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Screening Patients for Nonadherence

Bruce G. Bender, PhD

Nonadherence (noncompliance)—or the extent to which a patient's behavior, in particular medication consumption, does not conform to physician recommendations¹—is a frequent cause of treatment failure. When faced with a patient complaining of a poorly controlled chronic condition, many physicians fail to recognize the possible role of nonadherence, and hence do not attempt to determine whether treatment nonadherence is a causal factor. However, screening patients for nonadherence might change the course of treatment and significantly increase its success. Recognizing nonadherence and taking steps to increase effective self-management are keys to improved disease control.

RISK FACTORS

Virtually any patient can be nonadherent, regardless of sex, age, or socioeconomic status. Moreover, the problem of nonadherence is not specific to any disease or country.¹ Still, there are specific patient groups who tend to have more difficulty following a treatment regimen. Awareness of the patient factors associated with nonadherence can help the clinician to anticipate when and where more detailed screening for nonadherence should be implemented.

Adolescents may assert their need for independence from family by resisting medication use. For example, older adolescents with diabetes were found to be significantly more likely than younger children to mismanage their insulin injection.² In a study of renal transplant recipients, anger in adolescent patients was a red flag for medication nonadherence.³

Increasing age can be associated with decreasing adherence, largely because forgetfulness and confusion may develop at the same time that the number of required medications increases. Elderly patients are often placed on multiple-drug regimens but are at increased risk of having difficulty understanding and keeping track of the purpose(s), side effects, and dosing regimens of the drugs they are receiving.⁴

Psychologically dysfunctional patients may have difficulty organizing themselves and maintaining sufficient motivation to follow their treatment plan. With virtually any chronic condition, patient depression may signal erratic adherence.⁵ And as children's adherence largely depends on parents, family dysfunction has been associated with poor adherence.⁶

Low-income and minority patients often have particularly poor adherence rates. For example, family poverty and minority status are associated with greater asthma morbidity and mortality, and asthma mortality and hospitalization rates are particularly high among nonwhites⁷ and low-income patients.⁸ In a study of 50 adult asthma patients, nonadherence was linked to nonwhite race, low income, lower level of formal education, and poor physician-patient communication; 62% of black and Hispanic patients were nonadherent in contrast to 24% of white patients.⁹ For these patients, barriers to good asthma care may include decreased access to health care, presence of other crises requiring immediate attention, failure to recognize illness severity, and greater exposure to respiratory infections and environmental conditions that tend to exacerbate asthma (eg, air pollution, dust mites, indoor molds, cigarette smoke).¹⁰ Additionally, these families may be distrustful of the long-term safety of medications prescribed for their children.¹¹

Women are not less adherent than men. However, under certain circumstances, adherence rates among women may drop dramatically. In a survey of 5,107 female registered nurses with asthma, self-reported adherence was only 57% for mild persistent disease, 55% for moderate persistent disease, and 32% for severe persistent disease. Increasing age, lower socioeconomic status, current smoking, earlier onset of asthma, and having more than one medical condition were associated with decreasing adherence in women.¹² Mothers of inner-city minority children in Baltimore, Md, reported increased difficulty adhering to their child's asthma treatment plan; nonadherence was greatest when a mother was depressed and had decreased confidence in her ability to manage the asthma.¹³

Alcohol abuse in patients may signal a disregard for health and decreased adherence to disease management. In a study of 392 adult patients with diabetes, alcohol consumption within the previous 30 days was associated with poor adherence to glucose monitoring, oral medication use, diet control, and appointment-keeping.¹⁴

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SCREENING FOR NONADHERENCE

While the use of blood assays containing an "adherence marker" or employment of electronic medication monitors have been entertained as approaches to supervising adherence in an office practice, time and economic constraints limit what can be done by the physician to detect nonadherence. Nonetheless, a number of practical strategies can be incorporated into the office visit to screen for treatment nonadherence. Information obtained by interviewing the patient can suggest nonadherence and trigger more specific discussion with the patient.


