Adherence in the Management of Type 2 Diabetes Mellitus


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Adherence in the Management of Type 2 Diabetes Mellitus

  1. 1.   PODCAST  TRANSCRIPT:   ADHERENCE  Joel Zonszein, MD, CDE, FACE, FACP:Diabetes is a chronic disease and having a patient coming to the office and having the careprovider prescribing a medication without explaining to the patient what it is we are trying to do,doesn’t work. I find that one of the major problems we have with adherence is the lack of propereducation for the patients who have a chronic disease. It is very different from somebody whocomes with a sore throat and is treated with an antibiotic. Diabetes, a chronic and very complexdisease needs a multifactorial cardiovascular risk assessment and a global approach fortreatment.Education is paramount in order to have the patient take the prescribed medications; this isparticularly true early in a disease when patients like to treat their disease ONLY with lifestylechanges. I feel that medications together with life style changes work much better early in thedisease. What we have been doing through many years in this country is to treat hyperglycemiaand often cholesterol and blood pressurea bit too late when we already have organ disease.When patients feelwell and have an aggressive disease, we have to intervene very early andvery aggressively in order to prevent or stop complications. Patients need to have propereducation on what is diabetes and what for are the medications we prescribe, what are themedications doing and/or not doing, and their potential side effects.Another issue that I found quite common in our practice is the distrust in the health care system.Maybe because of the media and the way our healthcare system operates, the patients believethat when they come to see a doctor and we recommend a medication, we try to cause harm.The patients do not look at these medications as something that can prevent a stroke or a heartattack or dialysis. Actually they look at these medications as, “Oh the doctor is giving mesomething to harm my liver or to harm my kidney”. I use this as part of the education that I giveto the patients. Many of the patients we see, particularly the Latinoand the African Americanpatients, I need to reassure that their liver and their kidneysare working properly andthat themedications they are taking not only do not cause any harm to the kidneys and the liver, butactually protect them.When we treat diabetes, we do not treat only the high blood sugars, hyperglycemia; we want totreat all other cardiovascular risk factors such as dyslipidemia and hypertension. In the STENO2 trial we found that treating lipids by giving a statin was very important and it was responsible ingreat part of prevention of cardiovascular complications. In the very rich ethnic minority we seeDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  2. 2.  in the Bronx, I have always emphasized treating high blood pressure as number one becausewe have a large African American population who have severe hypertension, difficult to controlsometimes, and responsible for premature CVD events. So to control all cardiovascular riskfactors we address in the following order:1. Blood pressure2. Lipids3. GlucoseHaving said that, treatments of all these risk factors need to be done in conjunction.Weprescribe medications in a set up approach. We discuss with the patient the need formedications and the goals of treatment for blood pressure, lipids, and sugar. But going back toyour question, we found out that hypertension is rarely well controlled with one single agent, sowe often need combination therapy, and in fact from the UKPDS study, most patients had totake more than three medications to control the blood pressure and when we look at cholesterolwe find out that often, because of their dyslipidemia, that the statin alone is not sufficient andthey often need combination therapy.In treating hyperglycemia, we often have to givecombination therapy; in fact I like to use very early combination therapy. Sometimes even as afirst line therapySo again you have two or three pills for the sugar, two pills for the cholesterol, and maybe threepills for the blood pressure. One more time, education, having the patients understands whattheir numbers are, what their goal needs to be, and why to take these medications is very,important for good adherence. The better educated patient population, the better socioeconomicstatus the patient has, the easier it is to achieve adherence.Patients who are not very educated,who do not believe in the healthcare system, who do not have the means to buy medicationsetc., have less adherence. When we look at the variety of patients taking medicationsprescribed by the doctor we find that within six months or a year there is tremendous drop of inadherence, often only about 50% of patients are taking their medication. The adherence to pillsis very poor, but when we look to adherence to injectables, it is even worseSo I go back to three main things that we have to do, the first one is education, the second oneis education and the third one is education. It is very important; spending time with the patient,explaining what the disease is, what are the complications, what needs to be done, etc. So weneed to provide education very early and treat the patient with a nurse and the nutritionist, as ateam approach. The team emphasizes not only lifestyle changes but also prevention ofcomplications and how medications would work So, education is very important.Developed  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  3. 3.  