Adherence to mental health treatment in a primary care clinic

BACKGROUND: Patient nonadherence is common for the standard mental health treatments in primary care: antidepressants and referrals to specialty mental health treatment. This is one of few studies to prospectively identify predictors of nonadherence. METHODS: We observed 95 veterans attending an internal medicine clinic prescribed antidepressant medication or referred to mental health treatment. We collected information on sociodemographic factors, health beliefs, preferences about treatment, past experiences, and treatment knowledge. RESULTS: At 1 month, medication adherence was greater when patients experienced previous pharmacy trouble and traveled for less than 30 minutes to reach the clinic. Appointment attendance improved when patients were ready for treatment, perceived benefits, and saw their physician as collaborative. At 6 months, medication adherence was greater when patients reported a preference for medicine treatment, traveled for less than 30 minutes, and perceived greater benefits. Fewer negative effects from previous mental health treatment improved adherence to appointments. In multivariate analyses examining adherence to all treatments, greater readiness for treatment predicted 1-month adherence, whereas being unmarried and seeing the physician as more collaborative improved 6-month adherence. CONCLUSIONS: Adherence to antidepressant medications and to mental health referrals should be examined separately. A brief initial assessment for nonadherence risk factors may identify persons for targeted adherence promoting interventions.     

Techniques for Measuring Medication Adherence in Hypertensive Patients in Outpatient Settings

Lack of adherence to prescribed antihypertensive regimens constitutes a barrier to adequate blood pressure control and prevention of cardiovascular events. Various means of measuring adherence to antihypertensive medications are currently available for use in clinical practice. The choice of the specific measure used in clinical practice depends on the intended use of the information, the resources available to the provider, as well as patient acceptance and convenience of the method. This article presents an overview of the advantages and limitations of the methods used to measure medication adherence that are currently available for use in outpatient settings, it also outlines provider strategies for addressing adherence issues related to antihypertensive medications.Indirect methods used to measure adherence in the outpatient setting include self report, electronic adherence monitoring (e.g. medication event monitoring system), pharmacy refill rates, and pill counts. Direct methods include the use of bioassays or biomarkers, which involve laboratory detection of the drug or a metabolic product of the drug in a biologic fluid, or laboratory detection of a biologic marker. Direct observation of the patient taking the medication is also another direct method; however, it is impractical in the outpatient setting, especially for long-term treatment. Each of these methods has advantages and disadvantages; perhaps using a combination of methods may provide the most accurate assessment of adherence.The information gained from measurement of adherence can help to formulate recommendations for individual patients regarding necessary adjustments to their medication-taking behavior to achieve the optimum outcome. Part of the difficulty associated with achieving better medication adherence lies in the inherent complexity of medication-taking decisions and behavior and of relationships between patients, their healthcare providers, and often others involved in the patient’s care, such as family members. Poor medication adherence and ultimately, adverse cardiovascular outcomes, is related to a variety of factors: quality of life; complexity of medication regimens; costs of medications; adverse effects of medications; demographic, behavioral, treatment and clinical variables; knowledge of hypertension and healthcare system issues; and use of non-conventional therapies. To be effective, strategies employed in clinical practice to overcome nonadherence need to take into account patients’ individual characteristics. Frequently, more than one strategy is necessary to bring about the desired level of adherence. The benefits of proven medical treatments are only available to patients who actively use them; thus, patient adherence to healthcare provider recommendations is the key mediator between medical practice and health outcomes.     

The burden and management of dyslipidemia: practical issues

Abstract The objective of this study is to describe briefly the burden of dyslipidemia, and to discuss and present strategies for health professionals to improve dyslipidemia management, based on a review of selected literature focusing on interventions for dyslipidemia treatment adherence. Despite the availability of effective lifestyle and pharmaceutical therapies for dyslipidemias, they continue to present a significant economic burden in the United States. Adherence to evidence-based guidelines for the treatment of dyslipidemias is unsatisfactory. The reasons for medication nonadherence are complex and specific to each patient. The lack of progress in achieving optimal lipid targets is caused by many factors: patient (medication adherence, cost of medication, literacy), medication (adverse effects, complexity of regimen), provider (lack of adherence to evidence-based practice guidelines, poor communication), and the US healthcare system (being focused on acute care rather than prevention, lack of continuity of care, general lack of use of an electronic health record). Combined interventions that target each part of the system have been effective in improving treatment adherence and achieving lipid goals. Patients, providers, pharmacists, and employers all play a role in management of dyslipidemia. No single approach will solve the complex issue of improving dyslipidemia management. The required lifestyle changes are known and effective medications are available. The challenge is for all interested parties-including nurses, nurse practitioners, doctors, pharmacists, other health care professionals, employers, and health plans-to help patients achieve behavioral changes. (Population Health Management 2012;15:302-308).     

