Practical Strategies to Improve Patient Adherence to Treatment Regimens

Imran Aslam, MD; Steven R. Feldman, MD, PhD

Disclosures

South Med J. 2015;108(6):325-331. 

In This Article

Practical Solutions to Improve Adherence

Concepts 1 and 2: Perceived Severity of a Condition and Perceived Benefits of Treatment

Patient perceptions of disease severity and benefit of treatment have a significant influence on adherence. Patients' perceptions are linked directly to their knowledge of the disease process, and in some cases this knowledge is inadequate. For example, in the case of congestive heart failure, patients could not explain the cause of their condition, the influence of certain lifestyle choices on their condition, or the consequences of disease progression.[11] Increased patient education by providers can improve patient knowledge and is associated with improved adherence.[12] Researchers have confirmed that "education which guides treatment use and sensitizes patients to benefits and non-treatment risks result in adherence."[12] For example, sleep apnea is a chronic disease that is generally treated with a continuous positive pressure airway device (CPAP), and although CPAP is a highly effective treatment option, it has a poor adherence rate of 50%, with 20% to 30% of patients discontinuing treatment within the first 2 weeks. To address this issue, researchers conducted a study in which they provided patients with an informational brochure, an instructional CD, and a 4-hour educational session on sleep apnea and CPAP. This comprehensive intervention was successful in managing to improve adherence rates from baseline.[12] Although it may not be feasible for an individual office to provide all of these services, it is possible for physicians to point patients in the right direction with offerings such as Web sites, YouTube videos, and informational sessions offered in the community.

Another study demonstrating the effectiveness of educational interventions used an informational workbook designed to educate kidney transplant recipients on the risks of developing skin cancer, as well as training on how to detect lesions early. This workbook provided patients with "knowledge of how anti-rejection medications are a risk factor for squamous cell cancer (SCC), importance of early detection in limiting amount of surgery needed, how to identify sun spots, and the REACT mnemonic that emphasizes the early warning signs of SCC's [sic]."[13] The subjects who received this workbook demonstrated a greater understanding of the risks associated with skin cancer and were significantly more inclined to adhere to the recommendation of self-skin examinations and to make an appointment with a dermatologist if they detected a concerning lesion.[13]

For physicians to impress upon patients the severity of a disease and the importance of treatment, the relationship between physician and patient should be strong. One of the most commonly recommended strategies to improve adherence is to build this relationship.[7] Building starts with a good first impression; from the reception area to the examination room, patients should find themselves in a comfortable, clean environment complemented by a friendly office staff and a considerate physician. During the patient interview, physicians should allow patients to tell their story and refrain from interrupting; maintain eye contact to signify engagement; ask questions to affirm understanding; and explain the diagnosis and treatment plan in an understandable, unrushed manner. In addition, physicians should encourage patients to share their feelings and expectations regarding their condition. Traditionally, doctors have adopted a paternalistic approach when treating patients; this style of consulting is outdated. A more effective approach would be one that respects patient autonomy and facilitates collaborative decision making.[7]

The advent of electronic medical records (EMRs) makes it easier to provide patients with educational materials and visit summaries. EMRs are particularly useful in providing patients with a written action plan. Once the treatment has been selected, a written action plan that summarizes the patient visit and outlines the prescribed treatment can be printed. Written action plans are a great strategy to improve adherence because they remove the burden of trying to memorize instructions.[14,15] Pronouncing medication names is challenging enough, let alone remembering the names of multiple drugs along with how often to take each and for what condition. In the case of asthma, the Centers for Disease Control and Prevention recommends providing patients with written action plans that detail how to manage asthma long term, acute attacks, and emergency situations.[16] A sample written action plan for asthma is presented in Figure 1.[17] Asthma written action plans that incorporate peak expiratory flow and use of inhaled and oral corticosteroids were found to consistently improve asthma health outcomes.[18]

Figure 1.

Asthma action plan. From https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf.

Concept 3: Self-efficacy

Self-efficacy as defined earlier refers to patients' perception of their ability to follow a treatment plan. The long-term treatment regimens associated with chronic illness can be daunting and may negatively influence patients' sense that they can adhere to their treatment plan. A strategy to ease this process would be to schedule a follow-up visit a few days after the initial visit. Shorter time intervals between office visits can lead to better outcomes in chronic illnesses.[15,19] The best outcomes were noted when the interval was ≤2 weeks.[19] An application of this may be any new medication prescribed for a chronic condition. If patients are asked to begin treatment and return in 8 to 12 weeks, they may initially view this as an insurmountable task; an alternative approach would be to instruct patients to take the treatment and follow-up with the office in 3 to 7 days. The short time interval seems much easier to accomplish than 8 weeks, and patients will be better empowered to adhere to the treatment for that time period. This scenario is much better than patients giving up from the start because the task seems too difficult. Furthermore, this approach reassures patients that their physician is invested and is willing to support them.

