COMPLIANCE

1
COMPLIANCE
Oops ADHERENCE

• In the Treatment of Hypertension
• Bruce Buchanan, M.D., FACP,FCCP
• March 30, 2007

2

• I. INTRODUCTION
• A. Terminology
• 1. Compliance the extent to which patients
• behaviors coincide with health care
  providers recommendations for health and
  medical advice.

3

• I. INTRODUCTION
• A. Terminology
• 1. Compliance the extent to which patients
• behaviors coincide with health care
  providers recommendations for health and
  medical advice.
• a. Origin in medicine
• (1) Introduced by Sackett in 1976
• (2) Expanded by Haynes in 1978

4

• b. Defining attributes
• (1) Ability to complete or perform what is
  to do
• (2) Flexibility
• (3) Adaptability
• (4) Malleability
• (5) Subordinate behaviors
• 2. Adherence-the greater degree of patients
• responsibility and involvement in their
• medical care (a more politically correct
  term).

5

• a. Origin in medicine
• (1) Madden 1990,
• (2) Fawcett, Moore 1995
• b. Defining attributes
• (1) Not passively conforming to medical
  advice
• (2) A sense of loyalty or
  fidelity
• (3) Holding firmly to a plan
• (4) A participative endeavor with
  ultimate choice resting with the
  patient
• (5) Patient autonomy encouraged
• (6) Self directed health care

6

• 3. Partnering-the collaboration with patients to
  form alliances in health and wellness
• 4. Concordance-an agreement between a patient
  and a health-care professional about whether,
  when and
• how medicines are to be taken (the British
  approach)
• 5. Definitions
• a. Compliers take gt 80 of their
  prescribed
• regimens
• b. Noncompliers dont.
• c. Partial noncompliers take meds in
  unorthodox or irregular fashion

7

• B. Non-adherence is a 50 Billion Annual
• Cost and accounts for 10 of Hospital
  admissions
• C. This discussion will include
• 1. Social cognitive theory-Bandura
• 2. The effects of nurture

8

• II. HISTORICAL DATA

NHANES II NHANES III NHANES III NHANES
1976-1980 1980-1991
1991-1994 1999-2000 Awareness 51
73 68.4 70 Treatment
31 55
53.6 59 Control 10
29 27.4
34
Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure, JAMA 2003
2892560
9

• III. ISSUES RELATED TO ADHERANCE
• A. Major Predictors of Poor Adherence to
  Medication Regimen for hypertension
• 1. Psychological problems, particularly
  depression
• 2. Cognitive impairment
• 3. Asymptomatic disease
• 4. Inadequate f/u or discharge planning
• 5. Side effects of medication, quality of
  life issues
• 6. Lack of belief in benefits of treatment
  (Hypertension is never cured)

10

• 7. Poor provider-patient relationship
• 8. Barriers to care or medication
• 9. Missed appointments
• 10. Complexity of treatment
• 11. Cost of medication, co-payment or both
• 12. Patients lack of insight into illness
• 13. Chronicity of illness
• 14. Social isolation
• 15. No immediate consequences of stopping
  therapy
• 16. Long waiting time in office
• 17. Patients who do not perceive themselves
  as ill do not comply with their treatment
• regimens

11

• 18. Special veteran considerations ?
• a. Post Traumatic Stress Disorder
  (in addition to depression)
• b. Anger management issues
• c. Governmental blame for illness
• d. Vested interest in being sick

12

• B. Strategies for Improving Adherence to a
  Medication Regimen
• 1. Identify poor adherence. Look for
• a. Missed appointments
• b. Lack of response to medications
• c. Missed refills
• d. Ask about barriers to adherence
  without being confrontational.
• 2. Emphasize the value of the regimen and the
  effect of adherence.

13

• 3. Elicit patients feelings about his or
  her ability to follow the regimen, and if
  necessary, design supports to promote
  adherence.
• 4. Provide simple, clear instructions and
  simplify the regimen as much as possible.
• 5. Encourage the use of a medication-taking
  system.
• 6. Listen to the patient, and customize the
  regimen in accordance with the patients
  wishes
• 7. Obtain the help from family members,
  friends, and community services when
  needed

14

• 8. Reinforce desirable behavior and results
  when appropriate.
• 9. Consider more forgiving medications when
  adherence appears unlikely
• a. Medications with longer half-lives
• b. Fewer side effects
• c. Lesser monitoring
• 10. Better discharge education, support and
  planning

15

• C. Demographic Characteristics
• 1. White, Black, Hispanic mixed results
  dependent on study
• 2. Gendersuggestion women more
  adherent, but still mixed
• 3. Socioeconomic favors wealthier patients
• 4. Older gt younger

16

• D. Failure of government and society to factor
  in long term complications against
• high blood pressure treatment costs
• 1. Coronary artery disease
• 2. Stroke
• 3. Chronic renal failure

17

• E. Hypertension treatment includes
• 1. Focus on meds too narrow
• a. Overall medication taking
  relatively easy
• b. The medication treats my
  blood pressure for me
• 2. What about the role of
• a. Weight reduction
• b. Exercise (activity)
  regimen
• c. Smoking cessation
• d. Alcohol modification or
  cessation
• e. Salt restriction
• f. Stress modification