基于Andersen模型探讨卒中二级预防药物依从性的影响因素

目的 分析卒中二级预防措施中药物治疗依从性的影响因素。 方法 基于Andersen卫生服务利用模型构建卒中二级预防药物依从性影响因素的理论框架,通过二分类logistic回归模型对卒中二级预防药物依从性的影响因素进行分析。 结果 617名卒中患者被纳入本次研究中,患者平均年龄（67±8.16）岁,男性占比50.1%,药物依从比为67.9%。多因素logistic回归模型结果显示,女性、参与城镇职工医疗保险、年均收入2万元以上与二级预防药物依从有关,年龄在70岁以上、有心脏病史和血脂异常病史、MRS评分25分与二级预防药物不依从有关。 结论 卒中二级预防药物依从性偏低,高龄、心脏病史、血脂异常史和较高MRS评分与药物不依从有关,应加强对具有上述影响因素的卒中患者提供预防性干预。     

Management of Psychiatric Disorders in Patients with Poor Insight

Correction of lack of insight in psychiatric patients has the potential to improve both the accuracy of diagnosis and the effectiveness of therapy. Specific aspects of insight include ‘awareness’ by an individual of specific symptoms and behaviours, plus the awareness that such symptoms can be attributed (by the patient) to the presence of a mental disorder.Although this review focuses on adherence with medication, ‘insight’ encompasses far more than just medications and adherence with medication regimens. Impaired or restricted insight may be the result of many factors, including inability to read or to cognitively understand, deficient ‘health literacy’ and the presence of psychopathology such as delusions or hallucinations, among others. While there is a detrimental effect on therapy because of lack of insight, accurate and comprehensive diagnoses may also be negatively affected because the patient may be unable to provide an adequate history enabling the establishment of such a diagnosis.Nonadherence can now be predicted much more accurately, especially with the use of techniques that assess the insight of the patients and their significant others. A variety of management strategies can be implemented effectively with accurate monitoring of medications and treatment-related behaviours, and by measuring adherence and the prediction of nonadherence.Many factors have been identified which are amenable to diagnostic and therapeutic intervention. Among these are the many simple but frequently overlooked issues including the high cost of medication and general or specific health illiteracy sufficient to make understanding medication directions difficult. However, cost-effective education and truly effective collaborations with patients (and significant others) remain major challenges.The ideal programmes for most patients, and especially those with complex problems such as comorbid alcohol or drug use, are the more comprehensive, multidisciplinary rehabilitation programmes. Such comprehensive strategies are probably cost effective in the long term, although few cost analyses been carried out. Nevertheless, there is ample evidence that even patients who are difficult to manage can be effectively treated as inpatients and subsequently as outpatients.Perhaps the most important aspect of insight and adherence is early assessment and planning for those who are at risk of not cooperating with all kinds of therapy, including medication. The assessment and inventory of the positive factors that will facilitate cooperation and adherence to treatment regimens allows therapists to predict insight and adherence and to tailor their interventions and therapies so as to maximise the beneficial outcome.     

Adherence to medication regimens among low-income patients with multiple comorbid chronic conditions

This qualitative study sought to explore facilitators and barriers to adherence to multiple medications among low-income patients with comorbid chronic physical and mental health conditions. The 50 focus group participants identified personal/contextual and health system factors as major impediments to adherence to multiple medications. These factors included medication side effects, fear of harm from medication, fear of dependence on medication, complex instructions, suboptimal communications with doctor, suspicion about doctors' and pharmaceutical companies' motives in prescribing medication, and the high cost ofmedications. Participants also identified motivators, both internal (self-initiated) and external (initiated by family, doctor, support groups),to ensure adherence to multiple medications. These motivators included self-discipline, sense of personal responsibility, faith, support from family members and doctors, and focused health education and self-management support. Three themes emerged that enhanced understanding of the complexity of adherence to multiple medications: (1) reaching one's own threshold for medication adherence, (2) lack of shared information and decision making, and (3) taking less than the prescribed medication. Further analysis of the data revealed that the patients perceived a lack of shared decision making in the management of their comorbid chronic conditions and their medication regimen.     

