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Adherence in Patients On Dialysis:
Strategies for Success                                                                 ...
Adherence in Patients On Dialysis: Strategies for Success




patients on HD do not adhere to at                   The WHO...
Figure 1                                               resources and the motivation to adhere
                  Interactin...
Adherence in Patients On Dialysis: Strategies for Success




reducing the barriers that interfere with                   ...
Table 2                                                financial income (Holley & DeVore,
   The Relative Risk of Hospital...
Adherence in Patients On Dialysis: Strategies for Success




                                    Table 3                 ...
their own care and confers a sense of        regular treatment and disease-specific          of the problem. US Pharmacist...
Adherence in Patients On Dialysis: Strategies for Success




Kutner, N.G. (2001). Improving compli-                254-26...
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Adherence in Patients On Dialysis: Strategies for Success

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Adherence in Patients On Dialysis: Strategies for Success

  1. 1. Adherence in Patients On Dialysis: Strategies for Success Continuing Nursing Education Jean Kammerer, Glenn Garry, Marguerite Hartigan, Barbara Carter, and Linda Erlich atient adherence with the rec- P ommendations and treatments of healthcare providers is criti- cal to the efficacy of those inter- ventions. Unfortunately, poor patient adherence is a widespread problem in Adherence is a major problem in patients with chronic kidney disease. Patients can be non- adherent with different aspects of their treatment, which includes medications, treatment reg- imens, and dietary and fluid restrictions. Although many lessons have been learned from adherence research, the evidence of how to modify adherence is somewhat mixed. To mini- health care that carries with it sub- mize nonadherence, interventions need to focus on both patient factors and the extent to stantial medical, social, and economic which relationships and system problems compromise the patient’s ability to adhere to med- consequences, particularly among ication and treatment plans. There continues to be a tendency to focus on the patient as the patients with chronic kidney disease reason for problems with adherence, ignoring other factors such as the patient-health care (CKD). Much research has been provider relationships and the health care system that surrounds the patient. These latter fac- devoted to understanding patient tors can have a considerable effect on adherence. The nurse can develop a strong relationship nonadherence, but has generally of support with the patient, identify barriers, and offer strategies to help patients improve failed to demonstrate that any patient adherence. demographic or psychological char- acteristics are consistent predictors of adherence (Cvengros, Christiansen, & Lawton, 2004). Goal Patients undergoing chronic dialy- To raise awareness of factors that may cause problems in patients’ adherence sis have many problems, including to their treatment program. salt and water retention, phosphate retention, secondary hyperparathy- Objectives roidism, hypertension, chronic ane- 1. Compare and contrast compliance, adherence, and persistence as they relate to CKD. 2. Summarize the challenges to and results of poor adherence to treatment Jean K. Kammerer, BSN, RN, CNN, is Senior regimens Manager, Nephrology Medical Communications, 3. Describe strategies that may be used to improve adherence to their treat- Amgen, Inc., Thousand Oaks, CA. She is a member of ANNA’s Chumash Chapter. For more informa- ment regimen. tion on this article, contact the author at jeankam merer@gmail.com. Glenn Garry, BS, is Senior Marketing Manager mia, hyperlipidemia, and heart dis- Management of these health for Amgen, Inc., retail and specialty pharmacy ease. Almost half of patients on dialy- issues places multiple, complicated, adherence programs for Sensipar®, Thousand sis have diabetes, which leads to addi- and unavoidable demands on a Oaks, CA. tional complications. To address all of patient’s lifestyle (Saran et al., 2003). Marguerite Hartigan, MSN, RN, is Nephrology these problems, patients may require Nonadherence is a rampant problem Nurse Practitioner and Senior Manager, Aranesp® fluid restrictions, phosphate binders, among patients undergoing dialysis Medical Communications, Amgen, Inc., Thousand vitamin D preparations, calcimimetic (Cvengros et al., 2004) and can Oaks, CA. She is a member of ANNA’s Chumash agents, antihypertensive medications, impact multiple aspects of patient Chapter. hypoglycemic agents, erythropoietin, care, including medications, and Barbara Carter, MEd, BSN, RN, CNN, is iron supplements, and a variety of treatment regimens as well as dietary Clinical Educator, NxStage Medical, Inc., and was other medications (Loghman-Adham, and fluid restrictions Overall, it has Senior Manager, Nephrology Medical Affairs, 2003; Saran et al., 2003). been estimated that about 50% of Amgen, Inc., Thousand Oaks, CA at the time this article was prepared. She is a member of ANNA’s Chumash Chapter. This offering for 1.5 contact hours is being provided by the American Nephrology Nurses’ Linda Erlich MS, RN, is Clinical Consultant Association (ANNA). and Educator in Nephrology, Rancho Santa Fe, CA. ANNA is accredited as a provider of continuing nursing education (CNE) by the American Nurses Credentialing Center’s Commission on Accreditation. Note: Jean Kammerer, Glenn Garry, and ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP Marguerite Hartigan are all Amgen, Inc. employees 00910. and stockholders. Linda Erlich and Barbara Carter This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continuing nursing are both Amgen, Inc. stockholders. education requirements for certification and recertification. NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5 479
