- Email: [email protected]
Adherence to therapeutic regimens
Research in Social and Administrative Pharmacy 1 (2005) 375–377
Editorial
Adherence to therapeutic regimens Two studies reported in this issue of Research in Social & Administrative Pharmacy by Nau et al1 and Kavookjian et al2 addressing adherence to oral hypoglycemics and diet among diabetic patients contribute to the extensive literature regarding adherence in health care. Much of the research continues to search for the combination of factors that will ensure, or at least facilitate, adherence across a variety of preventative health interventions, including medication. The transtheoretical model of change has been a useful theory in understanding and predicting a variety of health behaviors. By understanding both decisional balance and self-efficacy among diabetic patients, especially in low-confidence areas of tempting situations, targeted interventions can be designed to assist patients in both urge management and social pressures that lead to poor dietary adherence. The issue of social desirability response in the study of Kavookjian et al is interesting in that the researchers apply this phenomenon to the observation that nonadherent patients tend to overestimate the degree of positive health behaviors in which they engage. Responding in a positive manner to questions soliciting disease-specific behaviors, as opposed to a general predisposition to providing socially desirably responses, demonstrates that patients are endorsing the ideal behavior but may not have the supports to act on the behavior. Most patients initially may desire to take the appropriate actions to manage their disease state. The critical issue that many adherence studies address, including the studies in this issue, is to identify the supports we can offer to supplement the natural tendency of desire in patients to engage in healthy behaviors. Nau et al1 raise interesting issues regarding depression as a major barrier to engaging in healthy behaviors. The negative impact of depression on adherence is understandable, as feelings of hopelessness and helplessness are core psychological symptoms of depression. The ‘‘learned helplessness’’ model of depression has much experimental support and can explain the findings in this study.3 Given the ubiquitous nature of depression and the effects of untreated depression upon a variety of comorbid diseases, the early 1551-7411/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2005.06.007
376
Editorial / Research in Social and Administrative Pharmacy 1 (2005) 375–377
identification and aggressive treatment can yield benefits for disease state management across a variety of conditions. In spite of a considerable body of research and emphasis upon adherencerelated counseling in a number of health professions, lack of adherence continues to be a problem. The research literature documents a wide range of factors related to nonadherence, including the diagnosis and nature of the disease, specific patient characteristics, and characteristics of the providerpatient relationship.4 The adherence literature has been for decades dominated by a nomothetic approach, generating a wealth of information on the correlates of nonadherence. However, the meaning and value of adherence for each patient is highly idiosyncratic and requires a much broader view. One approach will not work with all patients and all conditions. Subjective variables such as the individual’s meaning/interpretation of illness, the level of symptom relief or control over illness desired relative to other decisions, and various components of the patient-provider relationship may influence adherent behavior. Beyond the empirical research regarding adherence there are a number of questions that directly impact approaches to adherence. What is the operative set of assumptions of health care delivery? The terms ‘‘compliance,’’ ‘‘adherence,’’ and ‘‘therapeutic alliance’’ all contain different meanings for what patient acceptance of treatment regimens involve. Is nonadherence always negative? Is there such a phenomenon as intelligent noncompliance? Can less than optimal therapeutic outcomes be accepted if the patient is fully informed of risks and benefits? While much of the research attempting to understand the variables associated with nonadherence are useful, ultimately a strong therapeutic alliance between provider and patient involving the provision of information, support, encouragement, and respect for patient autonomy is the responsibility of the provider.5,6 The patient then needs to make decisions about costs, risks, and benefits relative to values that they wish to attain. The challenge for the health care system of the future will be to encourage patient responsibility for behavioral change while providing adequate social, emotional, and technological support. A final critical issue in health care delivery is the early identification and intervention of nonadherence. The relationship between patient counseling and adherence continues to be a significant issue in pharmacy practice. In spite of the Omni Bus Budget Reconciliation Act legislation, professional standards, and state pharmacy regulations, routine and regular drug regimen review and counseling have not been integrated well into community practice. With an average of 40% of the ambulatory population nonadherent to medication regimens and the cost of drug-related problems being significant (much of which is attributable to nonadherence),7,8 counseling may be the most important value-added service the profession can offer. Time constraints and lack of financial incentives have been offered as barriers to fully integrated adherence-oriented counseling in ambulatory
Editorial / Research in Social and Administrative Pharmacy 1 (2005) 375–377
377
settings. However, with considerable knowledge of the correlates of nonadherence generated by the research literature, a risk profile can be generated allowing early identification and intervention by pharmacists, thus preventing nonadherence before serious negative health consequences occur. To maximize outcomes and efficient management of time, adherence research can be used to identify key factors that predispose patients to nonadherence, allowing pharmacists to allocate time to patients with the highest risk. Asymptomatic disease, multiple medications with complex dosing regimens, sensory anomalies, age, lack of social supports, lack of relevant knowledge, psychiatric diagnosis, and financial problems can all cumulatively adversely affect adherence. Creating a standardized profile and index that can identify patients with multiple risk factors similar to secondary prevention models in public health should be a priority in research. Screening and intervention may result in significantly improved health and economic outcomes. Successful implementation of a standardized nonadherence profile may then increase the probability of acquiring reimbursement for cognitive services.