Patient Admits Nonadherence

While many patients will overreport medication adherence, underreporting is rare. However, patients who do admit nonadherence probably are nonadherent. While screening for nonadherence should not rest exclusively on the patient's response to an inquiry about whether they are taking their medication, asking patients about adherence can be an effective starting point. After all, even patients who are willing to state that they are not taking their medication may not admit nonadherence if they are not asked. The nature of adherence questioning must be considered carefully. The patient who is asked whether she is taking her medication as prescribed may feel compelled to answer in the affirmative for fear of disapproval and embarrassment. For this reason an approach such as "Many patients tell me they have difficulty remembering to take all their medication; when is it difficult for you?" suggests to the patient that her admission of nonadherence is not a source of shame. An acknowledgement of nonadherence opens the door to a productive discussion of the patient's dislike of, or concerns about, her treatment.


Poor Disease Control

When a patient returns to the office complaining of poorly controlled symptoms, many clinicians will go to the next step in therapy, believing that the patient is nonresponsive to the original, less intensive therapy. In addition, when a patient fails to respond to an apparently appropriate therapy, the physician may feel compelled to order expensive diagnostic tests. While not all nonadherence results in dangerous or costly complications, research across a range of chronic diseases suggests that nonadherence results in excess urgent-care episodes and hospitalizations. For example, pediatric asthma patients who were the least adherent were more likely to have asthma exacerbations requiring prednisone-burst treatment.¹⁵ Before ordering more tests or resorting to more intensive therapy, the clinician should inquire further about the patient's medication adherence.


Low Pharmacy Refill Rates

Pharmacy refill rates provide an excellent opportunity to assess whether patients are taking their medication, particularly over a period of time of 6 months or longer. When refill histories are available, such as in a health maintenance organization system, the clinician or other staff can quickly determine the number of refills that should have been collected if the patient was fully adherent. One study tracking statin prescription refills in 4,802 patients determined that, on average, patients were missing at least 20% of their doses.¹⁶ Even when automated pharmacy refill reports are not available, it is possible to implement a simple procedure to check pharmacy refills. In a study of 116 Medicaid children with asthma, office staff called the 66 identified pharmacies for refill histories, allowing them to determine which families were underutilizing medications.¹⁷


Erratic Appointment Attendance

Patients who are nonadherent with their medications often tend to be disorganized and nonadherent in other areas of their lives as well, including making and keeping appointments. Erratic attendance at appointments may signal that a patient also has difficulty filling and taking prescriptions. Attempts to reschedule appointments and encourage attendance can help improve adherence. A meta-analysis of adherence intervention studies across diseases concluded that few interventions were effective, but noted that simply telephoning patients who missed appointments was one of the most cost-effective strategies.¹⁸


Patient Cannot Name and Explain Medications

Patients who have difficulty describing their treatment regimen—particularly the dosing intervals—are unlikely to be highly adherent. A brief question about what medications the patient is taking and when can quickly reveal uncertainty that suggests poor adherence.


Depression

Patients with depression are at great risk of nonadherence to a treatment program for concomitant disease.⁵ Likewise, the child of a depressed parent is less likely to consistently receive medication.¹³ Depression may be relatively easy to recognize at an office visit, but some patients are adept at hiding their depression. Brief questioning about symptoms of depression was found to detect depression effectively in the primary care setting.¹⁹ A panel recently convened by the US National Institutes of Health has recommended such depression screening for cancer patients.²⁰ Depression cannot simply be accepted as an inevitable byproduct of chronic illness. Depressed patients require appropriate referral and treatment; the most effective treatments are those that include both medication and talk therapy.²¹


Families in Conflict

Families that present a picture of relative stability and emotionally close relationships tend to be more capable of administering a pediatric treatment regimen.6 Conversely, families who present with apparent conflict between members, or between parents and physician, are likely to have difficulty with adherence. Tragically, the risk of death from childhood asthma increases in families characterized by conflict, poor treatment adherence, and a pattern of ignoring worsening symptoms.²² Physicians may not be able to resolve the conflicts of dysfunctional families, but recognizing the problem can lead to referral to a mental health professional.