  2. 2. Adherence in Patients On Dialysis: Strategies for Success patients on HD do not adhere to at The WHO definition of adherence Acute care models tend to support least part of their dialysis regimen can easily be adapted to CKD, where interventions that are symptom- (Kutner, 2001). patients are confronted with multiple focused and intent on “cure,” while life-style changes. How well patients on chronic care focuses on controlling Understanding Compliance, dialysis are managing their care can be the progression of the condition, Adherence, and Persistence assessed using many parameters. In increasing survival and enhancing addition to adherence to prescribed quality of life (Sabate, 2001). In acute Health care providers (HCPs) medications and regular attendance at care, knowledge is in the hands of the need to understand the distinction hemodialysis sessions, most re- HCPs. The chronic care model between compliance, adherence, and searchers define nonadherence using requires that health care profession- persistence. Compliance is the extent to the objective parameters of interdialyt- als, patients, and families share com- which patients follow medication or ic weight gain (IDWG), serum phos- plementary knowledge to deal effec- treatment advice given to them by phorus and potassium levels. Of tively with chronic conditions providers. Some HCPs feel the term course, before nonadherence can be (Sabate, 2001). “compliance” suggests an obedience- determined to be the cause, patients The WHO adherence project based approach to patient care in with elevated serum phosphorus and adopted the following definition of which the HCP dictates behavior the potassium levels must first be assessed chronic disease: Diseases which have one patient is supposed to follow (Berger, for other causes of these imbalances or more of the following characteristics: Krueger, & Felkey, 2004). such as adverse interactions between they are permanent, leave residual disabil- The word adherence is preferred by medications, an inappropriate prescrip- ity, are caused by nonreversible pathological many HCPs because compliance sug- tion of vitamin D, and sources of bleed- alteration, require special training of the gests that the patient is passively fol- ing. patient for rehabilitation, or may be expect- lowing the HCP’s orders and that the Persistence is a measure of whether a ed to require a long period of supervision, treatment plan is not based on a thera- patient is continuing to use the pre- observation, or care (Sabate,2001). peutic alliance or contract established scribed therapy or medication (Berger For many with chronic illness, between the patient and the provider et al., 2004). It is most often used adherence to medical advice plays a (Osterberg & Blaschke, 2005). regarding medication prescriptions and vital role in survival. To manage Adherence means more than just fol- is defined as the continued use of med- chronic illness successfully, individu- lowing instructions (Sabate, 2001). It ication as indicated over time. A als must take responsibility for many indicates that goals of treatment are patient is nonpersistent if he or she aspects of their own treatment on a negotiated between patients and the never fills a prescription or stops taking regular and long-term basis. For HCP. The HCP may be an expert in it prematurely (Krueger, Felkey, & adherence to occur, the patient needs diagnosing an illness or in pharma- Berger, 2003). Studies have examined to incorporate lifestyle changes and cotherapy, but patients are experts on medication persistence among patients other behavior changes into their their own issues and activities of daily with a newly diagnosed disease, such as daily routines. Nowhere is this more living, including factors that enable hypertension, demonstrating that per- evident than in the area of CKD, them to carry out a treatment plan and sistence rates decrease over time (Caro, where adherence to dietary, fluid, and barriers that may interfere with it Salas, Speckman, Raggio, & Jackson, medication instructions are a critical- (Berger et al., 2004). The level of 1999). Adherence and persistence are ly significant factor in the continued adherence depends ultimately on the not mutually exclusive. It is possible for health and wellness of the patient adoption and maintenance of a range a patient to be persistent with his or her undergoing chronic dialysis (Rushe & of therapeutic behaviors by both the medication, that is to continue to take it McGee, 1998) (Curtin & Mapes, HCP and/or the patient that may over time, but to also be nonadherent 2001). include the patient’s self-management by not taking the medication as direct- of biological, behavioral, and social ed (Krueger et al., 2003). A Complex Interaction of factors that influence health and ill- Factors Affects Adherence ness. The World Health Organi- The evidence supporting the zation’s (WHO) Adherence Project Chronic Care Model Lends Itself impact of the factors that affect adher- has adopted the following definition of to Successful Adherence ence is somewhat mixed (Krueger, adherence to long-term therapy: the Behaviors Berger, & Felkey, 2005). Most studies extent to which a person’s behavior in tak- Acute care models of health service agree that to improve a patient’s abil- ing medications, following a diet, and-or delivery present barriers to adherence ity to follow medication and treat- executing lifestyle changes, corresponds with when applied to chronic disease, while ment regimens, all potential barriers agreed-upon recommendations from a HCP the characteristics of chronic care deliv- to adherence need to be considered. (Sabate, 2003). Inherent in this state- ery systems are aligned with the ability An expanded view takes into account ment is an agreement between the to achieve successful adherence behav- factors under the patient’s control as patient and the HCP. iors. well as interactions between the 480 NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5
