Evidence-based methods to enhance medication adherence

A Proposed Middle-Range Theory of Nursing in Hypertension Care

Nursing in hypertension care comprises counselling about lifestyle changes, blood pressure measurement, and being a translator for the physician. For the patient, changing lifestyle means performing self-care. As not much in the form of research and guidelines for nurses is available, a middle-range theory of nursing in hypertension care was developed to guide nurses in their practice, in order to improve the nursing of patients and design studies for investigating nursing in hypertension care. Concepts are presented related to the patient (attitude and beliefs regarding health and sickness, autonomy, personality and traits, level of perceived vulnerability, hardiness, sense of coherence, locus of control, self-efficacy, and access to social support and network) and the nursing (applying theories and models for behavioural change in the consultation and using counselling skills, patient advocacy, empowerment, professional knowledge and health education, and supporting the patient). Then the concepts related to the consultation (communication, shared decision-making, concordance, coping, adherence, and self-care) are integrated with Orem's theory of nursing. Clinical and research implications of the theory are discussed.

Promoting Adherence

This study compared the effects of a the oretically focused audiotape and a standard educational booklet on asthma preventive medication adherence and other asthma outcomes. Forty-six adult asthmatics were randomly assigned to receive either an experimental audiotape incorporating components of protection motivation theory, a standard asthma management booklet, both, or no educational materials. Outcomes were assessed at baseline, 3 months, and 6 months. Mean pharmacy-verified adherence improved 15% to 19% in the intervention groups and declined 22% in the control group at 6 months. Using analysis of covariance (ANCOVA) to control for baseline adherence, these changes were significant between the control and booklet group (t = 2.47; p = .02) and between control and combined group (t = 2.07; p = .04). Providing a minimal educational intervention can have a beneficial effect on asthma medication adherence that persists at least 6 months.

Development of new concepts of non-adherence measurements among users of antihypertensives medicines

OBJECTIVE

To identify various types of non-adherence among users of antihypertensive medications by establishing components of adherence measures and use these components for measuring the prevalence of non-adherence.

SETTING

Twelve community pharmacies from the Danish county of Funen.

METHOD

Users of antihypertensive medication were included in the study. 2,914 medication users received questionnaires by mail. Participating patients were asked to fill in two questionnaire regarding demographics, self-reported blood pressure, and various adherence measures. Two factor analyses were conducted based on responses to questions.

MAIN OUTCOME MEASURES

Medication-taking behaviour and self-efficacy (beliefs about ability and capacity to accomplish a task), respectively. Other measures of non-adherence collected by questionnaire were also addressed in the data for comparison of prevalence with the developed concepts.

RESULTS

1,426 (49%) participants answered the questionnaires. The analyses resulted in two sets of components: three adherence behaviour measures and two self-efficacy measures which showed similarities in concepts. The adherence behaviour measures included two concepts of intentional nonadherence (associated with aspects of self-regulation and effect concerns, respectively) and one measure of non-intentional non-adherence. Prevalence of the developed measures of behaviour related non-adherence ranged from 10.3 to 34.9% depending on which type of non-adherence measure was used. Established measures of non-adherence resulted in prevalence between 2.2 and 39.6%.

CONCLUSIONS

The study showed that concepts of non-adherence measurements could be determined including self-efficacy aspects, unintentional non-adherence and intentional non-adherence related to self-regulation and effect concerns respectively. The prevalence of the adherence behaviour components were found to be between 10.3 and 34.9%, which is in the range of expected values. Associations between the new concepts of non-adherence measurement and characteristics of nonadherers remain to be established and would be a subject for further studies.

Concept analysis of adherence in the context of cardiovascular risk reduction

TOPIC

Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient-centered care to prevent the development and progression of this largely preventable disease.

OBJECTIVE

The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision-making, reduction of relapse to unhealthy behaviors, and increased long-term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence.

METHOD

Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine.

RESULTS

Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self-efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets.

CONCLUSION

Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision-making between patient and healthcare provider.

A concept analysis: adherence and weight loss

There are numerous factors that influence an individual's ability to adhere to a healthy behavior. The literature cites common events that must take place prior to maintaining an exercise plan, a medication regimen, and a healthy diet. The purpose of this paper is to examine the concept of adherence in relation to weight loss using Walker and Avant's (1995) framework for concept analysis. This analysis revealed an extensive list of events or antecedents that may prove to be important when considering new strategies for weight management.

Nurses' attitudes toward their role in patient discharge medication education and toward collaboration with hospital pharmacists: a staff development issue

This qualitative pilot study explored nurses' attitudes toward their role in patients' discharge medication education and collaboration with pharmacists. Purposive sampling was used, and data were collected by a focus group interview. The findings give a clear indication of the need for extensive staff development. It is unfortunate that nurses in this study appeared not to value their role in educating patients on medications prior to discharge. They were somewhat resistant to collaboration with pharmacists, and they tended to accept limited responsibility for improving patient discharge medication adherence or compliance. Although the findings are of concern, they do provide clear evidence of the need for intensive staff development.

Evidence-based guideline. Improving medication management for older adult clients

All providers and professionals who care for older adults have an important role to play in the process of managing medications. The evidence-based guideline "Improving Medication Management for Older Adult Clients" (Bergman-Evans, 2004) provides assessments and interventions that are useful across settings. By focusing on reducing inappropriate prescribing, decreasing polypharmacy, avoiding adverse events, and maintaining function, professionals and providers have the opportunity to improve outcomes for this important population.

