Accountability in reminder-based adherence interventions: A review

ObjectiveInterventions to elicit accountability capitalize on social behaviors to improve adherence but are distinct from reminders. However, little is known about the impact of accountability in reminder-based adherence interventions. Through a literature review, we aim to identify the frequency and effectiveness of accountability in reminder-based intervention studies.MethodsPubMed and PsycArticles were searched for reminder-based adherence studies. Articles were categorized as reminder-only or reminder with accountability studies. Studies were characterized by outcome measures, and differences between control and intervention groups were compared for studies that used electronic monitoring devices.Results165 studies met the inclusion criteria; 154 used reminders without accountability (93%). 79 of the 154 reminder-only studies (51%) improved adherence in intervention groups compared to controls. Eleven of the 165 studies (6.6%) included an accountability aspect. The intervention group had better adherence than controls in 10 out of the 11 reminder with accountability studies (91%).ConclusionsAlthough distinct from reminders, accountability can be incorporated in reminder-based interventions. However, it is not commonly included in reminder-based interventions.Practice implicationsIt is important to consider accountability’s effects on encouraging patient medication adherence. The addition of accountability interventions may further boost adherence, but few studies currently incorporate these types of interventions.     

Impact of pictograms on medication adherence: A systematic literature review

ObjectiveThe aim of this systematic review was to investigate the potential effect of pictograms on patient adherence to medication therapies.MethodPubMed, MEDLINE, Embase, CINAHL, and CENTRAL were searched for relevant articles. Experimental studies testing the use of pictograms in patient counselling regarding medication therapy, which quantitatively measured adherence, were included.ResultsSeventeen studies were identified that fulfilled our inclusion criteria. These were heterogeneous with respect to study setting, population size, and the medication regimen tested. All the studies had methodological quality limitations. The pictogram interventions differed with respect to complexity, intervention length, and the measured adherence outcome. Ten studies (58.8 %) reported a statistically significant effect, of the pictogram intervention in question, on patient adherence to medication therapies. Of these, 80 % involved populations at elevated risk for non-adherence.Conclusion and practice implicationsPictograms used in combination with written and/or oral information can have a positive impact on patient populations that are highly at risk for non-adherence when counselled on the proper use of medicines.     

Patient-centered care in chronic disease management: a thematic analysis of the literature in family medicine

Objective

The objective was to provide a synthesis of the results of the research and discourse lines on main dimensions of patient-centered care in the context of chronic disease management in family medicine, building on Stewart et al.’s model.

Methods

We developed search strategies for the Medline, Embase, and Cochrane databases, from 1980 to April 2009. All articles addressing patient-centered care in the context of chronic disease management in family medicine were included. A thematic analysis was performed using mixed codification, based on Stewart's model of patient-centered care.

Results

Thirty-two articles were included. Six major themes emerged: (1) starting from the patient's situation; (2) legitimizing the illness experience; (3) acknowledging the patient's expertise; (4) offering realistic hope; (5) developing an ongoing partnership; (6) providing advocacy for the patient in the health care system.

Conclusion

The context of chronic disease management brings forward new dimensions of patient-centered care such as legitimizing the illness experience, acknowledging patient expertise, offering hope and providing advocacy.

Practice implications

Chronic disease management calls for the adaptation of the family physician's role to patients’ fluctuating needs. Literature also suggests the involvement of the family physician in care transitions as a component of patient-centered care.     

Interventions to improve medication adherence in inflammatory bowel disease: A systematic review

ObjectiveTo summarize existing literature examining interventions to enhance medication adherence and their effectiveness in enhancing care for inflammatory bowel disease (IBD) patients.MethodsThis review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. PubMed and Embase were searched for studies from June 2014 to Dec 2020. Only the studies published in English were included.ResultsOur systematic literature search identified 488 published articles. Seventeen studies with a total of 7073 patients were included. Out of seventeen different interventions, five were classified as educational, eight as multicomponent, three as behavioral and one as cognitive behavioral. Adherence was measured using patient self-report, administrative/pharmacy claims data, and electronic monitoring devices/pill dispensing systems. Twelve out of seventeen interventions showed a statistically significant improvement in medication adherence including three educational, seven multicomponent, one behavioral and one cognitive behavioral intervention.ConclusionsMulticomponent interventions demonstrated the greatest success in IBD patients in promoting medication adherence. Future research should focus on a multidisciplinary approach to design multicomponent interventions to optimize treatment adherence and enhance long-term clinical outcomes.Practice implicationsWhile stand-alone strategies have demonstrated effectiveness in improving adherence, better outcomes may be achieved by combining multiple strategies.     