  3. 3. Figure 1 resources and the motivation to adhere Interacting Factors Affecting Adherence to the treatment protocol (Morgan, 2000). Individuals with chronic illness who experience a diminished sense of con- trol often seek alternative methods to re-establish control. These behaviors may manifest in positive or negative Patient Provider ways. Many theories suggest that a per- ceived lack of control over the disease process and/or the dialysis procedure may help to explain nonadherence (Cvengros et al., 2004). Patients who shortened treatments were more likely to be bothered by the effects of kidney Health disease on their daily lives and more Care System likely to report perceived lack of con- trol over their future health (Kutner et al., 2002). Perhaps some patients on dialysis feel a sense of futility as well as a lack of control over their health care Note: Adapted from Osterberg & Blaschke (2005). outcomes. Health care system. Dialysis facil- ity size may be associated with nonad- herence. Larger facility size (10 or more patient and the HCP and between the younger age (for skipping, shortening, patients on HD) was associated with an patient and the health care system excessive IDWG, and hyperphos- increased likelihood of skipping treat- (see Figure 1). Interventions need to phatemia), African American race (for ments, shortening dialysis treatment focus on both patient factors and the skipping and shortening), female gen- time, and excess IDWG. When look- extent to which relationships and sys- der (for excessive IDWG), employed ing for an optimum facility size, it was tem problems compromise the status (for hyperphosphatemia), living found that in facilities with more than patient’s ability to adhere to medica- alone (for hyperphosphatemia), smok- 60 patients, the risk of skipping treat- tion and treatment plans. ing (for skipping and excessive ments increased 77% (P = 0.0001). In Patient. Patient-related factors rep- IDWG), depression (for skipping and facilities with greater than 75 patients, resent the resources, knowledge, atti- shortening), marital status (for the odds of shortening treatments tudes, beliefs, perceptions and expecta- hypephosphatemia), and time on dialy- increased 57% (P = 0.0006). Facility tions of the patient. Patients’ knowl- sis (for shortening, IDWG, and hyper- size greater than 125 patients was asso- edge and beliefs about the illness, moti- kalemia) (Saran et al., 2003). Leggat et ciated with greater odds for excessive vation to manage it, confidence (self- al. (1998) were the first to consider IDWG (P = 0.03) (Saran et al., 2003). efficacy) concerning the ability to smoking as a potential predictor of Time pressure in the clinical setting engage in illness-management behav- nonadherence, suggesting that smok- is a major barrier to understanding or iors, and expectancies regarding the ing is a marker of a patient’s lower pri- improving nonadherence. If we outcome of treatment and the conse- ority on health. Kutner et al. (2002) also believe that communication with quences of nonadherence interact to showed current smoking was signifi- patients is a crucial component of care, influence adherence in ways not yet cantly associated with skipping treat- HCPs must lobby for sufficient time to fully understood (Sabate, 2001). ments (P = 0.04). Some evidence sug- use “language” in our practices and Although studies do not show clear gests that a patient’s educational level must invest the time we do share with relationships between patient demo- plays a role in adherence, but under- patients in discussion of their behavior graphics and adherence, a few factors standing the treatment instructions and and motivations for self-care (Steiner & do seem to be associated with adher- the importance of the treatment is Earnest, 2000). Behavioral and educa- ence to dialysis therapy. In a study by probably more important than the tional research indicates that adherence Kutner, Zhang, McClellan, and Cole patient’s level of education (Krueger et is best enhanced when the patient (2002), patients who had skipped treat- al., 2005). Studies have shown that an receives individual attention (Morgan, ments were younger (P = 0.0007). In increase in knowledge does not neces- 2000). Large dialysis facilities with mul- the Dialysis Outcomes and Practice sarily increase a patient’s adherence to tiple shifts and rapid turnover of Patterns Study (DOPPS), predictors of the prescribed treatment. Most impor- patients may make it more difficult to higher odds of nonadherence included tantly, a patient must possess the provide personalized care aimed at NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5 481
