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What are the main ways to improve patient adherence?
Hi! Thank you for your question regarding improving patient adherence.
Patient adherence to medical treatment is a complex issue with no one correct solution for all patients. From my research the most significant factor involved in improving adherence centers on the physician-patient relationships. Patients who trust their physician and who feel play an active role in their own medical treatment decisions, are more likely to adhere to their regimens. Other factors that improve patient adherence is increasing health literacy, simplification of treatment regimens, and addressing health beliefs. A deep-dive of my findings can be found below.
PROBLEM OF NONADHERENCE
Nonadherence occurs in as many as 40% of all patients. Research has found that almost half of patients which chronic illnesses do not take their medication as prescribed. The fiscal consequences of nonadherence is estimated to be $300 billion. Related hospitalization alone is thought be around $13.35 billion annually.
Nonadherence also results in the worsening of health conditions, the development of secondary conditions, and up to 125 thousand deaths annually. For certain conditions, such as HIV and diabetes, adherence is particularly crucial for the prevention of further disease development and the maintenance of high life quality. In addition to the direct health and cost factors, nonadherence increases a patient's risk of medical mismanagement. When physicians fail to recognize the extent of a patient's nonadherence, they may change medication or dosage inappropriately, resulting in more problems.
BODY OF RESEARCH & TERMINOLOGY
There is a significant amount of research available for study on the topic of patient adherence. Over 40,000 adherence related citations can be found on PubMed and PsychLit from the past fifty years. The body of research varies in methodology from subjective self-reporting to the use of technology-based monitoring systems. Several literature reviews can be found analyzing the results of these studies.
One such review (conducted out of Europe but citing many U.S. papers) mentions the historical changes and significance of terminology when discussing the topic. Early literature uses the term compliance which carries negative connotations. "It suggests yielding, complaisance and submission." The alternative term, adherence, "incorporate the broader notions of concordance, cooperation and partnership" which are important elements in increasing a patient's likelihood of following a medical regimen.
PHYSICIAN-PATIENT RELATIONSHIP
Martin et al., states that "The physician–patient partnership itself, however, remains at the core of all successful attempts to improve adherence behaviors." A preliminary study of physicians treating HIV patients supports this idea by suggesting that a combination of brief physician training and patient coaching improves in-office communication. In other studies, "Adherence rates have been found to be nearly 3 times higher in primary care relationships characterized by very high levels of trust coupled with physicians' knowledge of the patient as a whole person. In fact, patients' trust in their physician has been found to far exceed many other variables when it comes to promoting patients' satisfaction with their care."
A positive physician-patient relationship, according to the literature consists not only of communication and trust, but also in a mutual respect that allows for a collaboration between the patient and physician in the treatment decision making process. A lack of such two-way conversation is identified as one of the most significant problems with adherence. "54% of patients' problems and 45% of patient concerns are neither elicited by the physician nor disclosed by the patient." Conversely, Martin et al. states that "Studies have found that both patient satisfaction and patient adherence are enhanced by patients' involvement and participation in their care "
A physicians ability to asses adherence is also effected by the physician-patient relationship. "Patients tend to be truthful in their adherence reports only when they feel free to admit adherence difficulties without the risk of criticism and in the context of true partnership with their physicians." In addition, "many of the factors necessary to carry out such assessment are the very elements that foster communication and partnership in the medical visit. Patients need to be given the opportunity to tell their story and to present their point of view to the physician."
PATIENT FACTORS
There are several factors pertaining to the patient that strongly influence adherence as well including health literacy, cognitive ability, beliefs,
Reason dictates that patients who fail to understand basic written medical instruction will have difficulty adhering to them. Studies show that health literacy is a common problem related to adherence, but this doesn't always have to do with education or language. While language barriers are sometimes a factor, in one study "even when patients could understand the language of their medical instructions, many could not comprehend the medical information." This study shows that around one third of patients experienced some level health literacy issue with 25% failing to comprehend appointment schedules and 60% unable to understand a informed consent document. Patient memory also plays a factor with studies showing that 56% of patients forgot instructions moments after leaving their physician's office. In addition, sometimes patients have patients have stubborn health-related beliefs and attitudes. In another study of asthmatic patients, even after extensive education, only 38% of patients adhered to their treatment while "the other 62% continued to mistakenly believe that their medication should only be taken when they were symptomatic." Mental state and attitude also plays a role in adherence. Depression increases a patient's risk of nonadherence by 27%.
COMPLEXITY OF TREATMENT
A strong coorelation is found between adherence and regimen or treatment complexity. While 40% of patients already tend fail to adhere, the number rises to 70% "when preventive or treatment regimens are very complex and/or require lifestyle changes and the modification of existing habits." Only 20% of patients who require taking 13+ daily pills are found to comply. In addition, 84% of patients will adhere to a once-daily medication regimen whereas only 59% will adhere to a thrice-daily schedule.
RECOMMENDED SOLUTIONS
Atreja et al. proposes the mnemonic SIMPLE as a method of categorizing proven patient adherence enhancements strategies. SIMPLE stands for:
Simplifying regimen characteristics
Imparting knowledge
Modifying patient beliefs
Patient communication
Leaving the bias
Evaluating adherence
The principles of SIMPLE collaborate well with other the discussion of other papers. Many of the points made by Atreja et al. concerning treatment simplification and physician-patient communication/relationships are also found in the other literature reviews.
They elaborate the importance of patient health beliefs by offering to following recommendations:
(1) perceive themselves to be at risk due to lack of adoption of healthy behavior (perceived susceptibility), (2) perceive their medical conditions to be serious (perceived severity),
(3) believe in the positive effects of the suggested treatment (perceived benefits),
(4) have channels to address their fears and concerns (perceived barriers), and
(5) perceive themselves as having the requisite skills to perform the healthy behavior (self-efficacy)."
The "Leaving the bias" part of SIMPLE refers to the prevalence of early studies that suggested adherence differences based on such factors as race, educations, sex, income, and other demographics. Recent reviews find little to no significant correlation between these demographics and adherence.
In adherence evaluation, SIMPLE suggests using the Morisky questionnaire for self-reporting. This has been found to be effective and only consists of four questions which are:
• "Do you ever forget to take your medications?"
• "Are you careless at times about taking medications?"
• "When you feel better, do you sometimes stop taking medications?"
• "Sometimes, when you feel worse, do you stop taking your medicine?"
Atreja et al. calculates a success rate of 68% for the proposed SIMPLE interventions. However, they warn that there are still challenges, such as limited time and budget, when implementing changes in a busy clinical setting. Also, it should be noted that there is no one-size-fits-all strategy as individual needs vary greatly between patients.
OTHER RELATED RESOURCES
The World Health Organization (WHO) provides in its resources a guide on the topic titled "Adherence to Long-Termk Therapies - Evidence for Action." Like the other cited resources, this guideline in the "Take-home messages" section emphasizes the importance of patient-tailored interventions as well as the patient support over patient blame. Section III may be useful resource in further research as it breaks down the discussion into disease specific adherence issues.
CONCLUSION
Although solutions to the problem of nonadherence are complex and must be individually tailored, there exists a rich body of research to assist healthcare professional in addressing the issues along with some proven techniques as outlined in principles of SIMPLE.
I hope this research is useful to you. Thanks for using Wonder!
Notes: One reference is from Medscape. You will be asked to set up a free Medscape account in order to view the source. Another reference - Vermeire, et al. - is a European literature review, but was included as many of its reference are U.S.-based.