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CAN ADHERENCE BE IMPROVED?

CAN ADHERENCE BE IMPROVED?. Status of Adherence Intervention Studies. To Medication To Exercise To Diet. 19 Adherence Intervention Studies. Randomized Control Group Assessment of Adherence Assessment of Outcome 6 month Follow Up

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CAN ADHERENCE BE IMPROVED?

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  1. CAN ADHERENCE BE IMPROVED?

  2. Status of Adherence Intervention Studies • To Medication • To Exercise • To Diet

  3. 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.

  4. 19 Adherence Intervention Studies  All Use Self - Report  1 Study addresses Remediation • Education/Counseling/Behavioral Strategies • All Address Single Regimen/Disease

  5. Characteristics of Successful Interventions • Educational/Behavioral • Multicomponent • Long-Term (from Haynes, 1996)

  6. 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

  7. Summary of Interventions • Education • Social Support • Self-Efficacy Enhancement • Behavioral Intervention • Electronic Monitoring/Feedback • Self-Monitoring • Counseling • Positive Reinforcement • Cuing • Verbal Persuasion

  8. 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

  9. Interventions to Promote Adherence to Dietary Regimen • Counseling 3,4,8 • Social Support 1,2,6 • Self-Efficacy Enhancement6 1 Barnard et al, 1992 2 Borbjerb et al, 1995 3 Dolecek et al, 1986 4 Glueck et al, 1986 5 Karvetti, 1981 • 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

  10. 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 RCT’s have been reported

  11. 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

  12. 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

  13. Proportion of Subjects> 75% Compliance Pre-intervention Post-Intervention* Experimental 0 9 Attention Control 0 1 Usual Care 0 3 * 2 = 10.21, 2dƒ, p = .006

  14. Change in Cholesterol Levels

  15. 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)

  16. 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

  17. RESULTS Group Differences Baseline To End Of Treatment • Average Change In Adherencex 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

  18. 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) *p<.01Changes in adherence were associated with changes in pain in carrying out activities of daily living, but no level of difficulty or assistance required

  19. 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

  20. 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

  21. 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

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

  23. 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

  24. 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

  25. Any Questions? Thank You!

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