Rethinking Adherence

Annals of internal medicine (Impact Factor: 17.81). 10/2012; 157(8):580-5. DOI: 10.7326/0003-4819-157-8-201210160-00013
Source: PubMed


In 2012, the Centers for Medicare & Medicaid Services (CMS) will introduce measures of adherence to oral hypoglycemic, antihypertensive, and cholesterol-lowering drugs into its Medicare Advantage quality program. To meet these quality goals, delivery systems will need to develop and disseminate strategies to improve adherence. The design of adherence interventions has too often been guided by the mistaken assumptions that adherence is a single behavior that can be predicted from readily available patient characteristics and that individual clinicians alone can improve adherence at the population level.Effective interventions require recognition that adherence is a set of interacting behaviors influenced by individual, social, and environmental forces; adherence interventions must be broadly based, rather than targeted to specific population subgroups; and counseling with a trusted clinician needs to be complemented by outreach interventions and removal of structural and organizational barriers. To achieve the adherence goals set by CMS, front-line clinicians, interdisciplinary teams, organizational leaders, and policymakers will need to coordinate efforts in ways that exemplify the underlying principles of health care reform.

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    • "Early PDC is a strong indicator of future nonadherence, and, in fact stronger than variables identified in prior studies[8] which have shown relatively low predictive power of insurance claims, with AUCs under 0.64[14]. We show, however, that while claims data have limited value prior to initiation of the medication, they contain important information after several weeks of filling behavior, as they become an indicator of personal behavior[16]. "
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    ABSTRACT: Medication nonadherence costs $300 billion annually in the US. Medicare Advantage plans have a financial incentive to increase medication adherence among members because the Centers for Medicare and Medicaid Services (CMS) now awards substantive bonus payments to such plans, based in part on population adherence to chronic medications. We sought to build an individualized surveillance model that detects early which beneficiaries will fall below the CMS adherence threshold. This was a retrospective study of over 210,000 beneficiaries initiating statins, in a database of private insurance claims, from 2008-2011. A logistic regression model was constructed to use statin adherence from initiation to day 90 to predict beneficiaries who would not meet the CMS measure of proportion of days covered 0.8 or above, from day 91 to 365. The model controlled for 15 additional characteristics. In a sensitivity analysis, we varied the number of days of adherence data used for prediction. Lower adherence in the first 90 days was the strongest predictor of one-year nonadherence, with an odds ratio of 25.0 (95% confidence interval 23.7-26.5) for poor adherence at one year. The model had an area under the receiver operating characteristic curve of 0.80. Sensitivity analysis revealed that predictions of comparable accuracy could be made only 40 days after statin initiation. When members with 30-day supplies for their first statin fill had predictions made at 40 days, and members with 90-day supplies for their first fill had predictions made at 100 days, poor adherence could be predicted with 86% positive predictive value. To preserve their Medicare Star ratings, plan managers should identify or develop effective programs to improve adherence. An individualized surveillance approach can be used to target members who would most benefit, recognizing the tradeoff between improved model performance over time and the advantage of earlier detection.
    PLoS ONE 11/2013; 8(11):e79611. DOI:10.1371/journal.pone.0079611 · 3.23 Impact Factor
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    ABSTRACT: Rationale/Background: Chronic insomnia is a prevalent and distressing symptom in women with breast cancer. Cognitive behavioral therapy for insomnia (CBTI) is an established behavioral treatment that is safe and effective in improving sleep and other health outcomes, however; adherence to CBTI is not optimal in breast cancer survivors. Lack of adherence can negatively affect insomnia treatment outcomes. Purpose/Aims: This presentation will discuss the feasibility of adding motivational enhancement therapy to CBTI (MET+CBTI) in breast cancer survivors. Preliminary results will be presented relative to the impact of MET+CBTI compared to CBTI alone to improve adherence and outcomes (sleep, mood, quality of life and daily functioning). Methods: Women aged 21-65, between 1-36 months following primary breast cancer treatment who meet the criteria for chronic insomnia, were recruited from two Western U.S. Cancer Centers and community support groups. Sleep parameters, mood, and cognitive functioning, among other characteristics were assessed prior to CBTI and MET+CBTI. Participants completed self-report instruments with established reliability in cancer populations including the Insomnia Severity Index (ISI), European organization for researchand treatment of cancer (EORTC) quality of life questionnaireC30 (QLQ-C30), Hospital Anxiety and Depression Scale (HADS) and Attentional Function Index (AFI). The 7-item ISI using a 0-4 Likert scale, provides a quantitative evaluation of insomnia perception by targeting the symptoms and consequences of insomnia as well as the degree of concern and distress experienced by the respondent. ISI scores range from 0-28 with higher scores representing more severe insomnia. The QLQ-C30 is a cancer-specific measureof QOL and is composed of five multi-item functional scalesthat evaluate physical, role, emotional, cognitive, and socialfunction and one global health status/QOL scale. The HADS measures anxiety and depression via 7- items subscales. The AFI assesses perceived effectiveness of cognitive functioning in daily life. Respondents rate themselves on 14 items anchored with polar opposite phrases ranging from 0 (not at all) to 100 (extremely well) in response to how well they were functioning in key cognitive activities. Results: Women ranged in age from 35-65 (M = 52.4 years, SD = 6.9). The overall average score of the ISI was > 17 which implies clinical insomnia of moderate severity. Recruitment, withdrawal rate, sleep intervention attendance suggest MET+CBTI is a feasible sleep intervention in breast cancer survivors. Eight participants interviewed at the conclusion of 6 weeks of MET+CBTI suggested that this intervention is well tolerated, acceptable, and helpful. Comments included: “Since sleep was not a problem before breast cancer, I didn’t know how to deal with it, and this treatment really helped me feel confident…a lot of it [treatment] was a joint effort…seeing [sleep] improvements boosted my confidence.” Our preliminary data suggests a trend toward greater subjective adherence. Thus, MET+CBTI may be effective in maximizing adherence, but a larger, longitudinal trial is needed. Implications: Insomnia has a significant impact on the daily lives of women with breast cancer. MET+CBTI has the potential to improve adherence and outcomes. Additional findings and implications will be discussed in greater detail during the presentation.
    2013 Western Institute of Nursing Annual Communicating Nursing Research Conference; 04/2012
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    ABSTRACT: : Children and families often have difficulty following prescribed medical treatment for chronic pediatric conditions. Such nonadherence has a significant impact on children's health care outcomes and the costs of their care. This review describes a comprehensive approach to increase treatment adherence in chronic pediatric illnesses and lessen its impact. Key elements of this proposed model of adherence promotion include the following: (1) a core approach to adherence promotion to be implemented by pediatric health care providers; (2) follow-up and ongoing management; and (3) tailoring and targeting specific more intensive family-centered interventions to children and adolescents who demonstrate clinically significant treatment nonadherence or risk for nonadherence. Behavioral specialists have important roles in conducting research on adherence promotion, training health care providers, and delivering services to children and adolescents with clinically significant adherence problems.
    Journal of developmental and behavioral pediatrics: JDBP 11/2013; 34(9):716-29. DOI:10.1097/DBP.0b013e31829f6781 · 2.13 Impact Factor
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