Less frequent dosing of bisphosphonates in osteoporosis: focus on ibandronate

BACKGROUND

Bisphosphonates form the mainstay of treatment in osteoporosis; however, current adherence with therapy is inadequate. Problems with adherence are thought to be linked to several factors, including frequency of dosing and bisphosphonate-associated intolerability. For non adherent patients, less frequent dosing may be desirable, because the frequency with which strict and inconvenient dosing procedures must be followed is reduced.

OBJECTIVES

A new nitrogen-containing bisphosphonate, ibandronate, offers sustained efficacy, with an extended between-dose interval. The molecular characteristics of ibandronate that support extended dosing are described, and trial outcomes for oral and intravenous ibandronate are summarized, in the context of other available bisphosphonates, based on the results of a search of MEDLINE publications (January 1975-December 2005). Relevant safety issues are discussed.

CONCLUSION

Awareness of the scientific basis, published trial findings, and clinical implications associated with a once-monthly bisphosphonate can guide treatment decisions and inform communications with patients.

Treatment compliance in patients with comorbid psychiatric and substance use disorders

This study examines clinical and non-clinical factors associated with treatment compliance problems in 342 patients with substance use disorders (SUD) seen in routine psychiatric practice. Weighted Wald-X(2) and multivariate logistic regression assessed sociodemographic, clinical, treatment, and health plan characteristics associated with treatment compliance problems. Among patients with SUD, 40.5% were reported to currently have treatment compliance problems. Patients with treatment compliance problems were significantly more likely to have personality disorders, lower global assessment of functioning scores, and medication side effects than those without treatment compliance problems. Patients seen by psychiatrists who were reimbursed by discounted rather than undiscounted fee-for-service were five times more likely to be reported to have treatment compliance problems. Both clinical and non-clinical factors appear to be associated with treatment compliance problems. Understanding these factors and targeting treatment interventions may improve treatment compliance and patient outcomes.

Predictors of psychiatrist-reported treatment-compliance problems among patients in routine U.S. psychiatric care

Characteristics associated with psychiatrist-reported treatment-compliance problems were investigated using the 1999 Study of Psychiatric Patients and Treatments from the Practice Research Network of the American Psychiatric Institute for Research and Education (n=1,843). Logistic regression was used to study characteristics associated with compliance problems as perceived by treating psychiatrists. Among the 22 potential predictors of interest, all but three (age, gender, and problems with primary support group) were found to be significantly associated with treatment-compliance problems in bivariate analyses. A predictive model was developed consisting of eight independently significant predictors from diagnostic, clinical, psychosocial, and treatment-history domains. These predictors included substance use disorder diagnosis, medication side effects, moderate to severe psychotic symptoms, personality disorder diagnosis, economic problems, prior hospitalization, current Global Assessment of Functioning scale score, and duration of treatment with current psychiatrist. This predictive model correctly identified the presence or absence of treatment-compliance problems in 91% of patients in a sample randomly drawn from the dataset before model construction. These findings may be useful to clinicians, researchers, and program planners interested in addressing the important issue of treatment-compliance problems in psychiatric care settings.

Medication non-adherence in the elderly: how big is the problem?

Adherence to medication is one of the most intriguing and complex behaviours demonstrated by patients. Non-adherence to a therapeutic regimen may result in negative outcomes for patients and may be compounded in populations with multiple morbidities which require multiple drug therapy. Such a population is exemplified by the elderly. However, non-adherence may not be more prevalent in older patients and there is no consensus in the literature that age is a predictor of poor adherence. Indeed, older patients may deliberately choose not to adhere to medication (intentional non-adherence) to avoid adverse effects. Furthermore, many of the studies on adherence lack commonality in terms of how adherence is measured, the definition of an 'older' patient and the range of disease states which have been examined. Adherence may also be affected by access to medications which may be restricted by the use of formularies or insurance programmes. However, non-adherence may represent a greater risk in older people resulting in poor disease control which may be compounded with multiple morbidity and polypharmacy. A range of strategies have been implemented to try and improve adherence in this patient population. The use of forgiving drugs (those which have a prescribed dosage interval that is 50% or less the duration of drug action) may facilitate occasional lapses in drug-taking. Drug holidays (deliberate, supervised non-adherence for a fixed period of time) have been used in Parkinson's disease to reduce adverse effects. Once-daily scheduling of drug administration may offer a pragmatic approach to optimising drug therapy in some patients; this may be supplemented through the use of compliance aids. What is increasingly apparent, however, is that the role of the patient (irrespective of age) is critical in decision-making about medication, together with communication between patients and healthcare professionals. This has been articulated through the concept of concordance which has been described as a therapeutic alliance between the patient and healthcare professional. In addition, interventions employed to improve adherence must be multifaceted, and together with practical approaches (reducing unnecessary drugs and simplifying dosage regimens), the patient perspective must be considered. Good adherence should be seen as a means of achieving a satisfactory therapeutic result and not as an end in itself.

Multicultural medication adherence: a comparative study

The purpose of this study was to evaluate the effect of several interventions on improving medication adherence among White, Black, and Hispanic older women. A total of 109 women older than age 65 who were participating in a clinical osteoporosis trial were recruited for this 12-month study examining medication adherence. After baseline medication adherence was assessed, participants underwent standardized teaching. Participants were contacted monthly by telephone and were seen in a clinic setting every 3 months. All participants used a pillbox for 6 months, and the minority women used an electronic monitoring bottle for 6 months. Adherence was highest in White women. Black women showed significant improvement in adherence at 9 and 12 months, and Hispanic women demonstrated a significant increase in adherence at 12 months. The use of electronic monitors had a positive effect on adherence for the minority women.