References 1. Nau DP, Chao J, Aikens JE. The relationship of guideline-concordant depression treatment and patient adherence to oral diabetes medications. Res Soc Adm Pharm. 2005;1:378–388. 2. Kavookjian J, Berger BA, Grimley DA, Villaume WA, Anderson HM, Barker KN. Patient decision-making: strategies for diabetes diet adherence intervention. Res Soc Adm Pharm. 2005;1:389–407. 3. Seligman MEP. Depression and learned helplessness. In: Fredman RJ, Katz MM, eds. The Psychology of Depression: Contemporary Theory and Research. Washington D.C.: Hemisphere; 1974. 4. Dimateo MR, DiNicola DD. Achieving Patient Compliance: The Psychology of the Medical Practitioner’s Role. New York: Pergamon Press; 1982. 5. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125:763–769. 6. Blackwell B, ed. Treatment Compliance and the Therapeutic Alliance. Newark: Harwood Academic Publishers; 1997. 7. Bond W, Hussar D. Detection methods and strategies for improving medication compliance. Am J Hosp Pharm. 1991;48:1978–1988. 8. Clepper I. Noncompliance: the invisible epidemic. Drug Topics. 1992;136:44–50.
Vincent Giannetti, Ph.D. Duquesne University, Mylan School of Pharmacy, Pittsburgh, PA 15282, USA E-mail address: [email protected]
Editorial
Adherence to therapeutic regimens Two studies reported in this issue of Research in Social & Administrative Pharmacy by Nau et al1 and Kavookjian et al2 addressing adherence to oral hypoglycemics and diet among diabetic patients contribute to the extensive literature regarding adherence in health care. Much of the research continues to search for the combination of factors that will ensure, or at least facilitate, adherence across a variety of preventative health interventions, including medication. The transtheoretical model of change has been a useful theory in understanding and predicting a variety of health behaviors. By understanding both decisional balance and self-efficacy among diabetic patients, especially in low-confidence areas of tempting situations, targeted interventions can be designed to assist patients in both urge management and social pressures that lead to poor dietary adherence. The issue of social desirability response in the study of Kavookjian et al is interesting in that the researchers apply this phenomenon to the observation that nonadherent patients tend to overestimate the degree of positive health behaviors in which they engage. Responding in a positive manner to questions soliciting disease-specific behaviors, as opposed to a general predisposition to providing socially desirably responses, demonstrates that patients are endorsing the ideal behavior but may not have the supports to act on the behavior. Most patients initially may desire to take the appropriate actions to manage their disease state. The critical issue that many adherence studies address, including the studies in this issue, is to identify the supports we can offer to supplement the natural tendency of desire in patients to engage in healthy behaviors. Nau et al1 raise interesting issues regarding depression as a major barrier to engaging in healthy behaviors. The negative impact of depression on adherence is understandable, as feelings of hopelessness and helplessness are core psychological symptoms of depression. The ‘‘learned helplessness’’ model of depression has much experimental support and can explain the findings in this study.3 Given the ubiquitous nature of depression and the effects of untreated depression upon a variety of comorbid diseases, the early 1551-7411/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2005.06.007
376
Editorial / Research in Social and Administrative Pharmacy 1 (2005) 375–377
identification and aggressive treatment can yield benefits for disease state management across a variety of conditions. In spite of a considerable body of research and emphasis upon adherencerelated counseling in a number of health professions, lack of adherence continues to be a problem. The research literature documents a wide range of factors related to nonadherence, including the diagnosis and nature of the disease, specific patient characteristics, and characteristics of the providerpatient relationship.4 The adherence literature has been for decades dominated by a nomothetic approach, generating a wealth of information on the correlates of nonadherence. However, the meaning and value of adherence for each patient is highly idiosyncratic and requires a much broader view. One approach will not work with all patients and all conditions. Subjective variables such as the individual’s meaning/interpretation of illness, the level of symptom relief or control over illness desired