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DOI: 10.2337/diaclin.26.1.17
© 2008 by the American Diabetes Association
Practical Pointer |
Working With Patients to Enhance Medication Adherence
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Introduction |
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 Top Introduction Introduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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Helping patients take medications effectively is a key clinical undertaking. Optimal medication adherence improves clinical outcomes and can even lower health care costs by reducing morbidity and decreasing health care use.1 Benefits are especially striking in patients with diabetes.2,3 Across chronic illnesses, patients take only
50% of medications
prescribed for those
conditions.4,5
Similar patterns are seen in patients with
diabetes,6
particularly in those who also have depressive symptoms. Among depressed
patients with diabetes, for example, nonadherence to hypoglycemic and
antihypertensive agents is even lower than among nondepressed patients with
diabetes.7,8
Even among nondepressed patients, levels of medication adherence may be
significantly lower than desired because of side effects and lack of
motivation to take the medications as prescribed.
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Patients, health care providers, and health care systems all play a role in creating this quality and outcome gap between current reality and optimal diabetes management.9,10 Barriers to effective use of medicines for diabetes care include: 1) poor provider-patient communication; 2) inadequate knowledge about a drug and its use (in both patients and clinicians); 3) psychological insulin resistance;11 4) complex regimens that require numerous medications with varying dosing schedules; 5) lack of follow-up to monitor treatment response; 6) lack of treatment titration to achieve optimal outcomes; and 7) cost and access barriers.9,12,13
The current lack of provider time and shortage of clinic resources to support good chronic illness care for diabetes further widens the quality gap. Additional health care system supports are necessary to reduce cost and access barriers and to enhance appropriate intensification of treatment and follow-up (barriers 5-7). Nevertheless, primary care physicians and teams can use evidence-based approaches for increasing collaboration with their patients as a way for improving adherence and clinical outcomes. The following clinical actions summarize systematic reviews of the literature and combine patient-centered approaches aimed at achieving better medication adherence and diabetes outcomes.9,12,14-16
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Introduce a collaborative approach by clarifying the patient-physician/team partnership. |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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Diabetes-related choices that patients make each day may have more impact than physicians' recommendations alone on how well diabetes is managed. Nevertheless, at the time of health care visits, offering information, education, and steps to motivate patients about their diabetes self-care behaviors—glucose monitoring, healthy nutrition, physical activity, and medication taking—is key for optimal management. In other words, patients are in charge of managing their diabetes, but clinicians are important advisors and can provide assistance and support. Thus, providers have an important role that is best accomplished in a patient-provider or patient-health team partnership.
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Explain key information when prescribing a medicine.12 |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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If possible, include family members and audiovisual aids at the time of initial prescribing of a medication. Address the key information (what, why, when, how, and how long) as follows:
- Name of the medicine
- Its purpose and potential role in reducing diabetes complications
- The number of tablets or units per injection of a dose and the frequency of
dosing
- Its duration, daily and in the long term
- Common side effects or adverse effects
Simple written information and instructions, in addition to verbal instructions, are necessary. Large preprinted labels can be affixed to the medication container for easy reference (Figure 1).
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Assess adherence. |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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- Anticipate that patients often do not "take medication as
prescribed."
- Express understanding or empathy that "taking medication as
prescribed" is often difficult and may not be possible for many
patients.
- Recognize likely red flags of nonadherence (e.g., lack of response to
treatment, missed appointments, and missed refills).
- Ask patients in a nonjudgmental manner how often they miss taking doses of
medicine and about their actual medication taking (e.g., "How many
tablets are you taking and when?").
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Simplify medication-taking. |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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- Minimize the number of doses/injections to once daily whenever
possible.
- Minimize the number of pills per day.
- Synchronize simultaneous dosing of different medicines unless
contraindicated.
- Select more forgiving medications (e.g., those that lead to fewer
hypoglycemic reactions).
Keep in mind that reducing the frequency of dosing is more important than the number of pills in a dose.
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Identify difficulties and barriers related to medication-taking. |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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- Identify patient fears and beliefs, such as those related to psychological
insulin
resistance17 (e.g.,
many patients view starting insulin as a sign of their failure to control
diabetes or as a sign of impending death).
- Identify and seek solutions to cost and access barriers to taking
medications.
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Provide behavioral support. |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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- Help to identify daily reminders. Collaborate with patients to identify a
daily action in their routine that serves as a prompt to take medicine (e.g.,
brushing teeth or turning out the light at bedtime).
- Suggest aids. Medication sets that can be prefilled provide easy,
organized, and ready access to a weekly supply of medications. A variation on
this theme is the "bubble pack," which is a sealed set of
medications with daily medications that is customized by the patient's
pharmacy (Figures 2 and
3).
