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Medication Adherence: What Can We Do to Help Patients Stick to Therapy

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OR 1.16 (1.06-1.26) / 10% adh 1. Lower CD4 count increase 6 versus 83 cell/ml increase 2 ... Caring for others: Putting off care 2. Women OR 1.6 (1.2 - 2.2) ... – PowerPoint PPT presentation

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Title: Medication Adherence: What Can We Do to Help Patients Stick to Therapy


1
Medication AdherenceWhat Can We Do to Help
Patients Stick to Therapy
  • Lois Eldred, DrPH, MPH
  • Special Projects of National Significance
  • HIV/AIDS Bureau, HRSA

2
Viral Suppression in Clinical Practice
Lucas, Annals Intern Med 1999
3
Adherence Critical to Care
  • Nonadherent patients with
  • Increased mortality from HIV
  • OR 1.16 (1.06-1.26) / 10 ? adh 1
  • Lower CD4 count increase
  • 6 versus 83 cell/ml increase 2
  • Increased hospital days
  • 12.9 versus 2.5 hosp. days / 1000 days F/U 2

1 Hogg, 7th CROI, 2000 2 Paterson, Ann Intern
Med, 2000
4
How much adherence is enough?
Paterson, Ann Intern Med, 2000
5
Viral Load by Adherence
Arnsten, 7th CROI, 2000
6
Viral load and adherence (MEMS)
Thompson M, et al. XIII IAC, Durban 2000.
Abstract 1129
Mostly women and minorities viral load copies/ml, ARV naive
7
Measuring Adherence
  • No gold standard
  • Use what is practical
  • Patient report will overestimate 30- 50
  • Pharmacies can be your friend
  • Electronic monitoring in selected cases,
    especially if it will help the patient
  • Drug levels not practical for adherence monitoring

8
Factors in Adherence
9
Predictors of Adherence Patient
  • Understanding of the regimen
  • Alcohol/drug use
  • Depression
  • Appointment keeping
  • Health beliefs and attitudes
  • Perception of control (self efficacy)
  • Social support

10
Adherence and Illicit Drug Use
Adapted Cheever, ICAAC, 1999
11
Drug Abuse Treatment Works
1 OR 1.88 (0.69- 5.28) 2 OR 4.91 (1.22-20.76)
Moatti, AIDS, 2000
12
Health Beliefs and Attitudes
  • Associated with antiretroviral (ARVs) use
  • ARVs will help me have fewer symptoms of HIV
  • ARVs will help me live longer
  • Associated with adherence
  • Medications will often fit into daily routine
  • If dont take right, resistance will develop

Paterson, Abs 92 Kaplan, Abs 96 Wenger, Abs 98
6th CROI, 1999 Cheever, Abs 591, 39th ICAAC,
1999
13
Interventions to Improve Adherence
  • Barriers to adherence
  • Differ among patients
  • Vary over time
  • Principles of interventions
  • Multifaceted
  • Repetitive
  • Initiated prior to resistance developing

14
Self Efficacy Counseling to Improve Adherence
  • Randomized, controlled trial
  • Intervention
  • Counseling to increase self efficacy
  • Strategies to increase adherence
  • Association of adherence and resistance
  • Telephone number for questions

Tuldra, JAIDS 2000
15
Self Efficacy Counseling to Improve Adherence
Tuldra, JAIDS 2000
16
Factors in Adherence
17
Adherence Treatment Regimen
  • Number of doses, medications, pills
  • Length of time on therapy
  • Dietary restrictions
  • Side effects

18
Side Effects Impact Adherence
Arnsten, 7th CROI, 2000
19
Factors in Adherence
20
Medical System
  • Team support and interventions
  • Doctor- Patient relationship
  • Trust / satisfaction
  • Patient education
  • Appointment reminders
  • Multiple and varied reinforcers
  • Accessibility of appointments, medication
  • Child care / child friendly environment
  • Transportation

21
Engagement in Care
  • Convenience Sample of 707 outpatients
  • Engagement in care Interaction with health care
    provider (13 item scale)
  • Listens to me
  • Cares about me
  • Respects me
  • Spends enough time with me
  • Includes me in decision making