  4. 4. Adherence in Patients On Dialysis: Strategies for Success reducing the barriers that interfere with Table 1 each patient’s ability to adhere to or The Relative Risk of Mortality by Nonadherence Measures cooperate with a health care plan. Although patient participation in Relative Risk (RR) health care is presumed to be support- Nonadherence measure of mortality* ed by the health care system at large, it Skipped 1 or more hemodialysis sessions/month 1.30 is difficult to assess to what degree such Shortened session by 10 minutes or more 1.11 encouragement actually occurs in prac- tice. It seems that often the health care IDWG greater than 5.7 % of dry weight 1.12 system itself is the most formidable PO4 greater than 6.5 mg/dL 1.27 challenge to a patient’s ability to effec- tively participate in their own care and *Multivariate adjusted treatment. Many care providers tend to emphasize strict compliance and may Note: Adapted with permission from Macmillan Publishers, Ltd.: Saran et al. (2003); Block et al. (1998). believe self-management to be a luxury that patients on dialysis can ill afford. Moreover, the atmosphere of depen- dency and passivity engendered in The Consequence of Poor more sessions by more than 10 minutes many dialysis delivery settings itself Adherence to CKD Therapies per month, had a serum potassium may contribute to providers’ prefer- Is Poor Health Care Outcomes level of greater than 6.0 mEq/L, a ence for and patients’ complicity with Nonadherence to the treatment reg- serum phosphate level of greater than non-participation (Curtin & Mapes, imen may affect both patient morbidi- 7.5 mg/dL, or an IDWG greater than 2001). ty and mortality (Bander & Walters, 5.7% of body weight. Provider. One of the most impor- 1998). Although there is much contra- Skipping one or more dialysis ses- tant factors affecting adherence is the dictory literature, it is logical to assume sions in a month was associated with a relationships that dialysis staff mem- that improvement in adherence would 30% increased mortality risk compared bers establish with patients (Krueger et decrease mortality. Studies have shown with not skipping, and shortening dial- al., 2005). DOPPS demonstrated an that the delivered dose of hemodialysis ysis time was associated with an 11% association between the presence of a is an important predictor of mortality. higher Relative Risk (RR) of mortality. dietitian in the facility and a lower like- Held et al. (1996) showed that a 5% Skipping dialysis decreased the total lihood of nonadherence in terms of increase in urea reduction ratio (URR) delivered dose and may affect mortali- excess IDWG (Odds Ratio [OR] = was associated with an 11% lower risk ty by that mechanism. The high mor- 0.75, P = 0.08). The results of the study of mortality. And when using Kt/V as a tality risk is perhaps secondary to point to the potential importance of the measure of dialysis dose, each 0.1 high- excessive cardiovascular burden relat- percentage of direct patient care staff er level of Kt/V delivered was associat- ed to expanded extracellular volume that is highly trained. For a 10% ed with a 7% lower mortality risk. One (Saran et al., 2003). Bleyer et al.(1999) increase in highly trained staff hours skipped treatment in a month of 13 found that even an occasional missed (defined as hours worked by staff with treatments yielded an 8% reduction in treatment places the patient at a much 2 or more years of formal nursing train- the monthly Kt/V and accounted for a higher risk of life-threatening condi- ing), there was a decrease in the likeli- 14% higher mortality risk. In a study of tions such as volume overload and hood of skipping (OR = 0.84, P = 6,251 patients by Leggat et al. (1998), hyperkalemia . 0.02). Odds of skipping were 11% 8.5% of patients skipped one or more Excessive IDWG was associated lower for every 10% increase in highly hemodialysis sessions within a month with 12% (P = 0.05) increased risk of trained staff in the unit (OR = 0.89, P = and 20.3% of patients shortened one or mortality. Increased phosphorus levels 0.06) (Saran et al., 2003). more hemodialysis sessions by 10 or were also associated with an increase in Both the percentage of highly more minutes. Overall, shortening one mortality. (Saran et al., 2003) This find- trained staff hours and of the number or more dialysis sessions was not asso- ing is further supported by the Block of highly trained staff members in a ciated with higher mortality, however, study, which showed that patients with facility seem to have an effect on shortening three or more sessions in 1 a serum phosphorus of greater than 6.5 patient adherence. Dedicated nursing month was associated with 20% higher mg/dL had a 27% higher mortality risk time spent counseling patients to mortality. The DOPPS also supports (RR = 1.27, see Table 1) than patients improve adherence is beneficial. the association between alterations in with a phosphorus of 2.4 to 6.5 mg/dL Furthermore, the presence of a regis- the dialysis prescription and mortality. (Block, Hulbert-Shearon, Levin, & tered dietitian seemed to lower the In this study published by Saran et al. Port, 1998). The risk of hospitalization odds of excess IDWG (Saran et al., (2003), patients were considered non- also increases when the patient fails to 2003). adherent if they skipped one or more adhere to treatment prescriptions (see sessions per month, shortened one or Table 2). 482 NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5
