Adherencia al Tratamiento. Dr. Antjefink Wagner

Adherence to Treatment
Adherencia al Tratamiento
Antje-Henriette Fink-Wagner, PhD
Executive Director
Global Allergy and Asthma Patient Platform GAAPP
Antje-Henriette Fink-Wagner, 2012 1

Statement of Interest
No conflict of interest!

– Status of Health Literacy as relevant issue to be adherent/
concordant
– Patient advocacy as 1st step to empower patients and to
increase adherence/concordance for better patient compliance
– Integral meaning and consequences of compliance
– Model of patient behavior
– Integration of all stakeholders to change patient behavior
– Conclusion
Examples: – Physician
– Nurse
– Pharmacist
– Insurance/funds
– Family and friends
– Policy Makers
– Pharmaceutical industry
– Patient associations
Content
or what you will take home from this presentation

– Literacy and misunderstanding prescription drug labels.
Annals of Internal Medicine 2006 :
Take two tablets twice daily.
How many patients can follow this direction?
Health Literacy
a precondition to achieve acceptable adherence/concordance

– Literacy and misunderstanding prescription drug labels.
Annals of Internal Medicine 2006 :
Take two tablets twice daily.
How many patients can follow this direction?
Only 34 % of patients were able to accurately follow this!
Health Literacy
a precondition to achieve acceptable adherence/concordance

Patient advocacy as 1st step to empower patients and
to increase adherence/concordance for better patient
compliance
– Advocacy empowers patients
– Empowered patients are more willing to feel responsible
for their therapy
– Patients who feel responsible want to understand
therapy opportunities, which means they request
education
– Educated patients are able to adhere to doctors‘ advice on
a level of concordance
– Concordance
will increase compliance
Patient advocacy will increase compliance

Source:
Reality of non-compliance
Compliance is the main challenge for optimal treatment of
patients in general

Source: N. Barber, J. Parsons, S. Clifford, R. Darracott, R. Horne; Qual Saf Health Care
2004; 13: 172-175, doi: 10.1136/ qshc.2003.005926
Still taking medication at 10 days
(n = 226/239)
Still taking medication at 4 weeks
(n = 171/197)
Adherent
Non-adherent
Partial non-adherence
Complete non-adherence
159 (70%)
67 (30%)
49
18
128 (75%)
43 (25%)
26
17
Adherence to new medication:
Patients‘ problems with new medication
for chronic conditions

Source: F.A. Al-Eidan et al. J Clin Pharmacol 2002, 53, 163-171
Example
Compliance with and without help taking
medication in Hp eradication therapy

Valerie uses her spray
twice daily –
without any relief!
… without any problems?

Model of patient behavior
Levendahl, et al. stated 1992:
Patients personal ideas
about their illness are often
organized around five
components:
– Identity
– Timeline
– Cause
– Consequences
– Control/cure
These can be thought of
as the answers to five basic
questions about the illness
or health threat:
– What is it?
– How long will it last?
– What causes it?
– How will it/has it affected me?
– Can it be controlled or cured?
People form a mental model or representation of the illness,
which is made up of their answers to these questions.

Conclusion
How can patient behavior be changed
Physician

Physician
Motivational interviewing: Ask open questions in
Patient friendly language
What changes would you most like to talk about?
What have you noticed about…….?
How important is it for you to change…?
How confident do you feel about changing…?
How do you see the benefits
Source:
Physician
BMJ 2010

Physician
Physician
Motivational interviewing
Develop Discrepancy
– How does current behavior
conflict with core values?
Minimize Unsolicited Advice
– Patients overcomes their own obstracles
– Dance not a wrestling match
Support Self-Efficacy
– Uncover and reinforce it
Usual Suspects
– Express empathy
– Good nonverbal listening skills
– Be a problem solving partners Antje-Henriette Fink-Wagner, 2012 14

Physician
Physician
Never forget the WRITTEN action plan!
Red Zone: Stop! Danger!
Yellow Zone: Caution! Slow Down!
Green Zone: Go!

Conclusion
Nurse

NurseExample: Nurse
Phone Dialog
doctor – patient – nurse triangle
COPD case management
by National Jewish Medical
and Research Center
– Individualized by patient and physician
– Driven by action plans from physician
– Nurses handle calls based on
developed algorithms as kind of call center
– Inbound and outbound calls
through Case Manager (nurse)
– Physicians always notified
– Can be done every 12 or 24 hours and will be
less after few weeks

National Jewish Medical and Research Center
COPD all plan members
12-month utilization data
0 Adult Days Missed
from Work
n = 272
500
1500
ER Visits
n = 751
Hospitalizations
n = 751
Unscheduled Dr. Visits
n = 751
Oral Antibiotic Bursts
n = 746
1383
245
164
582
Baseline
7 to 12 Months
p < 0.001
1000
756
-79.7%
281
-70.7%
48
- 48.2%
127
-58.9%
239
-45.1%
415
Source: Data provided by David Tinkelman, vice president Health Initiatives NJC, December 2002
NurseExample: Nurse

Conclusion
Pharmacist

PharmacistExample: Pharmacist
EFA Allergy Awareness Project 2011-2014:
Pharmacists are the first Health Care Professionals
seeing a patient on risk for allergies when asking for
OTC products.
Situation: People often “know” they have an allergy but
do not go for proper diagnosis.
Aim: Use pharmacists to motivate potential allergy
patients to visit a doctor for proper diagnosis and
therapy.
Pilot project planed in Austria and Germany to proof
positive role of pharmacists in 2013.