Health literacy explains racial disparities in diabetes medication adherence

Although low health literacy and suboptimal medication adherence are more prevalent in racial/ethnic minority groups than Whites, little is known about the relationship between these factors in adults with diabetes, and whether health literacy or numeracy might explain racial/ethnic disparities in diabetes medication adherence. Previous work in HIV suggests health literacy mediates racial differences in adherence to antiretroviral treatment, but no study to date has explored numeracy as a mediator of the relationship between race/ethnicity and medication adherence. This study tested whether health literacy and/or numeracy were related to diabetes medication adherence, and whether either factor explained racial differences in adherence. Using path analytic models, we explored the predicted pathways between racial status, health literacy, diabetes-related numeracy, general numeracy, and adherence to diabetes medications. After adjustment for covariates, African American race was associated with poor medication adherence (r = -0.10, p < .05). Health literacy was associated with adherence (r = .12, p < .02), but diabetes-related numeracy and general numeracy were not related to adherence. Furthermore, health literacy reduced the effect of race on adherence to nonsignificance, such that African American race was no longer directly associated with lower medication adherence (r = -0.09, p = .14). Diabetes medication adherence promotion interventions should address patient health literacy limitations.     

Does Health Information in Mass Media Help or Hurt Patients? Investigation of Potential Negative Influence of Mass Media Health Information on Patients’ Beliefs and Medication Regimen Adherence

As an important public health issue, patient medication non-adherence has drawn much attention, but research on the impact of mass media as an information source on patient medication adherence has been scant. Given that mass media often provide confusing and contradicting information regarding health/medical issues, this study examined the potential negative influence of exposure to health information in mass media on patients’ beliefs about their illnesses and medications, and medication adherence, in comparison with the effects of exposure to another primary medication information source, physicians. Survey data obtained from patients on blood thinner regimens revealed that the frequency of exposure to health information in mass media was negatively related to accuracy of patients’ beliefs about their medication benefits and patient medication adherence. On the other hand, frequency of visits with physicians was positively associated with patients’ beliefs about their medication benefits but had no significant relation to medication regimen adherence. The implications of the study findings are discussed, and methodological limitations and suggestion for future research are presented.     

Psychoeducational Approaches to Medication Adherence in Patients with Bipolar Disorder

There is growing consensus that a major obstacle to good outcomes among individuals with bipolar disorder (BPD) is premature discontinuation of medications. This review summarizes the current literature on prevalence and consequences of non-adherence in BPD populations, measurement of adherence, risk factors for non-adherence, and general and psychoeducational interventions to enhance treatment adherence among bipolar populations, and suggests future directions in psychoeducational approaches with respect to treatment adherence. Risks associated with discontinuation of medication among individuals with BPD are well documented and include manic and depressive relapses, re-hospitalization, and more lengthy hospital stays. A relatively limited but growing literature suggests that it is possible to enhance treatment adherence among patients with BPD. The most positive evidence for the improvement of medication adherence among patients with BPD comes from specific psychosocial interventions used in conjunction with pharmacotherapies. It has been suggested that improved treatment adherence is at least a partial component of the observed positive outcomes of psychoeducational approaches among bipolar populations. Many individuals with BPD remain relatively uninformed regarding their illness, creating potential barriers to optimal treatment adherence, and limiting self-management skills. Psychoeducation is based on the premise that individuals have a fundamental right to have information regarding their illness, and individuals who are informed are more likely to take a more active role in managing their illness, which results in better health outcomes. Psychoeducation strategies for BPD that have contributed to positive outcomes have ranged from simple one-site, education-only interventions that improve lithium adherence and attitudes about medications to a more complex, multi-site, collaborative care system intervention that yielded shorter durations of affective episodes for patients, improved functioning and quality of life, and treatment satisfaction. Although psychological therapies that emphasize psychoeducation generally support benefits in achieving and maintaining remission from bipolar symptoms, the effects of these interventions on treatment adherence are not consistent and the way in which psychoeducation improves outcomes is not entirely clear. There is an urgent need for greater understanding of interventions that can be implemented in real-world settings that address patient, provider/system, and environmental/social factors that are critical to treatment adherence.     