Another way for physicians to improve self-efficacy is through adopting the principles of motivational interviewing (MI). MI is a style of counseling aimed at producing behavioral changes and has many practical applications in the clinical realm, especially among nonadherent patients.[20] Although MI is a skill that requires training, physicians can start by learning the basic MI principles and incorporate some of them into practice. Table 2 demonstrates the four principles of MI: express empathy, develop discrepancy, roll with the resistance, and support self-efficacy.[21] Physicians can express empathy by listening to patients without interrupting and periodically responding with summary statements to signify attentiveness. To elicit behavioral changes, physicians must first help patients identify the discrepancy between their goals and their behavior.[21] For instance, if a patient's goal is truly to start feeling better, then the patient must realize that nonadherence is counteracting that goal. This realization can be a "tough pill to swallow" and patients are likely to resist initially. If this occurs, then physicians should avoid reacting to the resistance and instead respond by rephrasing the patient's argument against change.[21] This is called rolling with the resistance. Furthermore, resistance can be used as an opportunity to involve the patient in solution-generating dialog. Patients must reach their own conclusions, in their own time. Once patients reach the stage at which they are considering change, physicians can support self-efficacy by reassuring them that they are capable and praising them as their condition improves. A sample dialog using the principles of MI is provided in Figure 2.

Figure 2.

Sample dialog using motivational interviewing to help patients adhere to statin treatment of high cholesterol.

Multiple studies have demonstrated that MI techniques can improve adherence.[22–25] The literature contains evidence that supports the use of MI in improving adherence to human immunodeficiency virus medications, psychiatric medications, and behavioral changes in areas such as diet and exercise.[22–25]

Concept 4: Perceived Barriers to Treatment

Treatment plans should be as affordable as possible. Generic therapies should be considered when available. If treatments become too expensive, then patients may decide not to fill prescriptions. With the rising cost of health care, price is certainly a factor that patients consider when deciding whether to use a treatment. For instance, increased copayments have been associated with decreased adherence.[26] Out-of-pocket medication cost is a significant problem for older adult patients with chronic diseases such as diabetes mellitus. These patients may skip their medication and face the risk of complications simply because they cannot afford their prescriptions. Physicians should try to identify these patients and provide them with sources for affordable drugs and potential coverage programs.[27]

Simplifying treatment plans can be a challenging task, especially when patients have multiple comorbidities that require multiple treatments. One potential solution is to use combination drugs. Combination drugs reduce the risk of nonadherence and are recommended in patients with chronic diseases.[28] This is seen commonly in asthma treatment wherein patients use inhalers that combine multiple medications. Another tactic is to select drugs that need to be taken once per day as opposed to multiple times per day. The more doses that are required, the easier it is for patients to forget.[29]

Other barriers to treatment include medication adverse effects, patient motivation, patient lifestyle pattern, the physician–patient relationship, poor communication, and poor understanding of instructions.[30] Physicians should work with patients to identify barriers to adherence and design treatment plans that are tailored accordingly.

Concept 5: Cues to Action

Cues to action are aids that remind patients to take their medication. They can take a variety of forms including text messages, telephone calls, reminder packaging, or memory strategies (Table 3). Many offices already use text messages or telephone calls to remind patients of office appointments. This strategy is an effective means of improving attendance.[31] Numerous research trials using text messages as a means of reminding patients to take their medications have found them to be effective at improving adherence.[32,33] Other trials found that daily text message reminders actually reduced adherence, possibly because the patient found them irritating.[34] If a physician senses that a patient may benefit from daily reminders, then a medication reminder application for smart phones can be recommended. Other reminder strategies that have demonstrated a positive effect on adherence include weekly pill boxes and multidrug punch cards.[35] These types of "reminder packaging" are useful in helping patients remain organized, especially when they are taking multiple medications.[35] Other helpful recommendations for patients include techniques that help them remember to take their medications. For example, patients should select a visible location such as their bedside nightstand or dining table on which to leave their medication and they should try to leave it there consistently.[36] Another recommendation is to pair the medication with specific items such as keeping antifungal cream for tinea pedis on top of socks.

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