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Schedule follow-up contact. |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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- Assess treatment response.
- Reassess adherence and difficulties with medication-taking.
- Problem-solve difficulties using patients' preferences and solutions.
- Adjust treatment to achieve optimal outcome.
- Facilitate medication refills and follow-up care.
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Summary |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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Optimal diabetes care is achievable if clinicians collaborate with patients in managing diabetes and if health care systems support systematic patient response monitoring and enhance treatment titration to achieve favorable diabetes outcomes with minimal complications. A first step in working with patients is recognizing that not "taking medications as directed" is common. Useful clinical encounters and approaches include a nonjudgmental assessment of medication-taking, clear explanations about how to use medications, simplified regimens, and scheduled follow-up visits or telephone calls to monitor progress and adjust treatment. Such practical approaches are ones that health care providers and patients can use in a busy primary care setting.
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Footnotes |
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Elizabeth H.B. Lin, MD, MPH, is a family medicine physician and affiliate scientific investigator at the Center for Health Studies, Group Health Cooperative in Seattle, Wash. She is also a clinical professor. Paul Ciechanowski, MD, MPH, is an associate professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle.
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REFERENCES |
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TopIntroductionIntroduce a collaborative...Explain key information when...Assess adherence.Simplify medication-taking.Identify difficulties and...Provide behavioral support.Schedule follow-up contact.SummaryREFERENCES |
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1 Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS: Impact of medication adherence on hospitalization risk and healthcare cost. Med Care43 : 521-530,2005[Medline]
2 Ho PM, Rumsfeld
JS, Masoudi FA, McClure DL, Plomondon ME, Steiner JF, Magid DJ: Effect of
medication nonadherence on hospitalization and mortality among patients with
diabetes mellitus. Arch Intern Med166
: 1836-1841,2006
3 Rhee MK, Slocum W,
Ziemer DC, Culler SD, Cook CB, El-Kebbi IM, Gallina DL, Barnes C, Phillips LS:
Patient adherence improves glycemic control. Diabetes
Educ 31: 240-250,2005
4 Haynes RB,
McDonald HP, Garg AX: Helping patients follow prescribed treatment: clinical
applications. JAMA 288:2880
-2883, 2002
5 DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW: Patient adherence and medical treatment outcomes: a meta-analysis. Med Care40 : 794-811,2002[Medline]
6 Rubin RR: Adherence to pharmacologic therapy in patients with type 2 diabetes mellitus. Am J Med 118 (Suppl. 5A): 27S-34S, 2005[Medline]
7 Lin EHB, Katon
WVKM, Rutter C, Simon GE, Oliver M, Ciechanowski P, Ludman E, Bush T, Young B:
Relationship of depression and diabetes self-care, medication adherence and
preventive care. Diabetes Care27
: 2154-2160,2004
8 Ciechanowski PS,
Katon WJ, Russo JE: Depression and diabetes: impact of depressive symptoms on
adherence, function, and costs. Arch Intern Med160
: 3278-3285,2000
9 Osterberg L,
Blaschke T: Adherence to medication. N Engl J Med353
: 487-497,2005
10 Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C: Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv 27:63 -80, 2001[Medline]
11 Polonsky WH,
Fisher L, Guzman S, Villa-Caballero L, Edelman SV: Psychological insulin
resistance in patients with type 2 diabetes: the scope of the problem.
Diabetes Care 28:2543
-2545, 2005
12 Tarn DM, Heritage
J, Paterniti DA, Hays RD, Kravitz RL, Wenger NS: Physician communication when
prescribing new medications. Arch Intern Med166
: 1855-1862,2006
13 Rodondi N, Peng T,
Karter AJ, Bauer DC, Vittinghoff E, Tang S, Pettitt D, Kerr EA, Selby JV:
Therapy modifications in response to poorly controlled hypertension,
dyslipidemia, and diabetes mellitus. Ann Intern Med144
: 475-484,2006
14 Glasgow RE, Davis CL, Funnell MM, Beck A: Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf29 : 563-574,2003[Medline]
15 Funnell MM, Kruger
DF, Spencer M: Self-management support for insulin therapy in type 2 diabetes.
Diabetes Educ 30:274
-280, 2004
16 Kripalani S, Yao
X, Haynes RB: Interventions to enhance medication adherence in chronic medical
conditions: a systematic review. Arch Intern Med167
: 540-549,2007
17 Polonsky WH,
Earles J, Smith S, Pease DJ, Macmillan M, Christensen R, Taylor T, Dickert J,
Jackson RA: Integrating medical management with diabetes self-management
training: a randomized control trial of the Diabetes Outpatient Intensive
Treatment program. Diabetes Care26
: 3048-3053,2003
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