CAN ADHERENCE BE IMPROVED?

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CAN ADHERENCE BE IMPROVED?
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Status of Adherence Intervention Studies

• To Medication
• To Exercise
• To Diet

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19 Adherence Intervention Studies

• Randomized
• Control Group
• Assessment of Adherence
• Assessment of Outcome
• 6 month Follow Up
• Haynes, R. B., Montague, P., Oliver, T.,
  McKibbon, K. A., Brouwers, M. C., Kanani, R.
  (2001). Interventions for helping patients to
  follow prescriptions for medications. Systematic
  Review Cochrane Consumers Communication Group
  Cochrane Database of Systematic Reviews.

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19 Adherence Intervention Studies

• ? All Use Self - Report
• ? 1 Study addresses Remediation
• Education/Counseling/Behavioral Strategies
• All Address Single Regimen/Disease

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Characteristics of Successful Interventions

• Educational/Behavioral
• Multicomponent
• Long-Term
• (from Haynes, 1996)

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Adherence Monitoring as Intervention

• Use of Electronically Monitored Data as Feedback
• Improved Blood Pressure Control1
  Improved Blood Pressure Management
• Reduction in Seizures2
  Improved Adherence
• 1 Bertholet et al, 2000
• 2 Schneider et al, 2000

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Summary of Interventions

• Education
• Social Support
• Self-Efficacy Enhancement
• Behavioral Intervention
• Electronic Monitoring/Feedback

• Self-Monitoring
• Counseling
• Positive Reinforcement
• Cuing
• Verbal Persuasion

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Interventions to Promote Adherence to Exercise

• Self-Monitoring 1,6,8
• Counseling 2,6,7
• Positive Reinforcement 1,5
• 1 Atkins et al, 1984
• 2 Belise et al, 1987
• 3 Daltroy, 1985
• 4 Jakicic et al, 1995
• 5 Keefe Blumenthal, 1980

• Cuing 1,5
• Verbal Persuasion 3
• Education 4,9
• 6 King et al, 1988
• 7 King Frederikson, 1984
• 8 Rogers et al, 1987
• 9 Schneiders et al, 1998

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Interventions to Promote Adherence to Dietary
Regimen

• Education 5,7
• Behavioral Intervention 9
• 6 McCann et al, 1988
• 7 Mojonnier et al, 1980
• 8 Simkin-Silverman et al, 1995
• 9 Wing Anglen, 1996

• Counseling 3,4,8
• Social Support 1,2,6
• Self-Efficacy Enhancement 6
• 1 Barnard et al, 1992
• 2 Borbjerb et al, 1995
• 3 Dolecek et al, 1986
• 4 Glueck et al, 1986
• 5 Karvetti, 1981

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Summary

• Interventions are not targeted to patient
  adherence patterns or to patient-reported reasons
  for poor adherence
• Outcome measures are not reliable or accurate
• Very few RCTs have been reported

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3 Randomized Controlled StudiesDesigned to
Examine Strategies to Improve Compliance

• Study 1. An intervention study designed to
  improve poor adherers - asymptomatic condition
• Study 2. An intervention study with poor
  compliers - symptomatic condition
• Study 3. Adherence in clinical trials
• - an induction study

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An Intervention Study Designed to Improve Poor
Compliers

• Purpose To evaluate a multicomponent
  behavioral strategy designed to improve
  compliance among poor compliers
• Setting Multi-center randomized controlled
  clinical trial designed to test the cholesterol
  hypothesis
• Coronary Primary Prevention Trial

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Proportion of Subjects gt 75 Compliance

• Pre-intervention Post-Intervention
• Experimental 0 9
• Attention Control 0 1
• Usual Care 0 3
• ?2 10.21, 2dƒ, p .006

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Change in Cholesterol Levels
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Variability in Adherence and Treatment Response

• Greater response to monitoring/attention
• overestimated compliance (r .75)
• greater variability (r .50)
• Relationship between variability and
  overestimation (r .54)

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An Intervention Study Designed to Improve Poor
AdherersRAC-1

• Purpose
• To evaluate a series of behavioral/problem
  solving interventions to improve poor
  adherence
• Setting Specialty practice sites

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RESULTS

• Group Differences Baseline To End Of Treatment
• Average Change In Adherence x sd
• Intervention 4.30 24.7
• Usual Care -7.99 27.1
• t -2.02, p .023
• Proportion Greater Than 80 Adherence
• Intervention Maintenance 29.7
• Usual Care 15.6
• X2 2.25, df 1, p .065

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Relationship of Change in Adherence and
Functional Status

• Tx F/U
• Adherence Pain rs .02 rs -.22
• (n 96) (n 98)
• Adherence Difficulty rs .04 rs
  -.11
• (n 95) (n 97)
• Adherence Assistance rs .03 rs
  -.12
• (n 96) (n 97)
• plt.01 Changes in adherence were associated with
  changes in pain in carrying out activities of
  daily living, but no level of difficulty or
  assistance required

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Predictors of Change

• Baseline Correlates With Change Score
• End of Treatment rs -.20 p .036
• Follow-up rs -.32 p .001
• Session Attendance and Change Score
• Follow-up f 9.07, df 2, p .0007

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Compliance in Clinical Trials - An Induction
Study

• Purpose To evaluate a minimal strategy
  designed to promote initial compliance
• Setting Single center randomized, clinical
  trial designed to study the psychological and
  behavioral effects of cholesterol
  lowering
• M. Muldoon, the CARE Study

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Group Differences in AdherenceACTat 6 Months

• n 180 MEMS MEMS Pill Count
• ( days compliant) ( pills taken)
• Usual Care (Mdn) 62.5 85.7 93.5
• Habit Training (Mdn) 67.9 92.8 96.1
• Habit Training (Mdn) 61.6 90.2 93.8
• Problem Solving
• p NS NS NS

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Summary

• Poor Adherence is
• Wide Spread
• Costly
• Hard to Identify
• Difficult to Predict Who Does Not Adhere
• Few Studies Point to Interventions

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Summary

• Individuals vary in dosing adherence
• Measures to identify poor adherence need to be
  sensitive to dosing patterns
• Minimal intervention does not appear to improve
  long-term adherence
• Adherence can be improved with intensive
  interventions
• Improving adherence positively impacts clinical
  outcomes

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Recommendations

• Address individual adherence patterns in clinical
  and research setting
• Take careful account of method of assessment in
  interpretation of adherence data
• Design/evaluate adherence interventions

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Any Questions? Thank You!