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CLINICIAN-PATIENT COMMUNICATION

The effectiveness of adherence screening depends largely on clinician-patient communication. With the exception of more passive information sources (prescription refill history, documentation of missed appointments), the assessment of treatment adherence occurs in conversation with the patient. Because many patients do not inform the clinician that they are nonadherent, indirect evidence gathered through the screening strategies described here can help the clinician decide when to intervene to increase adherence. Pharmacy refill records are most informative of nonadherence, but the presence of several elements of indirect evidence suggesting nonadherence—for example, depression and inability to clearly describe the medication regimen—should convince the clinician that nonadherence must be addressed.

Likewise, the most effective nonadherence interventions occur in the physician's office. Effective physician-patient communication is not didactic, but rather interactive.²³ Although all clinicians experience time pressures and may need to limit time spent in the examination room, a commitment to communicating effectively is essential to good patient care. Active listening not only educates patients about their disease, but also recognizes and respects the validity of patient beliefs and goals. Without effective communication, the physician's goals for treatment may be markedly mismatched with those of the patient. Patients feel more positive about clinicians whom they perceive as taking time to listen to them, and are more likely to follow a treatment plan if they have sufficient faith in the physician and the treatment.²⁴ One study demonstrated that a training program to improve physician communication skills improved patient self-management of illness.²⁵ Sixty-nine primary care physicians were randomized to either a communication-skills training group or a control group. Patients of physicians who received the intervention, which consisted of training in recognizing and addressing patient concerns, demonstrated a greater reduction in psychological distress and a short-term reduction in health care utilization.²⁵ In another intervention study aimed at providing general-practice pediatricians with training in interactive communication skills, children with asthma seen by those in the active training group required fewer office or emergency department visits than those in the control group.²⁶

Shared decision-making is one communication approach that physicians and patients can use to find common ground.²⁷ Shared decision-making attempts to increase concordance about treatment choices and goals by promoting greater involvement of the individual patient in deliberations about treatment options. This promising communication strategy may have significant potential for improving patient adherence. The shared decision-making model requires the physician to allow some flexibility in the traditional decision-by-algorithm approach wherein the physician utilizes expert guidelines to choose the treatment, which the patient is then required to follow. Instead, physician and patient negotiate the best match of effective treatment and patient preference. Physician and patient must agree on the treatment goal. The objective of this collaboration is to arrive at a treatment that both physician and patient will embrace, producing a partnership in which the two work together to gain control of the illness, rather than accepting an authoritarian hierarchy in which the physician attempts to convince the patient to comply.^28,29

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CONCLUSION

The most meticulous diagnosis and evidence-based treatment recommendations are useless if the patient does not comply with therapy. When the physician does not detect nonadherence, a number of important issues can go unaddressed, including neglect/exacerbation of disease and/or failure to appreciate drug side effects leading to avoidance of use. Most causes of nonadherence can be remedied—once the problem is recognized. The key is to include the patient in decision-making and to have some familiarity with her milieu, so that issues can be anticipated and monitored appropriately.

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Bruce G. Bender, PhD, is head, Pediatric Behavioral Health, National Jewish Medical and Research Center, and professor of psychiatry, University of Colorado Medical School, Denver.