Bakken, AIDS Patient Care and STDs, 2000
22
Non-engaged Patients
  • More likely to be current/past injection drug
    users (p0.002)
  • Nonadherent with
  • Medication taking
  • Medical appointments
  • Following medical advice
  • Not associated type of provider, sex, race

Bakken, AIDS Patient Care and STDs, 2000
23
Satisfaction with Information
p0.02
Tuldra, 7th Euro. Conf. Clin. Aspect. And Tx of
HIV, 1999
24
Asking about AdherenceWhat works
Steele , J Fam Pract 1990
25
Asking About Adherence
  • Permission for missed dose Almost everyone
    misses medicines some of the time.
  • Specific questioning In the last (week/month)
    how many doses of medicine do you think youve
    missed?
  • Verify understanding of regimen Tell me exactly
    how you take your medicines.

26
Interventions to Improve Adherence Background
  • Clinicians play a specific role and significant
    role in initiating and monitoring adherence
  • Adherence research and other diseases focuses
    primarily on physicians
  • Most HIV adherence interventions involve a team
    of providers

27
Improving Access to Care
  • 1/3 of patients in U.S. sample (HCSUS) went
    without medical care due to1
  • Need for money for food/clothing/housing
  • Lack of transportation
  • Inability to get time off from job/work
  • Feeling too sick
  • Caring for others Putting off care 2
  • Women OR 1.6
    (1.2 - 2.2)
  • Having child in household OR 1.8 (1.4 - 2.3)

1Cunningham, Med Care 1999, 2 Stein Am J of Pub
Health 2000
28
Support Services and Retention in Care
n2647
  • 20 increase in regular visits (2/year) in an
    urban clinic with support services, 1997-1998

Sherer R, AIDS Care, 2002
29
Directly Observed Therapy
4
DOT directly observed therapy (incarcerated
cohort) SAT self-administered therapy (free
clinic cohort)
Fischl 7th CROI, SF, 2000. Abs 71
30
Interventions Incentives Work
Chaisson, JAIDS, 1996
31
Incentive to Improve Adherence
  • Randomized, controlled trial
  • MEMS device and AZT plasma levels
  • Intervention
  • Cue dose training
  • Feedback from MEMS device
  • Cash (2/correct dose up to 10/day, 280 max.)

Rigsby, J Gen Intern Med 2000
32
Incentive to Improve Adherence





Rigsby, J Gen Intern Med 2000
33
SPNS/HRSA Initiative Adherence
  • 14 Projects with varying adherence interventions
    (1999-2004)
  • Common core data evaluated among the projects
  • Evaluation Center New York Academy of Medicine
    Center for Adherence Support and Education (CASE)

34
CASE Findings
  • readiness component helps client maintain high
    levels of adherence
  • Interventions based on Prochaskas stages of
    change helpful over 6 months
  • No direct relationship between the intensity of
    encounters and improvement in adherence
  • Specific support and clinical services have
    positive impact over time

35
Medication Support Versus Standard of Care Johns
Hopkins HIV Clinic
  • Nurse Education
  • Case Management
  • Peer Advocacy
  • Group Education
  • Results High users of readiness program more
    likely to achieve improved viral suppression (50)

36
Self Efficacy Counseling to Improve Adherence
Multivariate Analysis Adh. 95 at 48 wks
Tuldra, JAIDS 2000
37
Adherence Conclusions
  • Adherence is critical for long term success of
    HAART
  • Interventions must be maintained over time
  • Barriers differ among patients and over time
    interventions must be patient-tailored
  • Adherence interventions are now a standard part
    of quality HIV care

38
Adherence Where do we go from here?
Self-management Programs
  • Needs assessment of readiness and active
    interventions to promote self-efficacy for taking
    medications
  • Collaborative approach in timing the initiation
    of medication
  • Group support and education is a powerful tool

39
Adherence Where do we go from here?
  • Use experiences with other chronic disease
    self-management programs
  • Cost effectiveness must be demonstrated as
    adherence interventions are integrated into
    practice

40
For more HIV-related resources, please visit
www.hivguidelines.org
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