The extent to which interventions to increase adherence to medical regimens have been successful - Essay Example

? THE EXTENT TO WHICH INTERVENTIONS TO INCREASE ADHERENCE TO MEDICAL REGIMENS HAVE BEEN SUCCESSFUL of Class: Professor: Submission Date: Abstract This paper investigates the extent to which interventions to increase adherence to medical advice/ regimens are successful. Despite the fact that patients actively seek medical help to resolve their health problem, their nonadherence to treatment protocols has been a cause for concern to physicians. The barriers to patients’ adherence to medical regimens are discussed. Based on the assumptions on which the Adherence/ Compliance Model is developed, as well as the barriers to patients’ adherence to medical regimens, it is acknowledged that the Adherence model is faulty. On the other hand, the Health Belief Model which centres on patient autonomy and on promoting preventive health care is an improved version of the Adherence model. Hence, various strategies including educating patients, promoting lifestyle modifications and participation in shared decision making with the physician, are studied. Adherence problems related to specific health conditions are outlined in the paper. It is concluded that patients’ adherence to medical regimens is successful with the implementation of the strategies, especially those focusing on patient autonomy, shared decision making with the physician and lifestyle modifications that include precautions to prevent future health problems. INTRODUCTION When patients are prescribed a treatment for an existing health problem, their adherence to the medical regimen advised by the physician, and compliance with the doctor’s guidance on medication schedule, changes in diet or lifestyle are important issues. Only by closely following the treatment guidelines can patients obtain the required health outcomes. The basic assumptions that underscore this approach are as follows: when a person has a diagnosed health problem, the requirement for initiating and maintaining treatment are necessary, not optional; patients who are suffering from an ailment should be motivated to adhere to treatment that provides symptom relief; and if a patient seeks medical help for a problem, he or she should be encouraged to accept prescribed treatment. In the model relating to adherence to medical regimens, there is a necessity to resolve the enigma of “why patients would not comply with the solution they sought out in the first place” (Bauman 2000, p.75). Thesis Statement: The purpose of this paper is to investigate the extent to which interventions to increase adherence to medical advice/ regimens have been successful. Key Words Adherence, compliance, medical advice, regimens. Research Evidence Using the above key words, databases such as Google Books, Google Scholar, and Questia Online Library were thoroughly scrutinised for suitable literature and research work on the topic. Because the key words used were specific, most of the books and articles that were obtained through search results were relevant. The books and journal articles that were more recently published were selected. Of these, the academic sources including research studies that pertained to the psychological aspects of adherence to medical regimens were used as references for writing the paper. PATIENTS’ ADHERENCE TO MEDICAL REGIMENS “Rates of adherence for individual patients are usually reported as the percentage of the prescribed doses of the medication actually taken by the patient over a specified period” (Osterberg & Blaschke 2005, p.487). Some researchers study adherence more closely by including data on dose taking related to the prescribed number of pills each day; and the timing of doses of the medication within a prescribed period. Usually adherence rates are higher among patients with acute conditions, in comparison with those with chronic conditions. Continuation of medication among patients with chronic conditions is disappointingly low, declining sharply after the first six months of treatment (Haynes, McDonald & Garg 2002; Jackevius, Mamdani & Tu 2002). For example, nearly 50% of patients administered hydroxymethylglutaryl-coenzyme A reductase inhibitor therapy will discontinue their medication within six months of starting the therapy, as seen in the study conducted by Benner, Glynn, Mogan et al (2002) to investigate long-term persistence in the use of statin therapy in elderly patients. Usually, it is found that in clinical trials the average rates of adherence can be high, based on the selection of patients and the attention they receive under research study. However, even clinical trials report only average adherence rates of around 43 to 78 percent among patients receiving treatment for chronic conditions, as found in studies conducted by Cramer, Rosenheck, Kirk et al (2003), and by Claxton, Cramer and Pierce (2001). There is no specific standard universally agreed upon, for what constitutes adequate adherence. While some clinical trials delineate rates over 80 percent to be acceptable, other studies mark rates greater than 95 percent to be essential for adequate adherence. This is especially so for patients with serious conditions such as infection with the human immunodeficiency virus (HIV). Data pertaining to adherence are frequently reported as dichotomous variables such as adherence versus nonadherence. At the same time, adherence can vary along a range of 0 to over 100 percent, “because patients sometimes take more than the prescribed amount of medication” (Osterberg & Blaschke 2005, p.487). Physicians may not be able to recognise nonadherence, and interventions to increase adherence have had mixed outcomes. Additionally, successful interventions are usually highly complex