Rethinking Adherence

ArticleinAnnals of internal medicine 157(8):580-5 · October 2012with22 Reads
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.
    • "Better adherence is associated with better response to and durability of metformin monotherapy, as well as metformin and sulphonylurea combination therapy [2, 3, 7]. Because medication adherence represents a complex series of patient behaviors rather than a single construct [8], the cumulative glycemic burden experienced by diabetes patients over time could be substantially lowered by adherence behaviors established early in the course of diabetes. To our knowledge, ours is the first study to examine the association between change in medication adherence and change in glycemic control. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction . Whether changes in adherence are associated with changes in HbA1c is assumed but not known. Methods . We conducted a observational study of 2,844 type 2 diabetes patients who initiated metformin as their first antihyperglycemic drug. Using HbA1c measures before, 6–12 months after, and up to 3 years after metformin initiation, we analyzed HbA1c change as a function of initial adherence and change in adherence. Results . Compared with no adherence, initial adherence of 50–79% was associated with an adjusted reduction in HbA1c of 0.45% while adherence ≥80% was associated with HbA1c reduction of 0.73%. Change from some initial adherence (1–79%) to total nonadherence was associated with 0.25% increase in HbA1c. Change from some to full adherence was associated with an HbA1c decrease of 0.15%. Those associations were accentuated among patients not in glycemic control: change from some to no adherence was associated with an HbA1c increase of 0.63% and change from some to full adherence was associated with an HbA1c decrease of 0.40%. Conclusions . Initial adherence to newly prescribed metformin therapy produces substantial HbA1c reduction. Among those with modest adherence but suboptimal glycemic control, the difference between moving to full adherence versus nonadherence results in lower HbA1c of one percentage point.
    Full-text · Article · Aug 2016
    • "Voils' group has developed two self-report adherence measures for use in hypertension research or clinical care that provide discrete assessment of the extent of medication adherence (3 items) and reasons for nonadherence (21 items), and the scales have shown promising psychometric properties and convergent and critierion validity [52]. Since many chronic conditions involve multiple forms of health behavior (e.g., medication dose-taking, dietary guidelines, exercise, prescription refills), researchers and clinicians should additionally be clear about the specific adherence behavior that they seek to assess when selecting an adherence measure [60, 67]. Optimize response options and recall periods to reduce ceiling effects—Research is yielding new insights into optimal response options and recall periods for self-report measures of medication adherence. "
    [Show abstract] [Hide abstract] ABSTRACT: Medication adherence plays an important role in optimizing the outcomes of many treatment and preventive regimens in chronic illness. Self-report is the most common method for assessing adherence behavior in research and clinical care, but there are questions about its validity and precision. The NIH Adherence Network assembled a panel of adherence research experts working across various chronic illnesses to review self-report medication adherence measures and research on their validity. Self-report medication adherence measures vary substantially in their question phrasing, recall periods, and response items. Self-reports tend to overestimate adherence behavior compared with other assessment methods and generally have high specificity but low sensitivity. Most evidence indicates that self-report adherence measures show moderate correspondence to other adherence measures and can significantly predict clinical outcomes. The quality of self-report adherence measures may be enhanced through efforts to use validated scales, assess the proper construct, improve estimation, facilitate recall, reduce social desirability bias, and employ technologic delivery. Self-report medication adherence measures can provide actionable information despite their limitations. They are preferred when speed, efficiency, and low-cost measures are required, as is often the case in clinical care.
    Full-text · Article · Jul 2015
    • "Thus, interventions that focus solely on reducing out-of-pocket costs of medications, but do not address the source of these patients' unfavorable beliefs about the medications, are unlikely to improve their adherence (Bandura, 2004). Because medication nonadherence is often unrecognized by providers (Steiner, 2012), efforts to improve provider–patient communication about nonadherence are worthwhile. Health care providers should routinely ask their patients about reasons they are not adhering to their prescribed medication regimen and use a tailored approach to promote better adherence (Ho et al., 2006). "
    [Show abstract] [Hide abstract] ABSTRACT: In addition to individual-level socioeconomic and psychological factors, the neighborhood environment has been found to be related to medication nonadherence, particularly among low-income, minority populations managing a chronic disease. In this article, we synthesize the relevant literature on how neighborhood factors contribute to engagement in health behaviors and reasons for medication nonadherence among this population. We propose a theoretical framework for understanding the mediating and moderating mechanisms whereby the neighborhood environment may impact medication nonadherence among individuals most at risk for adverse disease outcomes. Guided by this model, we provide recommendations for future research, practice, and policy. © The Author(s) 2015.
    Full-text · Article · Jun 2015
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