relative to other decisions, and various components of the patient-provider relationship may influence adherent behavior. Beyond the empirical research regarding adherence there are a number of questions that directly impact approaches to adherence. What is the operative set of assumptions of health care delivery? The terms ‘‘compliance,’’ ‘‘adherence,’’ and ‘‘therapeutic alliance’’ all contain different meanings for what patient acceptance of treatment regimens involve. Is nonadherence always negative? Is there such a phenomenon as intelligent noncompliance? Can less than optimal therapeutic outcomes be accepted if the patient is fully informed of risks and benefits? While much of the research attempting to understand the variables associated with nonadherence are useful, ultimately a strong therapeutic alliance between provider and patient involving the provision of information, support, encouragement, and respect for patient autonomy is the responsibility of the provider.5,6 The patient then needs to make decisions about costs, risks, and benefits relative to values that they wish to attain. The challenge for the health care system of the future will be to encourage patient responsibility for behavioral change while providing adequate social, emotional, and technological support. A final critical issue in health care delivery is the early identification and intervention of nonadherence. The relationship between patient counseling and adherence continues to be a significant issue in pharmacy practice. In spite of the Omni Bus Budget Reconciliation Act legislation, professional standards, and state pharmacy regulations, routine and regular drug regimen review and counseling have not been integrated well into community practice. With an average of 40% of the ambulatory population nonadherent to medication regimens and the cost of drug-related problems being significant (much of which is attributable to nonadherence),7,8 counseling may be the most important value-added service the profession can offer. Time constraints and lack of financial incentives have been offered as barriers to fully integrated adherence-oriented counseling in ambulatory
Editorial / Research in Social and Administrative Pharmacy 1 (2005) 375–377
377
settings. However, with considerable knowledge of the correlates of nonadherence generated by the research literature, a risk profile can be generated allowing early identification and intervention by pharmacists, thus preventing nonadherence before serious negative health consequences occur. To maximize outcomes and efficient management of time, adherence research can be used to identify key factors that predispose patients to nonadherence, allowing pharmacists to allocate time to patients with the highest risk. Asymptomatic disease, multiple medications with complex dosing regimens, sensory anomalies, age, lack of social supports, lack of relevant knowledge, psychiatric diagnosis, and financial problems can all cumulatively adversely affect adherence. Creating a standardized profile and index that can identify patients with multiple risk factors similar to secondary prevention models in public health should be a priority in research. Screening and intervention may result in significantly improved health and economic outcomes. Successful implementation of a standardized nonadherence profile may then increase the probability of acquiring reimbursement for cognitive services.
References 1. Nau DP, Chao J, Aikens JE. The relationship of guideline-concordant depression treatment and patient adherence to oral diabetes medications. Res Soc Adm Pharm. 2005;1:378–388. 2. Kavookjian J, Berger BA, Grimley DA, Villaume WA, Anderson HM, Barker KN. Patient decision-making: strategies for diabetes diet adherence intervention. Res Soc Adm Pharm. 2005;1:389–407. 3. Seligman MEP. Depression and learned helplessness. In: Fredman RJ, Katz MM, eds. The Psychology of Depression: Contemporary Theory and Research. Washington D.C.: Hemisphere; 1974. 4. Dimateo MR, DiNicola DD. Achieving Patient Compliance: The Psychology of the Medical Practitioner’s Role. New York: Pergamon Press; 1982. 5. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125:763–769. 6. Blackwell B, ed. Treatment Compliance and the Therapeutic Alliance. Newark: Harwood Academic Publishers; 1997. 7. Bond W, Hussar D. Detection methods and strategies for improving medication compliance. Am J Hosp Pharm. 1991;48:1978–1988. 8. Clepper I. Noncompliance: the invisible epidemic. Drug Topics. 1992;136:44–50.
Vincent Giannetti, Ph.D. Duquesne University, Mylan School of Pharmacy, Pittsburgh, PA 15282, USA E-mail address: [email protected]