The impact of medication regimen factors on adherence to chronic treatment: a review of literature

This article reviews recent literature in chronic illness or long-term health management including asthma, contraception, diabetes, HIV disease, and hypertension/cardiovascular disease, mental disorders, pain, and other diseases to determine the relationship between regimen factors and adherence to medications. The authors conducted an electronic literature search to detect articles published between 1998 and 2007. Articles were included if they pertained to a chronic illness or to contraception, included a clear definition of how adherence was measured, and included regimen factors as primary or secondary explanatory variables. Methodology of the studies varied greatly, as did methods of measuring adherence and regimen factors. Surprisingly few of these articles concerned (1) chronic treatment, (2) regimen factors such as dosing, pill burden, and regimen complexity, and (3) adherence measured in a clear manner. Most studies failed to use state-of-the-art methods of measuring adherence. Despite these flaws, a suggestive pattern of the importance of regimen factors, specifically dose frequency and regimen complexity, emerged from this review.     

A method to determine the impact of patient-centered care interventions in primary care

Objective

The implementation of patient-centered care (PCC) innovations continues to be poorly understood. We used the implementation effectiveness framework to pilot a method for measuring the impact of a PCC innovation in primary care practices.

Methods

We analyzed data from a prior study that assessed the implementation of an electronic geriatric quality-of-life (QOL) module in 3 primary care practices in central North Carolina in 2011–2012. Patients responded to the items and the subsequent patient–provider encounter was coded using the Roter Interaction Analysis System (RIAS) system. We developed an implementation effectiveness measure specific to the QOL module (i.e., frequency of usage during the encounter) using RIAS and then tested if there were differences with RIAS codes using analysis of variance.

Results

A total of 60 patient–provider encounters examined differences in the uptake of the QOL module (i.e., implementation-effectiveness measure) with the frequency of RIAS codes during the encounter (i.e., patient-centeredness measure). There was a significant association between the effectiveness measure and patient-centered RIAS codes.

Conclusion

The concept of implementation effectiveness provided a useful framework determine the impact of a PCC innovation.

Practice implications

A method that captures real-time interactions between patients and care staff over time can meaningfully evaluate PCC innovations.     

Blood pressure outcomes of medication adherence interventions: systematic review and meta-analysis

This systematic review applied meta-analytic procedures to integrate primary research that examined blood pressure outcomes of medication adherence interventions. Random-effects model analysis calculated standardized mean difference effect sizes. Exploratory dichotomous and continuous moderator analyses using meta-analytic analogues of ANOVA and regression were performed. Codable data were extracted from 156 reports with 60,876 participants. The overall weighted mean difference systolic effect size was 0.235 across 161 treatment versus control comparisons. The diastolic effect size was 0.189 from 181 comparisons. Effect sizes were significantly heterogeneous. Common risks of bias included lack of allocation concealment, unmasked data collectors, and absent intention-to-treat analyses. Exploratory moderator analyses suggested that habit-based interventions may be most effective. The largest effect sizes were for interventions delivered by pharmacists. The modest magnitude effect sizes suggest future research should explore novel higher dose interventions that might address multiple levels of influence on adherence behavior.     

Decision-making and goal-setting in chronic disease management: Baseline findings of a randomized controlled trial

ObjectiveGrowing interest in collaborative goal-setting has raised questions. First, are patients making the ‘right choices’ from a biomedical perspective? Second, are patients and providers setting goals of appropriate difficulty? Finally, what types of support will patients need to accomplish their goals? We analyzed goals and action plans from a trial of collaborative goal-setting among 302 residents of a high-poverty urban region who had multiple chronic conditions.MethodsPatients used a low-literacy aid to prioritize one of their chronic conditions and then set a goal for that condition with their primary care provider. Patients created patient-driven action plans for reaching these goals.ResultsPatients chose to focus on conditions that were in poor control and set ambitious chronic disease management goals. The mean goal weight loss −16.8lbs (SD 19.5), goal HbA1C reduction was −1.3% (SD 1.7%) and goal blood pressure reduction was −9.8 mmHg (SD 19.2 mmHg). Patient-driven action plans spanned domains including health behavior (58.9%) and psychosocial (23.5%).ConclusionsHigh-risk, low-SES patients identified high priority conditions, set ambitious goals and generate individualized action plans for chronic disease management.Practice implicationsPractices may require flexible personnel who can support patients using a blend of coaching, social support and navigation.     

Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review

Background

Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals: a condition labelled as ‘uncontrolled’ hypertension. The optimal way to organise and deliver care to hypertensive patients has not been clearly identified.

Aim

To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension.

Design of study

Systematic review of randomised controlled trials.

Setting

Primary and ambulatory care.

Method

Interventions were categorised as following: self-monitoring; educational interventions directed to the patient; educational interventions directed to the health professional; health professional- (nurse or pharmacist) led care; organisational interventions that aimed to improve the delivery of care; and appointment reminder systems. Outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and proportion of patients followed up at clinic.

Results

Seventy-two RCTs met the inclusion criteria. The trials showed a wide variety of methodological quality. Self-monitoring was associated with net reductions in systolic blood pressure (weighted mean difference [WMD] −2.5mmHg, 95%CI = −3.7 to −1.3 mmHg) and diastolic blood pressure (WMD −1.8mmHg, 95%CI = −2.4 to −1.2 mmHg). An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large randomised controlled trial.

Conclusion

Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring is a useful adjunct to care while reminder systems and nurse/pharmacist -led care require further evaluation.     

Methodological features of quantitative studies on medication adherence in older patients with chronic morbidity: A systematic review

ObjectivesThe growing number of chronic, multimorbid older adults encourages healthcare systems to cope with polypharmacy and non-adherence. However, methodology on how to provide effective interventions to enhance medication adherence is still object of debate.MethodsTo describe methodological features of quantitative studies concerning older adults’ medication adherence, by means of a PRISMA systematic review (Scopus, PubMed, Medline). A specific focus was devoted to theoretical models and to the ABC Taxonomy model, as stated by the EMERGE guidelines.Results55 papers were included. Most of the studies were conducted using randomized control trials (63.6%) and focused on a single disease only (72.7%). Most of the interventions were provided by a single professional figure (70.9%). Medication adherence was mainly evaluated by means of questionnaires (61.8%) and by clinical records (30.9%). Sixteen studies considered a theoretical model in the intervention framework. The Initiation phase (ABC Taxonomy) was the most neglected.ConclusionsFuture studies upon medication adherence should account real-life challenges such as multimorbidity, polypharmacy and interdisciplinarity, analyzing adherence as a complex, holistic process.Practice implicationsTheoretical models may be useful to enhance the soundness of the results, to ease their comparability, to calibrate tailored strategies and to plan patient-centered interventions.     

Promoting adherence to health behavior change interventions: Recent findings from behavioral research

This paper provides an overview of adherence issues as they relate to health behavior change programs. A selective review of the weight loss, smoking cessation, and exercise literatures was conducted to illustrate basic principles and the current state of knowledge. The review suggested that the current literature lacks coherence and direction. There is a need for greater theoretical organization, standardization of interventions, examination of specific manoeuvres in relation to process and setting variables, and more systematic evaluation of intermediate as well as ultimate outcomes of adherence enhancement manoeuvres.     

Educational programs to teach shared decision making to medical trainees: A systematic review

ObjectiveShared decision-making (SDM) is a process of collaboration between patients and clinicians. An increasing number of educational programs to teach SDM have been developed. We aimed to summarize and evaluate the body of evidence assessing the outcomes of these programs.MethodsWe conducted a systematic review of studies that aimed to teach SDM to medical trainees. Reviewers worked independently and in duplicate to select studies, extract data and evaluate the risk of bias.ResultsEighteen studies were included. Most studies focused on residents/fellows (61 %) and combined a didactic component with a practical experience (50 % used a standardized patient). Overall, participants reported satisfaction with the courses. The effects on knowledge, attitudes/confidence and comfort with SDM were small; no clear improvement on SDM skills was noted. Evaluation of clinical behavior and outcomes was limited (3/18 studies). Studies had moderate risk of bias.ConclusionVery low quality evidence suggests that educational programs for teaching SDM to medical trainees are viewed as satisfactory and have a small impact on knowledge and comfort with SDM. Their impact on clinical skills, behaviors and patient outcomes is less clear.Practical implicationsIntegration of formal and systematic outcomes evaluation (effects on behavior/clinical practice) should be part of future programs.     