  5. 5. Table 2 financial income (Holley & DeVore, The Relative Risk of Hospitalization by Nonadherence Measures 2006). Relative risk (RR) Elements of Successful Nonadherence measure of hospitalization* Intervention to Improve Skipped 1 or more hemodialysis sessions/month 1.13 Adherence Shortened session by 10 minutes or more 1.09 A collaborative approach to care augments adherence (Osterberg & IDWG greater than 5.7 % of dry weight 1.00 Blaschke, 2005). An expanded view PO4 greater than 7.5 g/dL 1.07 will take into account factors under the patient’s control as well as interac- *Multivariate adjusted tions between the patient and the health care system and the patient Note: Adapted with permission from Macmillan Publishers, Ltd.: Saran et al. (2003). and the HCP. We must assess what our patients are doing and under- stand why they do it if we wish to help them change. In this effort, communi- Adherence to the Medication ally important to the patient. Patients cation is as powerful a tool as the Prescription Has Additional are more likely to adhere if they treatment or medication that is pre- Challenges believe the medication will work and scribed (Steiner & Earnest, 2000). It is not difficult to understand that they really need the medication The relationship between the why medication nonadherence to cure or control their illness. If the patient and the HCP (be it physician, among patients on dialysis occurs. cost of the medication is more than nurse, or other health practitioner) Both the complexity of the regimen the patient expected or more than the must be a partnership that draws on and its need to be “life-long” con- patient can afford, this presents an the competencies of each. The litera- tribute to nonadherence. Patients on additional barrier to adherence. The ture identifies the quality of the treat- dialysis take multiple medications patient may not feel the cost is worth ment relationship to be an important every day. the benefit (Berger et al, 2004). determinant of adherence. Effective Often the term medication adher- Inadequate prescription coverage, treatment relationships are character- ence does not distinguish between dif- lack of transportation, and medication ized by an atmosphere in which alter- ferent patient behaviors. The defini- cost are primary contributors to med- native therapeutic means are dis- tion for each patient needs to differ- ication adherence among patients on cussed, the regimen negotiated, entiate those who do not fill their pre- chronic dialysis (Holley & DeVore, adherence discussed, and follow-up scriptions from patients who miss an 2006). In one survey, patients under- planned (Sabate, 2001). The nurse has occasional pill, take a consistent but going chronic dialysis were asked more face-to-face interactive time reduced dose of their medication, about their social and financial situa- with the patient than any other HCP. consume medication sporadically, or tions, medication coverage, and rea- During this time, it is the role of the completely discontinue medication sons for not obtaining all prescribed nurse to engage in communication use (Steiner & Earnest, 2000). In a medications. Most patients (69%) with the patient and use active listen- Medication Event Monitoring System took 11 or more medications daily. ing and talking skills to help increase (MEMS) study using microelectronic Although 70% of these patients had adherence. medication bottle caps to record dates some medication coverage, 67% Adherence requires the pa- and times of all bottle openings over a reported not filling prescriptions tient’s agreement to the recom- specified time, almost 93% of the because they had no money. mendations. Patients should be patients monitored for their antihy- Seventeen percent had no transporta- active partners with health profession- pertensive medications did not tion to get to the pharmacy. When als in their own care, and good com- adhere and 97% of the patients moni- asked if they ever chose not to take a munication between patient and tored for their phosphate binders specific medication, 21% said yes HCP is a must for effective clinical failed to adhere (Curtin, Svarstad, & because of side effects (36%), cost practice (Sabate, 2003). Strategies to Keller, 1999). (27%), or because they already took improve adherence are of little value For patients to adhere to a med- too many medications (18%). Despite unless the patient agrees that the pre- ication regimen, they must be certain having a local pharmacy plan that sig- scribed regimen is personally worth- that the benefits of taking the medi- nificantly reduced patient cost and while. This approach attempts to cine outweigh the real or perceived prescription co-pays, many patients involve patients in their own care by barriers. Setting clear goals with the failed to enroll because of the infor- helping them regain a measure of patient is essential to improving mation required on plan applications control and achieve an understanding adherence. The goals must be person- and the required reporting of all of how their behaviors affect their NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5 483
  6. 6. Adherence in Patients On Dialysis: Strategies for Success Table 3 interventions consistently and with- Strategies for Improving Adherence out judgment. First, the patient must understand why the medication is • Identify poor adherence being prescribed and believe in the • Look for markers of poor adherence, both biochemical and behavioral, such importance of following the pre- as missed treatments, lack of response to medication, excess IDWG, missed scribed medications. When instruct- refills, etc. ing the patient, emphasize the posi- • Emphasize the value of the treatment and medication regimens and the posi- tive effects and benefits of taking the tive effect of adherence. medication rather than the negative consequences of not taking it. If you • Listen to the patient, and as much as possible, customize the treatment and know the patient is going to change medication plan in accordance with the patient’s preferences and needs. Individualize patient care. the regimen, spend time with the patient brainstorming ideas