as well as expensive (Burnier 2000). Barriers to Patients’ Adherence to Medications Research on adherence has frequently investigated the barriers patients confront in taking their medications. The commonly occurring barriers to adherence are under the patient’s control; hence these factors such as forgetfulness, lack of information, emotional reasons, decision to omit doses, as well as patients’ other priorities have to be examined towards increasing adherence to medical regimen (Osterberg & Blaschke 2005). Physicians contribute to patients’ poor adherence to their medication course by prescribing complex regimens, not making known the potential side effects or the benefits of a medication adequately, not taking into account the patient’s lifestyle or the cost of the medication, and by having a poor therapeutic relationship with their patients. “The failure of patients to follow medical advice or prescriptions reduces the effectiveness of health care and increases its cost” (Gazzola & Muskin 2003, p.401). Estimates of noncompliance differ, but around 50 percent of patients may fail to adhere to their medical regimens. In cases of preventive regimens or long-term lifestyle modifications, the estimates of noncompliance are even higher. Long-term treatment for asymptomatic illnesses such as hypertension is more problematic in relation to adherence to the required protocol. It is important for physicians to invoke in the patients a moderate level of fear regarding the adverse consequences of poor hygiene, improper diet, inadequate exercise, and other lifestyle factors, in order to change health attitudes. Further, positive incentives such as information regarding beneficial outcomes and reduction in heart disease risk can promote dietary change and reduction in smoking and other addictive and harmful behaviours. Further, nonadherence is also linked with social class and language barriers. Moreover, a doctor who uses a formal manner with patients may create an environment in which patients feel intimidated and discouraged from asking questions, thereby increasing the potential for misunderstandings and subsequent non-adherence. Chrisler and O’Hea (2000, p.332) state that “if patients do not understand what they are being asked to do, they cannot possibly do it”. The Adherence/ Compliance Approach is Faulty “The adherence/ compliance approach is faulty if the assumptions underlying it do not apply” (Bauman 2000, p.75). The model assumes that an existing health problem represents real and present danger, not a theoretical or possible harm in the future. However, several patients are diagnosed on the basis of routine screening tests of a condition in its early stage before it is symptomatic, when the goal of treatment is to prevent long-term serious sequelae, as in hypertension, obesity, or early stage cancer. These predominantly asymptomatic patients often require therapy that produce side effects, as in chemotherapy, hypertension medication that can have harmful effects on fertility. On the other hand, symptomatic patients may feel motivated to adhere to treatment regimens if they get relief, but when the symptoms are cured, the motivation to continue with the treatment may also disappear. Examples are termination of antibiotic treatment for infection and daily oral steroid use in patients with asthma. Even when patients seek relief from symptomatic conditions, there are numerous barriers to perfect compliance, often rooted in the nature of the treatment. These include degree of difficulty, pain, and a need for ongoing change in lifestyle as in dialysis treatment, intrusiveness as in blood sugar monitoring, diet as in diabetes, and daily radiation therapy for cancer. Complexity as in HIV triple therapy, expense as in growth hormone treatment, length of time, or lack of perceived effectiveness are factors that lead to nonadherence to medication regimens. Bauman (2000, p.75) reiterates that “the Adherence/ Compliance approach rests on assumptions that often do not apply”. Further, these assumptions may not be applicable for patients with a diagnosed illness, or for those prescribed a regimen to prevent a condition or to reduce risk. Persuading people to adopt health-promoting and disease-preventing behaviours has been guided by a different tradition, termed as the Health Belief Model. The Health Belief Model When an individual is prescribed a regimen to prevent a health problem or to lower risk for the future, patient acceptance of advice is not based on a model of compliance assumptions or language. On the other hand, theoretical models using cognitive-behavioural approaches such as the Health Belief Model are used. This conceptual approach different from the Adherence/ Compliance model prevents future harm rather than manage a current problem. Without assuming that adherence has to occur, the theory acknowledges that patients are autonomous not passive, that “there should be a partnership between provider and patient in choosing a prevention strategy, and that the patient chooses to adhere with a prevention regimen” (Bauman 2000, p.76). The Health Belief Model puts forward that people will adopt preventive health practices if they understand that: first, they are at risk of illness whose consequences are serious; second, that there is an effective action that can be initiated to reduce the risk or severity of the outcomes; and third, the barriers or costs of adopting the preventive practice are lower than the benefits. This model has been modified for studying compliance with medical advice when an illness is diagnosed to include health concerns and beliefs, particularly general beliefs about illness susceptibility, trust in provider, and features of the medical regimen (Bauman 2000). Both the Adherence model and the