Current conditions or future risks: certainty and uncertainty in decisions about statins

Preventive medications such as statins are recommended to an increasingly large number of people. To those who make these recommendations, prevention is synonymous with risk reduction; the clinical task of helping people decide about preventive medication is therefore widely framed as one of risk communication. In this article, I explore the role of risk and uncertainty in accounts of medication decisions, drawing on qualitative data from interviews carried out between 2011 and 2013 in the east of England with people who had been offered statins. I found that very few participants mentioned risk or likelihood, or described weighing benefits against harms, the process central to the risk communication project. Instead, those who had decided to take statins described their certainty that statins were needed to treat current problems. This certainty was informed by knowledge about the present or the past; information about possible future harms was presented solely as contributing to concern about current problems. In contrast, those who had decided not to take statins explained their decisions in terms of the inherent uncertainty of information about the future, presenting this uncertainty as a reason to decline medication. This asymmetry between explanations for accepting and for declining statins is rooted in differences between the ways past, present and future information are handled. These findings challenge the assumption that decisions about statins are construed as decisions about risk by those offered them, and raise questions about the usefulness of using risk and uncertainty as key concepts for theoretical accounts of what is going on when people consider taking preventive medication.     

An integrated pharmacy-based program improved medication prescription and adherence rates in diabetes patients

A substantial threat to the overall health of the American public is nonadherence to medications used to treat diabetes, as well as physicians' failure to initiate patients' use of those medications. To address this problem, we evaluated an integrated, pharmacy-based program to improve patients' adherence and physicians' initiation rates. The study included 5,123 patients with diabetes in the intervention group and 24,124 matched patients with diabetes in the control group. The intervention consisted of outreach from both mail-order and retail pharmacists who had specific information from the pharmacy benefit management company on patients' adherence to medications and use of concomitant therapies. The interventions improved patients' medication adherence rates by 2.1 percent and increased physicians' initiation rates by 38 percent, compared to the control group. The benefits were greater in patients who received counseling in the retail setting than in those who received phone calls from pharmacists based in mail-order pharmacies. This suggests that the in-person interaction between the retail pharmacist and patient contributed to improved behavior. The interventions were cost-effective, with a return on investment of approximately $3 for every $1 spent. These findings highlight the central role that pharmacists can play in promoting the appropriate initiation of and adherence to therapy for chronic diseases.     

The use of incentives to reinforce medication adherence

ObjectivePoor medication adherence is a longstanding problem, and is especially pertinent for individuals with chronic conditions or diseases. Adherence to medications can improve patient outcomes and greatly reduce the cost of care. The purpose of the present review is to describe the literature on the use of incentives as applied to the problem of medication adherence.MethodsWe conducted a systematic review of peer-reviewed empirical evaluations of incentives provided to patients contingent upon medication adherence.ResultsThis review suggests that incentive-based medication adherence interventions can be very effective, but there are few controlled studies. The studies on incentive-based medication adherence interventions most commonly feature patients taking medication for drug or alcohol dependence, HIV, or latent tuberculosis. Across studies that reported percent adherence comparisons, incentives increased adherence by a mean of 20 percentage points, but effects varied widely. Cross-study comparisons indicate a positive relationship between the value of the incentive and the impact of the intervention. Post-intervention evaluations were rare, but tended to find that adherence effects diminish after the interventions are discontinued.ConclusionsIncentive-based medication adherence interventions are promising but understudied. A significant challenge for research in this area is the development of sustainable and cost-effective long-term interventions.     

Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss

ABSTRACT: BACKGROUND: Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications. METHODS: We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers' assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP [GREATER-THAN OR EQUAL TO]140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG [GREATER-THAN OR EQUAL TO]20 % is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication. RESULTS: 1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3 %. Adherence assessments by providers correlated poorly with refill history. 211 (20 %) patients did not have BP medication available for > =20 % of days; providers characterized 79 (37 %) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46 %). Providers intensified BP medications for 451 (42 %) patients, similarly whether assessed by provider as having significant non-adherence (44 %) or not (43 %). CONCLUSIONS: Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.