that • Elicit patient’s feelings about his or her ability to follow the regimen and work might help improve adherence. with the patient to establish support systems, i.e., family and friends, retail Steiner and Earnest (2000) recom- pharmacies, financial supports. mend inquiring about the specific cir- • Encourage use of community support systems such as retail pharmacy and/or cumstances under which patients miss pharmaceutical manufacturer-sponsored persistency or patient assistance pills, distinguishing between uninten- programs. tional and intentional lapses, and ask- • Provide instruction and instructional materials which are patient-appropriate. ing patients in a nonjudgmental way Use education materials provided by pharmacies or pharmaceutical compa- about the motivation for their behav- nies when available. Use written materials to reinforce oral counseling, not as iors. Careful attention must be given a substitute for it. how the patients are approached with • When possible, decrease the complexity of the medication regimen by using questions about adherence to help once-a-day dosing and extended release medications. them understand that they are not • Establish cues within the patient’s daily routine to help with adherence to med- being judged and that honest answers ication doses. are sought (Turner & Hecht, 2001). • Continually give the patient feedback on his or her actions and how they are Adherence decreases as the com- influencing the benefits they are receiving (or not receiving) from the medica- plexity and duration of the regimen tion regimen. increases (McDonald, Garg, & • Reinforce desirable behaviors and results. When asking questions, use a non- Haynes, 2002). The more often the judgmental approach. patients need to take a medication, the more likely they are to forget. Whenever possible, simplify the med- ication regimen. Is less frequent dos- own health (White, 2004). Com- ing control and having a better sense ing a possibility or can an alternate municate to patients that the HCP of well-being. This “small amount” of medication be prescribed in a long- wants them to be active and manage nonadherence may help them carry acting form? Are there daily cues or their own health care regimens. out other aspects of the treatment reg- activities that can be associated with Strategies for improving patient imen, dietary, or medication prescrip- taking of medications? Are there adherence (see Table 3) should tion. other social support individuals will- include assessing the patient’s prefer- Since research has failed to pin- ing to help them remember? What do ences for control and improving the point any one factor influencing the patients think would help them perception of control in those patients adherence, it is important to deter- remember to take the medication? who want control and involvement in mine what barriers are keeping each The effect of missing medications decision-making (Cvengros et al., patient from getting medications and on the patient’s health care outcomes 2005). As dialysis health care to eliminate barriers to patient access. should be emphasized. For example providers, we cannot condone chron- This is best achieved by asking with antihypertensive medications, ic shortening of dialysis treatments. patients non-judgmentally about acknowledge that an occasional However, perhaps we should be less medication-taking behavior (Oster- missed dose is probably safe, but critical of the occasional need to berg & Blaschke, 2005). By giving emphasize the risk for frequently request ”coming off” dialysis early. patients permission to discuss their missed doses. Also, encourage Leggett et al. (1998) suggest that occa- nonadherent behavior, HCPs can patients to take blood pressure mea- sionally shortening sessions (less than help them reach set goals. surements at home to illustrate the three per month) may give patients a Increasing adherence with long- effect of missing prescribed medica- sense of control over hemodialysis. term medication therapies will tions, thus giving them feedback. This This may be the patients’ way of gain- require the combination of many also keeps the patients involved in 484 NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5
  7. 7. their own care and confers a sense of regular treatment and disease-specific of the problem. US Pharmacist, control in the decision-making education, in the result is a reduction 29(11), 50-54. Retrieved August 21, process. in the numbers of patients being hos- 2007 from http://www.uspharma- Resources outside of the dialysis pitalized and total days in hospital cist.com/index.asp?show=article&pa ge=8_1378.htm. facility should be explored. Many (Sabate, 2003). Bleyer, A.J., Hylander, B., Sudo, H., retail pharmacies and pharmaceutical The epidemiologic shift in disease Nomoto, Y., de la Torre, E., Chen, companies provide comprehensive burden from acute to chronic disease R.A., & Burkart, J.M. (1999). An programs to help patients with adher- over the past 50 years has rendered international study of patient compli- ence and persistence issues. Patients acute care models of health service ance with hemodialysis. Journal of the may not be aware that these pro- delivery inadequate to address the American Medical Association, 281(13), grams exist or how to enroll. It may health needs of the population 1211-1213. be necessary for the dialysis unit to (Sabate, 2001). Acute care models Block, G.A., Hulbert-Shearon, T.E., contact the patient’s local pharmacy tend to support interventions that are Levin, N. W., & Port, F.K. (1998). to determine what type of support is symptom-focused and intent on Association of serum phosphorus and calcium