References

1. Sabate E, ed. Adherence to Long-term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003.
2. Weissberg-Benchell J, Glasgow AM, Tynan WD, Wirtz P, Turek J, Ward J. Adolescent diabetes management and mismanagement. Diabetes Care. 1995;18(1):77-82.
3. Penkower L, Dew M, Ellis D, Sereila S, Kitutu J, Shapiro R. Psychological distress and adherence to the medical regimen among adolescent renal transplant recipients. Am J Transplant. 2003;3(11):1418-1425.
4. Spiers M, Kutzik D, Lamar M. Variation in medication understanding among the elderly. Am J Health Syst Pharm. 2004; 61(4):373-380.
5. DiMatteo M, Lepper H, Croghan T. Depression is a risk factor for nonadherence with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch intern Med. 2000;160(14):2101-2107.
6. Bender B, Milgrom H, Rand C, Ackerson L. Psychological factors associated with medication nonadherence in asthmatic children. J Asthma. 1998;35(4):347-353.
7. McQuaid E, Kopel S, Klein R, Fritz G. Medication adherence in pediatric asthma: reasoning, responsibility, and behavior. J Pediatr Psychol. 2003;28(5):323-333.
8. Wasilewski Y, Clark N, Evans D, et al. The effect of paternal social support on maternal disruption caused by childhood asthma. J Community Health. 1988;13(1):33-42.
9. National Heart, Lung, and Blood Institute. Expert Panel 2. Clinical Practice Guidelines: Guidelines for the Diagnosis and Management of Asthma, NIH Pub No. 97-4051. Bethesda, Md: National Institutes of Health; July, 1997.
10. Cromer B. Behavioral strategies to increase adherence in adolescents. In: Cramer J, Spilker B, eds. Patient Adherence in Medical Practice and Clinical Trials. New York, NY: Raven Press; 1991:99-105.
11. Stewart M. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J. 1995; 152(9): 1423-1433.
12. Barr RG, Somers SC, Speizer FE, Camargo CA Jr; National Asthma Education and Prevention Program (NAEPP). Patient factors and medication guideline adherence among older women with asthma. Arch Intern Med. 2002;162(15):1761-1768.
13. Bartlett SJ, Lukk P, Butz A, Lampros-Klein F, Rand CS. Enhancing medication adherence among inner-city children with asthma: results from pilot studies. J Asthma. 2002; 39(1):47-53.
14. Ciechanowski PS, Katon WJ, Russo JE, Walker EA. The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry. 2001; 158(1):29-35.
15. Milgrom H, Bender B, Sarlin N, Leung D. Difficult to control asthma: the challenge posed by non-adherence. Am J Asthma Allergy Ped. 1995;7(3):141-146.
16. Ellis JJ, Erickson SR, Stevenson JG, Bernstein SJ, Stiles RA, Fendrick AM. Suboptimal statin adherence and discontinuation in primary and secondary prevention populations. Gen Intern Med. 2004;19(6):638-645.
17. Sherman J, Hutson A, Baumstein S, Hendeles L. Telephoning the patient's pharmacy to assess adherence with asthma medications by measuring refill rate for prescriptions. J Pediatr. 2000;136(4):532-536.
18. Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev. 2002;(2): CD000011.
19. Henkel V, Mergl R, Coyne J, Kohnen R, Moller H, Hegerl U. Screening for depression in primary care: will one or two items suffice? Eur Arch Psychiatry Clin Neurosci. 2004;254(4):215-223.
20. Patrick DL, Ferketich SL, Frame PS, et al. National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002. J Natl Cancer Inst. 2003;95(15):1110-1117.
21. Friedman MA, Detweiler-Bedell JB, Leventhal HE, Horne R, Keitner GI, Miller IW. Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol Sci Pract.v 2004;11:47-68.
22. Strunk RC. Asthma deaths in childhood: Identification of patients at risk and intervention. J Allergy Clin Immunol. 1987;80(3 Pt 2):472-477.
23. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83-90.
24. Spilker B. Methods of assessing and improving patient adherence in clinical trials. In: Cramer J, Spilker B, eds. Patient Adherence in Medical Practice and Clinical Trials. New York, NY: Raven Press; 1991: 37-56.
25. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155(17):1877-1884.
26. Clark NM, Gong M, Schork MA, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998; 101(5):831-836.
27. Wensing M, Elwyn G, Edwards A, Vingerhoets E, Grol R. Deconstructing patient centered communication and uncovering shared decision making: an observational study. BMC Med Inform Decis Mak. 2002;2(1):2.
28. Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Science Med. 1999;49(5):651-661.
29. Godolphin W. The role of risk communication in shared decision making. BMJ. 2003;327(7417):692-693.