Development and content of a group-based intervention to improve medication adherence in non-adherent patients with rheumatoid arthritis

Objective

To describe the systematic development and content of a short intervention to improve medication adherence to disease-modifying anti-rheumatic drugs in non-adherent patients with rheumatoid arthritis (RA).

Methods

The intervention mapping (IM) framework was used to develop the intervention. The following IM steps were conducted: (1) a needs assessment; (2) formulation of specific intervention objectives; (3) inventory of methods and techniques needed to design the intervention and (4) production and piloting of the intervention.

Results

The intervention (consisting of two group sessions led by a pharmacist, a homework assignment, and a follow-up call) aims to improve the balance between necessity and concern beliefs about medication, and to resolve practical barriers in medication taking. The central communication method used is motivational interviewing.

Conclusion

By applying the IM framework, we were able to create a feasible, time-efficient and promising intervention to improve medication adherence in non-adherent RA patients. Intervention effects are currently being assessed in a randomized controlled trial.

Practice implications

This paper could serve as a guideline for other health care professionals when developing similar interventions. If the RCT demonstrates sufficient effectiveness of this intervention in reducing medication non-adherence in RA patients, the intervention could be embedded in clinical practice.     

Telephone nurse counseling for medication adherence in ulcerative colitis: A preliminary study

Objective

Adherence is challenging in episodic chronic conditions that require medication during both symptomatic and quiescent periods, such as ulcerative colitis (UC). Adherence for these conditions is under-studied. This study was a preliminary test of telephone nurse counseling to address cognitive and emotional barriers to adherence in UC.

Methods

524 people taking mesalamine for UC were referred by their health care providers, and 278 (53%) enrolled. There were no demographic differences between program participants and nonparticipants. Participants reported multiple comorbidities and concomitant medications. All participants received telephone follow-up (M = 2.1 calls) from a registered nurse who used cognitive-behavioral and motivational interviewing counseling techniques. Adherence measured by structured interview was compared to a population baseline using a binomial test.

Results

Attrition was 51% over 6 months but was unrelated to adherence. Participants had better adherence than the expected population rate, with a significant dose-response effect. Reasons for nonadherence were primarily psychological or efficacy-related.

Conclusion

Adherence following intervention was better than typical mesalamine adherence. Self-efficacy predicted adherence, but demographic and clinical variables did not. Adherent participants reported more adverse events.

Practice implications

Attention to patients’ cognitive and emotional reactions may help to improve adherence in episodic chronic diseases such as UC.     

Motivational interviewing adherence tools: A scoping review investigating content validity

ObjectiveWe sought to understand the content validity of Motivational Interviewing (MI)as a concept and the relative emphasis of specific MI aspects by assessing MI adherence measures.MethodWe followed PRISMA guidelines for scoping reviews. Twenty-eight adherence measures were identified. From these, 407 specific MI adherence codes were extracted and submitted to content analysis.ResultsFifteen MI themes emerged, 13 focused on clinician behaviors and 2 on client responses. Four themes (OARS, MI Spirit, evoking motivation, and MI-inconsistent behaviors) accounted for 72% of all codes. No other theme (e.g., preventing/responding to resistance, engaging ambivalence) accounted for more than 6% of codes. One measure assessed 11 of 15 themes; on average, 5.68 themes were assessed with a mean of 14.54 questions per measure. Process and psychometric characteristics of the measures are described.Conclusions/Practice ImplicationsMI adherence measures agree about the importance of certain aspects of MI but lag behind current research and best skill practice. Considerable variance exists in assessing MI nuances and specific behaviors, suggesting questions about what constitutes MI in practice settings and what should be taught. Importantly, most measures focused only on the counselor’s behavior, missing the impact of MI on the client.     

Technological adjuncts to increase adherence to therapy: a review

This paper identified and reviewed technological adjuncts to increase client adherence to therapy. Three areas of adherence were identified, namely treatment dropout and non-attendance, engagement during and between therapy sessions, and aftercare. Database searches were conducted in each of these areas to identify relevant studies published between the years of 1990 and 2010. Adjuncts designed to replace or reduce direct therapist contact, change the medium of communication between the client and therapist, or alter the content or style of the therapy were not included in this review. Adjuncts were reviewed in light of theories of adherence, including Self Determination Theory, the Transtheoretical Model, and the Theory of Planned Behaviour. Adjuncts reviewed included appointment reminders, exercises and monitoring delivered by mobile phone, and exercises and data collection delivered by computer. Limitations and directions for future research were addressed and discussed.