It is also important to look at the cultural values that patients have and to establish a goodrapport. In our current healthcare system, we have a few minutes to see the patient, we say “ohthe cholesterol is high”, and we give a prescription and go to the next patient. That does notwork in patients with the chronic disease who are still healthy and need to take medications fora long period of time. So looking at the patient characteristics, ethnicity, discussing the patientmanagement, providing education, talking in a very frank way of the benefits and side effects ofeach pill, is important and will improve adherence. We use other issues and we often involvethe entire family for support and sustained lifestyle changes. We discuss with the patient anyquestions they may have; in my practice I often find out that they listen more to their neighbor orto their family members than to their doctor, Patients like to learn what medications do from theinternet, from the media, and from their friends or neighbors; They look at the doctor with lesstrust but often their questions are very valid. We need to answer each question, we have to findtime to discuss the benefits and/ or potential harm of each medication and we need to find out ifthey take or why they don’t take their medicationLenora Lorenzo, DNP, APRN, FNP/ADMUnfortunately compliance and adherence are really found to be relatively low and the results ofthe analysis vary widely and they do depend on the study selected and their analytical methods.In addition, factors that influence adherence differ from patient to patient and many of thesefactors have not even been identified yet. So I am going to just review some of the results in theliterature; the results of one systematic analysis from 2004 by Cramer revealed adherence tohypoglycemic regimen has widened. In patients on oral regimens for six months to two yearsadherence was so variable, say 61 to 85% for up to six months and as low as 16 to 18% forthose who remained on treatment for 6 to 24 months. Even retrospective data for a largeCohort study of long-term and no use of insulin in type 2 revealed an average of 63%adherence to oral therapy.So, adherence is not very high and as healthcare providers, our awareness of the differentfactors that can influence the patient compliance and adherence is very helpful. Some of theseinclude looking at patient factors such as age, -we know that older patients have greateradherence-, economic status, -patients in the higher socioeconomic groups exhibit greateradherence-, educational levels, - patients with lower levels have lower adherence and morediabetes related to mortality. Another important factor is health beliefs. Patients who actuallybelieve that medications are harmful or that their regimen that we suggested is going to beharmful, will not be adherent, will not follow the program, and this is definitely going to impactthe cost and the success and prevention of the complications. Of course finances is always abig issue, and the less money you have, the less you are able to pay for the medications and/orDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  4. 4.  anyother diagnostic testing or management visit.That becomes a very big issue, I think verycommon issue, especially now with the financial issues we are going through nationally.Studies also revealed that there are social and medical factors that affect adherence. Thisincluded the relationship with the healthcare provider. I just talked about therapeutic allianceand the importance of working with, and partnering with our patients, so that we can getengagement and get them to agree upon a treatment plan and work towards that plan. Theother thing is, patients have to trust their healthcare providers and so we have to be very openand really listen and be frank with them, and not be blaming in anyway, not causing them to feelthat what they are doing is part of the problem. The positive and negative experiences thatfamily members and acquaintances have also have a great impact. In my own experience, Iworked with a lot of groups and I always include the patients and families because that reallygives me insight in to what is going on and some of the barriers they may be facing in their ownfamilies and that also has a huge impact.Stress has a huge impact on compliance and adherence to diabetes management. If you areworried about a family member who is dying of leukemia, it is very hard to focus on your ownhealth, or if you are worried about losing your job. Stress is very important, let us not forget thatstress also increases your blood sugar level so it becomes almost a vicious cycle. Manypsychological problems such as anxiety and depression can also affect adherence, and thestudies have shown about 30% of the adults with diabetes have comorbid depression, which isassociated with poor metabolic control, more complications, increased healthcare cost andreduced quality of life. So depression is a huge problem we see in the patients with diabetes,Additionally, I believe healthcare providers have a difficult time or may have a lack confidence inthemselves in their ability to recognize all of the psychological problems, and to deliver thepsychosocial support that the patients need. That would be a good segway into our next sectionwhere we are going to talk about working in teams and partnering with other people and theirexpertise to get this knowledge and to improve in this area.Other disease related factors for adherence is that patients who have a lot of other chronicconditions often have lower adherence. They have so many things they are dealing with, forexample if you are going to dialysis three times a week and you are barely able to manage toget to dialysis then how are you to going to be managing your diabetes too, so it becomes verydifficult for them. Medication related factors are also important and if they have positiveattitudes about their medications, or their treatment plan, then of course they are going to getbetter adherence.The simpler the treatment regimen, the less medications that we use, thegreater the adherence. And if we can pay real close attention, really listen to our patients interms of what types of side effects they are having, if they cannot tolerate it even if to us itDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  5. 5.  seems important or unimportant, if it is important to them we have to listen and try to impact thetreatment plan based on that.There are also many other management related factors including their health beliefs or theircultural belief systems, which cause reduced understanding of the diabetes and the treatmentregimen. In the Hawaiiann, the Asian and the Pacific islanders, in particular, what we see a lotis that the family is very important and if we do not get the whole family involved then you arenot going to have any success.There is almost a fatalistic attitude of being punished and youhave to unravel some of these cultural beliefs and try to work with them so that you canunderstand what they are dealing with. We all know that lack of information and incompleteunderstanding of diabetes and even conflicting information can be very, very hard. I just had apatient the other day who has stopped all of his hypertension medication because he was toldthat his blood pressure was well controlled and so he figured that he did not need it anymoreand then of course his blood pressure was back up.They do not understand a lot of