Patient adherence – what’s the problem?

John Weinman | Professor of Psychology as applied to medicineKing’s College London

John Weinman

Institute of Pharmaceutical Sciences,

Kings College London

PATIENT ADHERENCEWhat’s the problem?

The problem of non-adherence

WHO report on non-adherence

• Estimated that over 30 -50% medicines prescribed for long term illnesses are not taken as directed

• Similar levels for psychol treatments - e.g . Attendance/homework for CBT

• If treatment is evidence- based, then this represents a loss for patients and for the health care system

Risk of hospitalisation & non-adherence

Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on

hospitalization risk and healthcare cost. Medical Care. 2005;43:521-530.

Health care cost of non-adherence

CAUSES OF

NON-ADHERENCE

• Common myths• Current evidence

Myth 1: Non-adherence is a feature of the disease

Non-adherence is not linked to type of disease

Low adherence rates are problematicin most chronic diseases e.g.•HIV1 •Cancer2 •Heart disease3

1Friedland, Williams. AIDS 1999;13(Suppl 1):S61–72.2Lilleyman, Lennard. BMJ 1996;313:1219–1220.3Horwitz et al. Lancet 1990;336:1002–1003.

• Rheum. arthritis4 • Diabetes5

• Asthma6

4Hill et al. Ann Rheum Dis 2001; 869-875.5Glasgow et al. J Behav Med 1986;9:65–77.6Cochrane et al. Respir Med 1999;93:763–769..

Myth 2Myth 2

•Non-adherence is related to:

Gender Educational experience Intelligence Marital status Occupation / income Ethnic background

Most patients will be non-adherentsome of the time

Most patients will be non-adherentsome of the time

Adherence Rates Vary

Between patients

Within the same patient over time and across treatments

Myth 3Myth 3

•Non-adherence is easily fixed by : -

Providing information Providing reminders Being authoritative Fear arousal

ADHERENCE INTERVENTIONS

Cochrane review: Haynes et al (2008)

“Current methods of improving adherence are mostly complex and not very effective, so that the full benefits of treatment cannot be realized.

High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term disorders”

How can the problem be tackled?How can the problem be tackled?

• Need to understand types and causes of non-adherence

•Need to tailor interventions to take account of this

•Develop & test theoretical models

TYPES OF NON-ADHERENCE

RANGE OF POSSIBLE FACTORS :-

•Poor HCP-Patient Communication•Low patient satisfaction and/or recall•Problems in planning/executive function

or prospective memory•Financial or other barriers

UNINTENTIONAL NON-ADHERENCE

Beliefs influence unintentional non-adherence - forgetfulness 2

1 BCG Harris 2002; Conrad Soc Sci Med 1985;20:29–37; Ley 1988; Peterson Am J Health-Syst Ph 2003;60:657–652 Unni , Pat Edu Coun 2010 doi:10.1016/j.pec.2010.05.006

Patients know what to do & how to do it

BUT are reluctant to adhere because either :-

•TREATMENT DOESN’T MAKE SENSE

•WORRIES/CONCERNS ABOUT TREATMENT

INTENTIONAL NON-ADHERENCE

Predictors of non-adherence : Overview of Evidence

What are the key beliefs influencing adherence to

treatment?

1) Patients’ perceptions of illness

2) Patients’ perceptions of treatment

Core beliefs about Illness

• IDENTITY Abstract label eg, hypertension;asthma; arthritis

Concrete symptoms that aperson associates with thecondition

• CAUSAL BELIEFS Stress, environment, genetics,own behaviour, ageing etc

• TIMELINE Perceived duration and profile eg,chronic, acute, cyclical

• CONSEQUENCES Personal, economic, social

• CURE / CONTROL Beliefs about the amenability tocontrol or cure

ILLNESS PERCEPTION & treatment adherence

• Some illness perceptions are associated with treatment adherence in some conditions :-e.g. - causal beliefs predict adherence behaviour in post- MI

- timeline beliefs predict preventer medication

adherence in asthma etc

- causal, timeline & control beliefs predict adherence to CBT for Psychosis (Freeman et al, in press)

• BUT – illness beliefs per se are not strong predictors of treatment adherence – need to consider more proximal predictors (ie patients’ beliefs re. treatment)

TreatmentTreatmentIllnessIllness

What are the links between illness and treatment beliefs?

GOODNESS OF FITbetween illness reps and

treatment recommendations• Patients evaluate the need for treatment in the

light of their understanding of illness

• But some treatments may not make sense :- - exercises for back pain , balance disorder etc - daily adherence to preventer medication in

asthma - smoking cessation in early cervical cancer - phosphate binding medication in ESRD

• CHALLENGE TO HP – to identify these situations and to assess treatment

beliefs -- develop interventions to increase

adherence goodness of fit and increase motivation to adhere

TREATMENT BELIEFS: What is the patient's perspective ?

Beliefs about Medicines Questionnaire(BMQ)

GENERAL BELIEFSabout medicines as a whole

SPECIFIC BELIEFSabout medicines prescribed for a particular illness

SPECIFIC BELIEFSViews about prescribed medication

NecessityBeliefs about necessity

of prescribed medication for maintaining health

Concerns Arising from beliefs about potential negative effects

Low adherence

Doubts about

NECESSITY

CONCERNS about potential adverse effects

Studies in asthma, CHD, cancer, renal dialysis, HIV/Aids, hypertension, diabetes

Horne et al (in press), Cooper et al (2002), Horne et al (2001), Horne & Weinman (2002), Horne (2000), Horne & Weinman (1999) Horne et al (1999), Horne (1988)

SUMMARY

• Influence adherence• Have an internal logic• Are influenced by symptoms• May differ from the ‘medical view’• May be based on mistaken beliefs/premises• May not be disclosed in consultation• Are not set in stone and can be changed

Patients’ beliefs about their illness and treatment

Implications for health care ?

1. Use the consultation to anticipate and plan

2. Interventions to :-- improve goodness of fit

- improve understanding of illness and treatment

Using the consultation to facilitate informed adherence

• Check patient’s understanding of treatment and , if necessary :-

• Provide clear rationale for NECESSITY of treatment

• Elicit and address CONCERNS

• Agree practical plan for how, where and when to take treatment

• Identify any possible barriers

NEEDS TRAINING OF HCPs – studies in progress

Interventions to improve adherence

Now a number of successful approaches which are based on a good understanding of patients’ beliefs, using different media, such as :-

• text messaging• web-based interactive programmes• phone based support

British Journal of Health PsychologyVolume 17, Issue 1, pages 74–84, February 2012

Method212 patients aged 16-45 recruited from medicine package inserts or heath websites - dx asthma (not

COPD), not taking preventer meds as

prescribed

Normal careTailored Txt messages

18 weeks

Baseline assessment

Adherence assessments at 6,12, 18 weeks and 6 months

Your asthma is always

there, even when you don’t have symptoms

Your preventer

controls your asthma over the long term

& stops attacks

Your preventer is safe to take every day

Timeline

Personal control

Treatment control

Illness consequen

ces

Medication necessity

Medication concerns

Targeted Texting

Preventer Adherence Levels M

ean c

om

plia

nce

sco

re

Compliance = puffs taken/puffs prescribed Group difference p <.01

Percentage of patients reporting adherence at 80% or greater in control and intervention groups

Conclusions• A better understanding of patients

perspectives of illness and treatment is key to understanding adherence

• This approach offers a framework for identifying and addressing the key barriers to adherence to medication

• Urgent need to•1. develop interventions which can be delivered in routine consultations•2 provide patients with better access to specialist tailored interventions