x phosphate product available to the patient and help the “cure,” while chronic care controls with mortality risk in chronic patient access these programs. Long- the progression of the condition, hemodialysis patients: A national term follow-up and reminder pro- increases survival, and enhances qual- study. American Journal of Kidney grams may be an invaluable adjunct ity of life. In acute care, knowledge is Diseases, 31(4), 607-617. to education programs within the in the hands of the HCPs. In chronic Caro, J.J., Salas, M., Speckman, J.L., dialysis unit. It is the role of the nurse care, health professionals, patients, Raggio, G., & Jackson, J.D. (1999). and the social worker to link patients and families share complementary Persistence with treatment for hyper- with assistance programs. Nurses do knowledge. tension in actual practice. Canadian not need to provide all education and For outcomes to be improved, Medical Association Journal, 160(1), 31- support for patients, but they must health policy and health system 37. Curtin, R.B., Svarstad, B.L., & Keller, know other resources available to the changes are essential. Effective treat- T.H. (1999) Hemodialysis patients’ patient and make them aware of such ment for chronic conditions requires noncompliance with oral medica- programs. a transformation of health care, away tions. ANNA Journal, 26(3), 307-316. from a system that is focused on Curtin, R.B., & Mapes, D.L. (2001). Conclusions episodic care in response to acute ill- Health care management strategies Many lessons have been learned ness, towards a system that is proac- of long-term dialysis survivors. from adherence research. Patients tive and emphasizes health across a Nephrology Nursing Journal, 28(4), 385- need to be supported, not blamed. lifetime (Sabate, 2001). 394. Despite evidence to the contrary, With the estimate that about 50% Cvengros, J.A,, Christensen, A.J., & there continues to be a tendency to of patients on HD are nonadherent to Lawton, W.J. (2004) The role of per- ceived control and preferences for focus on patient-related factors as the at least part of their dialysis regimen, control in adherence to a chronic reason for problems with adherence, it is easy for the HCP to become dis- medical regimen. Annals of Behavioral to the relative neglect of provider and couraged. Helping patients adhere to Medicine, 27(3), 155-161. health system-related causes. These fluid restrictions and dialysis regi- Held, P.J., Port, F.K., Wolfe, R.A., latter factors make up the health care mens and take multiple medications Stannard, D.C., Carroll, C.E., & environment in which patients may seem overwhelming. It is impor- Daugirdas, J.T. (1996). The dose of receive care and have a considerable tant to remember that a good patient- hemodialysis and patient mortality. effect on adherence (Sabate, 2003). HCP relationship and the use of Kidney International, 50(2), 550-556. The consequences of poor adher- active listening and talking skills are Holley, J.L., & DeVore, C.C. (2006). Why ence to long-term therapies include vital to getting patients involved in all prescribed medications are not taken: Results from a survey of poor health outcomes and increased their own health care. Investing the chronic dialysis patients. Advances in health care costs. Poor adherence to time to discuss patient behaviors and Peritoneal Dialysis, 22, 162-166. long-term therapies severely compro- motivations for self-care will improve Krueger, K.P., Felkey, B.G., & Berger, mises treatment effectiveness making adherence and patient outcomes. B.A. (2003). Improving adherence it a critical issue in population health and persistence: A review and assess- from both quality of life and health References ment of interventions and descrip- economic perspectives (Sabate, 2001). Bander, S.J., & Walters, B.A. (1998). tion of steps toward a national adher- In addition to their positive impact on Hemodialysis morbidity and mortal- ence initiative. Journal of the American the health status of patients with ity: Links to patient non-compliance. Pharmacists Association, 43(6), 668-79. chronic illness, higher rates of adher- Current Opinion in Nephrology and Krueger, K.P., Berger, B.A., & Felkey, B. Hypertension, 7(6), 649-653. (2005) Medication adherence and ence confer economic benefits. When Berger, B.A., Krueger, K.P., & Felkey, persistence: A comprehensive review. self-management programs are Advances in Therapy, 22(4), 313-356. B.G. (2004). The pharmacist’s role in offered to patients and combined with treatment adherence. Part 1: Extent NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5 485
  8. 8. Adherence in Patients On Dialysis: Strategies for Success Kutner, N.G. (2001). Improving compli- 254-262. ance in dialysis patients: Does any- Steiner, .J.F., & Earnest, M.A. (2000). The thing work? Seminars in Dialysis, 14(5), language of medication-taking. Annals 324-327. of Internal Medicine, 132(11), 926-930. Kutner, N.G., Zhang, R., McClellan, W.M., Turner, B.J., & Hecht, F.M. (2001). Imp- & Cole, S.A. (2002). Psychosocial pre- roving on a coin toss to predict dictors of non-compliance in patient adherence to medications. haemodialysis and peritoneal dialysis Annals of Internal Medicine, 134(10), patients. Nephrology Dialysis and 1004-1006. Transplantation, 17(1), 93-99. White, R.B, (2004). Adherence to the dial- Leggat, J.E., Orzol, S.M., Hulbert-Shearon, ysis prescription: Partnering with T.E., Golper, T.A., Jones, C.A., Held, patients for improved outcomes. P.J., & Port, F.K. (1998). Noncom- Nephrology Nursing Journal, 31(4), 432- pliance in hemodialysis: Predictors 435. and survival analysis. American Journal of Kidney Diseases, 32(1), 