schooler et al (1979) 214 1 year 33 24 9 — + Mantel-Haenszel: P < 0.0002. Davis JM et al. Drugs. 1994;47:741-773.
  41. 41. Degree of difficulty to produce adherence sufficient for therapeutic effect Weight Reduction Schizophrenia Exercise Flossing g Hypertension Diabetes (insulin depot) Diabetes (oral) Depression Rheumatoid Arthritis Asthma Strep Throat Birth Control Pills Headache 20 40 60 80 100 Easy Difficult Keith & Kane J Clin Psychiatry, 2003; 64: 1308-1315
  42. 42. Oral medication Tips [ Churchill et al] proposed the following improvement strategies ; i t t t i Keeping the regime simple. Providing explicit written information information. Involving patients in decision making. Encourage p g patient p participation in their own care. p Implementing drug regimes gradually. Tailoring to daily rituals. Providing warm positive feedback.
  43. 43. Interventions to improve adherence Osterberg et al 2005 grouped intervention in to four categories; Patient education education. Improved dosing schedules of medication. Increasing clinic hours. Improved communication between the p therapist and the patient.
  44. 44. Contd - 2 Further interventions studied include ; Providing more information [ both written and oral material and programmed learning ]. Compliance therapy. Manual tele follow up. Special reminder pill packing. S i l i d ill ki Appointment and prescription refill reminders. Leverage and rewards. L d d
  45. 45. Contd - 6 Other interventions ; In a systematic review [ Bennett & Glaziou 2003 ] which included 26 RCTs of computer generated medication reminders or feedbacks provided to the pts / health care providers concluded that the reminders are effective than feedback in improving adherence adherence. Mugford et al showed that information was most effective when presented close to the time of decision d i i making.ki
  46. 46. Conclusion In a systematic review [ McDonald et al 2005 ] of RCTs f i t RCT of interventions to assist patient ti t i t ti t adherence to meds concluded in psychiatric disorders the overall combination interventions and compliance counselling for pts appeared to be effective for improving adherence followed closely by family oriented therapies . The y y y p education oriented therapies on their own were generally unsuccessful in improving the adherence. adherence
  47. 47. Conclusion Evidence for any single intervention to improve adherence is weak however a combination of educational, cognitive and behavioural measures [ collaborative care ] have shown to improve the adherence to medication with the psychiatric patients. Further research is needed.

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