Health Belief Model are similar in some respects. These include patient motivation in adherence to advice; high motivation with greater severity of the condition and accompanying prognosis; the extent to which adherence to the regimen will reduce discomfort; the extent to which adherence will improve or cure the underlying condition; and the degree to which the illness interferes with daily activity. Further, Bauman (2000) states that both models also focus on the barriers to adherence to medication, the factors that interfere with patients’ ability to follow the treatment protocols, such as patient limitations such as poor eyesight, forgetfulness, regimen characteristics such as complexity or side effects, and provider-patient relationship. The Health Belief Model which acknowledges patients as autonomous decision makers is similar to the improved version of the Adherence Model, implementing strategies for increasing adherence such as patient participation in formulating treatment plans, and using shared decision making with the physician (Bauman 2000). Strategies for Optimizing the Adherence/ Compliance Model Interventions that help to improve patients’ adherence to medication can be grouped into four general categories. These include: patient education, improved closing schedules, increased hours for keeping the clinic open leading to shorter wait times, improved communication between physician and patient and shared decision making. Educational interventions involve patients, their family members, or both, and can effectively improve adherence. According to Flynn (2003), the rationale underlying patient education strategies consists of the following components. The provision of salient and relevant information that facilitates patients’ understanding of their conditions, and of how a particular course of action will impact upon their quality of life before, during and after treatment. Further, to increase awareness of the different treatment options available, and the potential desirable as well as undesirable effects which are known to result from particular treatments. Similarly, to provide patients with sufficient information about their condition, which is essential for participation in shared decision making together with physicians, in selecting a treatment. Patients’ education can be done during physician-patient encounters which are full of teachable moments. However, time constraints and patient resistance may hinder the teaching process. Even so, “enlightening patients about their medical problems, instructing them on how to follow their treatment regimens and focus their online research, benefit all concerned” (Weiss 2010, p.22). At the same time, patient education is required to be tailored according to individual patients’ age, educational level, cultural background, and tech-saviness, which can affect the extent of patients’ understanding and adherence to doctor’s advice. Methods used to improve dosing schedules include “the use of pillboxes to organise daily doses, simplifying the regimen to daily dosing, and cues to remind patients to take medications” (Osterberg & Blaschke 2005). Those patients who miss appointments are frequently those who require the most help to improve their ability to adhere to a medication regimen. Such patients will often benefit from assistance in clinic scheduling and ‘cuedose training’ to optimise threir ahderence. Strategies pertaining to clinic scheduling to increase adherence encompass follow-up visits which are according to the patient’s convenience. Delays in seeing patients, and problems encountered in transportation and parking can reduce a patient’s willingness to adhere to a medication regime, and to keep follow-up appointments. Interventions that include the assistance of ancillary health care providers such as pharmacists, behavioural specialists, and nursing staff can increase adherence. This is evident from the randomised, controlled study conducted by Bouvy, Heerdink, Urquhart et al (2003) on the effect of a pharmacist-led intervention on diuretic compliance in heart failure patients. Lastly, increasing the communication between the physician and the patient is a basic and effective strategy in promoting the patient’s ability to follow a medication regimen. Strategies for increasing adherence have used combinations of behavioural interventions and reinforcements besides increasing the convenience of care, providing educational information about the patient’s condition and the treatment, and other forms of supervision or attention. An example is Zygmunt, Olfson, Boyer, et al’s (2002) study of interventions to improve medication adherence in schizophrenia. Successful methods are complex and require intensive labour, hence innovative strategies will need to be developed that are practical for routine clinical use. It is evident that numerous factors contribute to poor adherence to medication, hence a multifactorial approach is required, because a single approach would not be effective for all patients. In traditional medical practice, decision-making about the patient’s treatment was physician-centred. However, in contemporary times, a new influential drive promotes shared decision-making between physicians and patients, although it may not yet be universally practised. Shared decision-making shifts the entire responsibility of decision-making away from the physician. The greater advantages of shared decision making include a reduction in patient’s uncertainty, increased acceptance of responsibility for decisions, and higher levels of compliance with medical regimens and advice, because of patients’ participation in the decision-making process. Based on these outcomes, there are fewer complaints and legal claims from patients, and greater patient satisfaction