Pharmacist
Voilà – Amuse gueule!
Appetizer …

Conclusion
Insurance/
Funds

Source: Techniker Krankenkasse, 2005; www.tk-online.de
Example: Insurance/Funds
Reminder service
Reminder service for preventive measures
of members
– Dental prophylaxis
– Health check-up
– Cancer prophylaxis
– Preventive care for children and youths
– Smoking cessation
Telephone reminder or information by e-mail
as requested by the member
Insurance/
Funds

Source: Techniker Krankenkasse, www.tk-online.de, Januar 2005
Example: Insurance/Funds
Diagnostic information for members
– After online entry of a diagnosis (often provided in codes only),
a diagnosis text is displayed in patient friendly language
– including additional information, e.g. links to treatment guidelines
Insurance/
Funds

Source: Chest 2011
Insurance/Funds
The impact of co pay costs on non adherence Insurance/
Funds
Rates of cost-related non-adherence (black bars) by monthly out-of-pocket
inhaler costs in the Inhaler +/CPD+ group. There is a roughly linear increases in
cost –related non-adherence as the out-of-pocket costs of inhalers increases
(test for trend, P<.0001). Error bars represent SEM.

Conclusion
Family
and
Friends

Example: Family and Friends
Smoking cessation
“Feel free to say no”,
an initiative of the European Union:
Testimonials presents the friends
of the target groups

Paul, hurry!
You have to be at
the doctor’s
at eleven …
Memory function …
Family
and
Friends

Conclusion
Public/
Policy Makers

Policy Makers
Health Literacy: a precondition to achieve acceptable
adherence/concordance
Public
Policy Makers
European Health Award October 2012 :
• Survey of the HLS-EU CONSORTIUM
Source: HLS-EU CONSORTIUM (2012): COMPARATIVE REPORT OF HEALTH LITERACY IN EIGHT EU MEMBER STATES. THE EUROPEAN HEALTH LITERACY SURVEY HLS-EU , ONLINE PUBLICATION:
HTTP://WWW.HEALTH-LITERACY.EU
About 12% of
respondents
have inadequate general
health literacy, and more
than one third (35%)
problematic health
literacy, thus nearly
every second respondent
shows limited health
literacy,
in the general sample.
8000 respondents from
8 countries.

Joint messages in as many countries
As possible
Public
World Awareness days
Public
Policy Makers
Creates awareness about a special
disease to patients, public and Policy Makers

Conclusion
Pharma-
ceutical
Industry

Pharma-
ceutical
Industry
Example: Pharmaceutical Industry
ZacPac
History
3 packages to eradicate Hp:
PPI plus two different antibiotics
(French triple therapy)
Compliance friendly solution
Development of ONE compliance-supporting
medication package for all three drugs
– Received the international award

Example: Technical Industry
Helping Hand™
– Electronic tool offered
by Bang & Olufsen
– Reminds patients to take
medication correctly
– Helps patients to feel secure on
level of compliance
– In use for 4 indications
(CNS, cardiovascular,
osteoporosis, immune suppression)
– Improves compliance from
45 – 80% and 95% of doctors
believe patients benefit from it
– Increased persistence
affects market shares
(according to B&O)
Pharma-
ceutical
Industry

Conclusion
Patient
Associations

Patient Association
European Federation of Allergy and Airways
Diseases Patient Associations EFA
– 32 Member organizations in 22 countries
– EFA Respiratory Allergy Awareness Project:
– Raise awareness of respiratory allergies (Rhinoconjunctivitis and
Allergic Asthma Rhinitis, Asthma) as serious chronic disease
– Call for
– Early identification of symptoms by target audience
– Early diagnosis and appropriate strategies including life style changes
and physical activities to manage and control allergic diseases to
– Avoid exacerbations of severe allergies
Patient
Associations

EFA Call to Action
– EU policy-makers are called to coordinate actions to
1) Increase the political recognition of respiratory allergies as a
real and serious disease
2) Promote national programmes on respiratory allergies
3) Prioritize the management and control of respiratory allergies
4) Promote training in allergy for healthcare professionals to
improve accurate and early diagnosis
5) Align healthcare and reimbursement policies, to support
appropriate disease management
6) Improve indoor air quality
Invitation to sign the EFA Call to Action:
http://www.efacallaction.net/sign.aspx Antje-Henriette Fink-Wagner, 2012

Patient
Associations
Patient Association
Global Allergy and Asthma Patient Platform
– 24 member organizations on all
Continents
– Sport Games for children with asthma to promote
adherence to sport for asthmatics (see first talk of this
session)

Conclusion
Adherence / Concordance will improve
as the sum of individual advocacy initiatives
by all allied healthcare professionals and the
patients themselves.

COMPLY –
OR DIE
Thank You!

Adherencia al Tratamiento. Dr. Antjefink Wagner

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