139-145. Loghman-Adham, M. (2003). Medication noncompliance in patients with chronic disease: Issues in dialysis and renal transplantation. American Journal of Managed Care, 9(2), 155-171. McDonald, H.P., Garg, A.X. & Haynes, R.B. (2002). Interventions to enhance patient adherence to medication pre- scriptions. Journal of the American Medical Association, 288(22), 2868- 2879. Morgan, L. (2000). A decade review: Methods to improve adherence to the treatment regimen among hemo- dialysis patients. Nephrology Nursing Journal, 27(3), 299-304. Osterberg, M.D., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353(5), 487-497. Rushe, H., & McGee, H.M. (1998). Assessing adherence to dietary rec- ommendations for hemodialysis patients: The renal adherence atti- tudes questionnaire (RAAQ) and the renal adherence behavior question- naire (RABQ). Journal of Psychosomatic Research, 45(2), 149-157. Sabate, E, (2001). World Health Organ- ization Meeting Report. Adherence to long-term therapies: Policy for action. Retrieved March 29, 2007 from http://www.who.int.chp/know ledge/publications/adherencerep.pdf Sabate, E., (2003). World Health Organ- ization. Adherence to long-term therapies: Evidence for action. Retrieved March 29, 2007 from http://www.emro. who.int/ncd/Publications/adher- ence_report.pdf. Saran, R., Bragg-Gresham, J.L., Rayner H.C., Goodkin, D.A., Keen, M.L., van Dijk, P.C. et al. (2003). Nonadherence in hemodialysis: Asso- ciations with mortality, hospitaliza- tion, and practice patterns in the DOPPS. Kidney International, 64(1), 486 NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5
  9. 9. ANNJ0716 ANSWER/EVALUATION FORM Adherence in Patients On Dialysis: Strategies for Success Jean Kammerer, BSN, RN, CNN, Glenn Garry, BS, Marguerite Hartigan, MSN, RN, Barbara Carter, MEd, BSN, RN, CNN, and Linda Erlich, MS, RN 1.5 Contact Hours Complete the Following: Expires: October 20, 2009 Name: ____________________________________________________________ ANNA Member: $15 Non-Member: $25 Address: __________________________________________________________ Posttest Instructions __________________________________________________________________ • Select the best answer and circle the appropriate letter on the answer grid Telephone: ______________________ Email: _____________________________ below. • Complete the evaluation. CNN: ___ Yes ___ No CDN: ___ Yes ___ No CCHT: ___ Yes ___ No • Send only the answer form to the ANNA National Office; East Holly Payment: Avenue Box 56; Pitman, NJ 08071- ANNA Member: ____ Yes ____ No Member #___________________________ 0056; or fax this form to (856) 589- 7463. ■ Check Enclosed ■ American Express ■ Visa ■ MasterCard • Enclose a check or money order payable to ANNA. Fees listed in pay- Total Amount Submitted: _________________ ment section. • If you receive a passing score of 70% or Credit Card Number: _______________________________ Exp. Date: _______ better, a certificate for the contact hours will be awarded by ANNA. Name as it Appears on the Card: ______________________________________ • Please allow 2-3 weeks for processing. You may submit multiple answer forms Special Note in one mailing, however, because of var- Your posttest can be processed in 1 week for an additional rush charge of $5.00. ious processing procedures for each ■ Yes, I would like this posttest rush processed. I have included an additional fee of answer form, you may not receive all of $5.00 for rush processing. your certificates returned in one mailing. Online submissions through a partnership with HDCN.com are accepted on this posttest at $20 for ANNA members and $30 for nonmembers. CNE certificates will be available immediately upon successful completion of the posttest. Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at www.annanurse.org/journal 1. What would be different in your practice if you applied what you have learned To raise awareness of factors that may cause from this activity? problems in patients’ adherence to their treat- ____________________________________________________________ ment program. ____________________________________________________________ New Posttest Format ____________________________________________________________ Please note that this continuing education activity does not contain multiple-choice questions. We have introduced a new type of posttest ____________________________________________________________ that substitutes the multiple-choice questions with an open-ended ____________________________________________________________ question. Simply answer the open-ended question(s) directly above the evaluation portion of the Answer/Evaluation Form and return the ____________________________________________________________ form, with payment, to the National Office as usual. ____________________________________________________________ Strongly Strongly Evaluation disagree agree 2. By completing this offering, I was able to meet the stated objectives a. Compare and contrast impliance, adherence, and persistence as they relate to CKD. 1 2 3 4 5 b. Summarize the challenges to and results of poor adherence to treatment regimens. 1 2 3 4 5 c. Describe strategies that may be used to improve adherence to their treatment regimen. 1 2 3 4 5 3. The content was current and relevant. 1 2 3 4 5 4. This was an effective method to learn this content. 1 2 3 4 5 5. Time required to complete reading assignment: _________ minutes. I verify that I have completed this activity ________________________________________________________________________________ (Signature) NEPHROLOGY NURSING JOURNAL ■ September-October 2007 ■ Vol. 34, No. 5 487

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