with health care. Additionally, physicians’ uncertainty is likely to be reduced as patients receive treatments in accordance with their “values, needs and preferences associated with improved health outcomes” (Flynn 2003, p.241). As a result, there may be a reduction in the practice of defensive medicine where the medical practitioner avoids potential problems that he may have to face, and tailors the treatment accordingly. This change is beneficial for improved provision of healthcare. According to King and Moulton (2006), involving the patient even to a minimal extent such as providing information and alternative treatment options helps in the decision-making process. This improves the patient’s overall physical and mental health thereby leading to enhanced psychological and well-being outcomes, greater sense of satisfaction with their physicians, and increased control over their own recovery. The possible reasons are patient’s greater sense of investment in their treatment choice and being more informed about why certain components of the treatment are necessary. Poorer conrol over diseases such as diabetes and hypertension was found in patients who participated less in conversations with their physician, were less involved in the medical decision, and expressed less opinions and emotion with their physician. Further, a few more simple strategies are suggested by Osterberg and Blaschke (2005, p.493), for enhancing a patient’s ability to follow a medication regimen. These include: identifying poor adherence, looking for markers of nonadherence such as missed appointments, lack of response to medication, missed refills of medicines. Physicians are required to find out about barriers to adherence without being confrontational, they should emphasize the value of the regimen and the benefits of adherence, and should interact with patients to determine the patient’s feelings about their ability to comply with the regimen, and develop supports to promote adherence if necessary. Moreover, it is vital that instructions to patients are clear and simple, and the medication regimen is also simplified to the greatest extent. Additionally, it is essential that the physician listens carefully to the patient, and customises the regimen according to the patient’s wishes. When required, help should be obtained from family members, friends, and community services. Desirable behaviour and beneficial results, have to be reinforced when considered appropriate, and more ‘forgiving’ medications should be provided when adherence appears unlikely. Examples are medications with long half lives, depot or extended release medications, and transdermal medications. Evidence from a study conducted by Auslander, Thompson, Dreitzer et al (1997) indicates that increased satisfaction with medical care may improve patient adherence to medical regimens, thereby creating optimal health outcomes. Similarly, results from a study conducted by Cox (2009), revealed that psysicians rated patients as having good adherence more frequently in the cases concerning older patients, those employed at the time of enrollment, those who showed altruism, and considered HIV to be serious. CONCLUSION This paper has highlighted adherence to medical advice/ regimens, and determined the extent to which interventions to increase adherence have been successful. It is evident that patients’ adherence to medical regimens is based on a number of assumptions. These include the requirement for initiating and maintaining treatment for a patient being mandatory and not optional; patients with an ailment should be motivated to adhere to treatment that provides relief; and patient seeking medical help for a condition should be urged to accept treatment prescribed by the physician. It is incomprehensible to physicians why patients often do not comply with the solution to their problem which they had sought. The barriers to patient adherence to medications have been examined, and several strategies for increasing patient adherence to medical regimens have been discussed. Essential strategies for increasing patients’ adherence to medical regimens include educating patients, promoting lifestyle modifications, and supporting adherence through shared decision making between physicians and patients. Keeping in view the assumptions which form the basis of the Adherence/ Compliance Model, and the various barriers that prevent patients from adhering to treatment protocols, the Adherence Model was found to be faulty. However, by implementing the strategies for increasing patient adherence, the Adherence Model is found to be suitable for ensuring treatment adherence by patients, and is similar to the Health Belief Model which emphasizes patient autonomy, implementing actions to prevent future health problems, and optimal quality of life. It is concluded that patients do not fail to adhere to treatment guidelines, instead they choose a different course of behaviour. The doctor’s advice is only a part of several inputs on handling health and illness. Bauman (2000, p.77) reiterates that “providers may consider the decisions that patients make irrational, but they may be quite rational from the patient’s perspective”. BIBLIOGRAPHY Auslander, W.F., Thompson, S.J., Dreitzer, D. & Santiago, J.V., 1997. Mother’s satisfaction with medical care: Perceptions of racism, family stress, and medical outcomes in children with diabetes. Health and Social Work, 22(3): pp.190-199. Bauman, L.J., 2000. A patient-centered approach to adherence: Risks for nonadherence. In D. Drotar (Ed). Promoting adherence to medical treatment in chronic childhood illness: Concepts, methods, and interventions. Mahwah, New Jersey: Lawrence Erlbaum Associates. Chapter 3, pp.71-94. 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