18

• IV. RESEARCH INADEQUACIES
• A. Pressures of Research
• 1. Publish or perish
• 2. Long term studies more costly and time
  consuming
• 3. Hypertension not as sexy as other
  disease states
• 4. Hypertension silent disease with delayed
  ramifications

19

• B. Criteria for Study Improvement
• 1. More comprehensive
• 2. Longer studies
• 3. More careful f/u
• 4. Distinguish intervention
  and control groups
• 5. Separate individual
  components of combination
  interventions

20

• 6. Measurement of long term clinical
  outcomes
• 7. Assessors blinded to the
  group assignment
• 8. Creation of patient tailored approaches
  targeting more of the underlying factors
• influencing individual
  adherence

This concludes the standard, usual presentation
21
(No Transcript)
22

• V. SOCIAL COGNITIVE THEORY-
• Albert Bandura
• A. Core Determinants
• 1. Knowledge of health risks and benefits of
  different health packages
• 2. Perceived self-efficacy that one can
  exercise control over ones health habits
• 3. Outcome expectations about the expected
  costs and benefits for different health
  habits

23

• 4. Goals people set for themselves and the
  concrete plans and strategies for
  realizing them
• 5. Perceived facilitators and social and
  structural impediments to the changes
  they
• seek

24

• A. Core Features of Human Agency
• (Social Cognitive Theory An Agentic
  Perspective)
• 1. Intentionality
• 2. Forethought
• 3. Self-reactiveness
• 4. Self-reflectiveness

25

• C. Knowledge of Health Risks and Benefits
• 1. Creates the precondition for change
• 2. Lack of knowledge about how their
  lifestyle habits affect their health
• 3. Little reason to put themselves
  through the travail of changing the
  detrimental
• habits they enjoy
• 4. Additional self-influences are needed to
  overcome the impediments to adopting
• new lifestyle habits and
  maintaining them.

26

• 5. Beliefs of personal efficacy play a central
  role in personal change
• 6. This focal belief is the
  foundation of human motivation and action
• 7. They are rooted in the core belief that one
  has the power to produce desired changes by
  ones actions.

27

• D. Health Behavior is also affected by the
  outcomes people expect their actions to produce
• 1. Physical outcomes
• a. Pleasurable and aversive
  effects of the behavior
• b. Accompanying material
  losses and benefits
• 2. Social approval and disapproval the
  behavior produces in ones interpersonal
  relationships

28

• 3. Positive and negative self-evaluative
  reactions operant
• a. Do the things that give self-satisfaction
  and self-worth
• b. Refrain from behavior that breeds
  self- dissatisfaction
• c. Motivation enhanced by helping people
  see how habit changes are in their
• interest and the broader goals
  they value highly
• d. Personal goals, rooted in a value system,
  provide further self-incentives and guides
  for health habits

29

• e. Long-term goals set the course of personal
  change
• f. There are too many influences at hand for
  distal goals to control current behavior
• g. Short-term attainable goals help people to
  succeed by enlisting effort and guiding
  action in the here and now

30

• 4. Self-efficacy assessment
• a. Perceived facilitators and obstacles
• b. Gradation of challenges
• c. Health systems impediments and supports

31
Outcome Expectations Physical Social Self-evaluati
ve
Self-Efficacy
Goals
Behavior
Sociostructural Factors Facilitators Impediments
32

• VI. THE EFFECTS OF NURTURE
• A. The Role of the Subconscious/Preconscious
• 1. Learning/conditioning begins much earlier
  than previously appreciated
• 2. If one is fighting for survival, used to
  being physically and emotionally abused,
• competing for food ones data base will look
  much different than one where these are not
  operant

33

• 3. Power of a dominate parent
• 4. Quality and type of communication in
  transactions (transactional analysis)
• 5. Socioeconomic status predetermines at an
  early age
• 6. Quality and quantity of exposure to society
• 7. Incentives for lifestyle change are
  somatic, social/practical, cognitive and
  Affective

34

• 8. Thou shalt not bow down thyself to them
  (graven images),nor serve them for I, the
• LORD thy God, am a jealous God, visiting
• the iniquity of the fathers
  upon the children unto
  the third and fourth generation of
  them that hate me,
• (Exodus 205, part of Third
  Commandment)

35

• 9. Cultural change over last 25 years from
  service to others to personal
• financial gain (Allan Bloom, The Closing of
  the American Mind)

36
Generation X and Y

• Classic example of emphasis on gain
• Far fewer individuals entering health care
• Live in 2 dimensional view of the World
• TV
• Computer Screen
• Chat Rooms
• Cell Phones
• Interaction is impersonal
• Instant gratification,
• Violent computer games
• Sexually explicit music

37

• VII. SUMMARY
• Adherence is a far more complicated issue than
  the taking of ones medications or complying with
  a request for diet modification, exercise, etc.
  If we are truly meaning to impact patient
  behavior we will need to be cognizant of the much
  larger scope within which adherence is, but one
  small factor. Research needs to be expanded and
  our approach more comprehensive. We must also
  anticipate the changes in our culture over time.