times thatthe reason they are able to control it, is because of this treatment plan that we have. It isworking so we do have to keep them informed of what is going right and what is not, and oftentimes if we deal with the patients negatively or blame them in anyway, that’s really going toimpact whether or not they are going to follow the treatment plan. So that is going to be veryimportant.There are many strategies that we can use to encourage therapeutic alliance with type 2diabetes; these are things that I use in my own practice and I do a lot of group clinic. I thinkmost important is taking the time to really develop a partnership or relationship with the patient,understanding their prospective about their condition and the treatment, and what they arewilling to work on in terms of lifestyle changes, diet, and medications.Working with them is goingto be really important.Behavior change counseling is a huge task and important strategy that we can use in ourmanagement for therapeutic alliance. I use the motivational interview technique and have hadextensive training in this. You can get a lot of the training online so you do not have tonecessarily go to a class. There are lots of different online sites, but basically motivationinterviewing is a counseling strategy that has demonstrated its success. It is a communicationcoaching technique that we use to empower, motivate, and help our patients move through thestages of change towards choosing healthy behaviors. We use many different tools; some of theMI tools include what we call open-ended questions, affirmations, reflections, support. Itdemonstrates an interest in our patient in trying to understand their case and it helps to engagein conversation with the patient. The patient comes up with the solution and with the things thatare impacting diabetes and starts to make a decision. We help them to move them through thestages of change. The theoretical underpinnings of motivational interviewing includes this transDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  6. 6.  theoretical model of behavior change and also social cognitive theory. So lots of behavioraltheories are very important in any type of lifestyle changes like diabetes, that is going to changeyour whole life, it is going to be key to getting success.Another breakthrough is a collaborative goal setting and behavioral action plan that McGregorwrote about; we cannot make someone do something that they do not want to do. So abehavior action plan is an agreement and a means of working with the patient towards anagreement to make healthy changes in their life. They choose what they want to work on andyou then help them to focus on one or two action goals; it is a contract plan that you use to helpguide them for a specific measurable time frame. You can do small things, like walking 10minutes once a day at a certain time and helping them to see through their plans and makethem successful. Those are going to be really important in terms of the behavioralmanagement.Other things that have been talked about extensively is diabetes self-management education. Iadd skill building because all of these studies showed that just giving the patient information andeducation really only produce short-term effectiveness in improving the knowledge, their dietarychanges, and monitoring. What patients need to learn is not just what to do to stay healthy, butthe ultimate goal is for them to actually adopt and support healthy behaviors. You really have tohave programs that build skills, as well as inform them, because diabetes can cause majorchanges in their behaviors and their self-management skills may prevent their complicationsand improve their outcome. Components of a good self-management support program wouldinclude providing not just information, but intensive disease specific skill buildings; for instanceblood glucose monitoring, where you go over numbers and you see what they need and youhelp them to see before and after and what was the impact of food and what was the impact ofexercise. So they actually understand what they are using the numbers for.Encouraging healthy behavior change and teaching problem solving techniques: what to dowhen their blood sugars are low, and what to do when their blood sugars are high. Also,assisting with a lot of psychosocial and emotional issues, all chronic conditions such asdepression and stress and of course our encouragement to help them become activeparticipants in self-care. Those are all part of the self-management skills that they need toinclude. Also note that if you have an RN or Certified Diabetes Educator they have these skillsand often know how to put these programs on as part of ADA (American Diabetes Curriculum).But if you do not, the conversation MAP Program is an ideal program for group visits for self-management and skill building. It is actually free training online and MAPS are mailed once youcomplete the training.They have a series of five different MAPS. It is kind of a gaminginteractive type of session; MAPS are huge and there is one on diet and one on blood glucosemonitoring, and one on diabetes and short-term and long-term complications and oneDeveloped  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.  
  7. 7.  gestational diabetes. The Conversation Maps are excellent, there is no cost for the Maps or theonline training and there is support for this too.Another strategy for getting into self-management is group shared appointment and that is awhole other topic that we can get into. Studies also support that healthcare teams and nursecase manager really help to promote compliance and therapeutic alliance in terms of self-monitoring and even weight loss. Another important strategy is what we call “telephone followup”; it is crucial to close the loop and to call the patient to see how they are doing, check on theirbehavior action plans, how they are doing on their safe change in medication and it also makesthe patient feel very important and they really do appreciate the phone calls. So there are manydifferent strategies that we can use in diabetes self-management to increase the therapeuticalliance and we went through a few of those today.       Developed  in  collaboration  with  the  Center  for  Continuing  Medical  Education  at  Albert  Einstein  College   of  Medicine  and  Montefiore,  and  the  American  Academy  of  Nurse  Practitioners,  through  a  strategic   educational  facilitation  by  Medikly,  LLC.     Supported  by  an  unrestricted  educational  grant  from  Lilly  USA,  LLC.