CAN ADHERENCE BE IMPROVED?

Status of Adherence Intervention Studies

To Medication

To Exercise

To Diet

19 Adherence Intervention Studies

Randomized Control Group Assessment of Adherence Assessment of Outcome 6 month Follow Up

Haynes, R. B., Montague, P., Oliver, T., McKibbon, K. A., Brouwers, M. C., & Kanani, R. (2001). Interventions for helping patients to follow prescriptions for medications. [Systematic Review] Cochrane Consumers & Communication Group Cochrane Database of Systematic Reviews.

19 Adherence Intervention Studies

All Use Self - Report

1 Study addresses Remediation

Education/Counseling/Behavioral Strategies

All Address Single Regimen/Disease

Characteristics of Successful Interventions

Educational/Behavioral

Multicomponent

Long-Term

(from Haynes, 1996)

Adherence Monitoring as Intervention

Use of Electronically Monitored Data as Feedback

Improved Blood Pressure Control1 Improved Blood Pressure Management

Reduction in Seizures2 Improved Adherence

1 Bertholet et al, 20002 Schneider et al, 2000

Summary of Interventions

Self-Monitoring

Counseling

Positive Reinforcement

Cuing

Verbal Persuasion

Education

Social Support

Self-Efficacy Enhancement

Behavioral Intervention

Electronic Monitoring/Feedback

Interventions to Promote Adherence to Exercise

Self-Monitoring 1,6,8

Counseling 2,6,7

Positive Reinforcement 1,5

1 Atkins et al, 19842 Belise et al, 19873 Daltroy, 19854 Jakicic et al, 19955 Keefe & Blumenthal, 1980

Cuing 1,5

Verbal Persuasion 3

Education 4,9

6 King et al, 19887 King & Frederikson, 19848 Rogers et al, 19879 Schneiders et al, 1998

Interventions to Promote Adherence to Dietary Regimen

Counseling 3,4,8

Social Support 1,2,6

Self-Efficacy Enhancement 6

1 Barnard et al, 19922 Borbjerb et al, 19953 Dolecek et al, 19864 Glueck et al, 19865 Karvetti, 1981

Education 5,7

Behavioral Intervention 9

6 McCann et al, 19887 Mojonnier et al, 19808 Simkin-Silverman et al, 19959 Wing & Anglen, 1996

Summary

Interventions are not targeted to patient adherence patterns or to patient-reported reasons for poor adherence

Outcome measures are not reliable or accurate

Very few RCT’s have been reported

Study 1. An intervention study designed to improve poor adherers - asymptomatic

condition

Study 2. An intervention study with poor compliers - symptomatic condition

Study 3. Adherence in clinical trials - an induction study

3 Randomized Controlled StudiesDesigned to Examine Strategies to Improve

Compliance

Purpose: To evaluate a multicomponent behavioral strategy designed to improve compliance among poor compliers

Setting: Multi-center randomized controlled clinical trial designed to test the cholesterol hypothesis

* Coronary Primary Prevention Trial

An Intervention Study Designed to Improve Poor Compliers

Proportion of Subjects > 75% Compliance

Pre-intervention Post-Intervention*Experimental 0 9

Attention Control 0 1

Usual Care 0 3

* 2 = 10.21, 2dƒ, p = .006

Change in Cholesterol Levels

Variability in Adherence and Treatment Response

Greater response to monitoring/attention overestimated compliance (r = .75) greater variability (r = .50)

Relationship between variability and overestimation (r = .54)

Purpose:To evaluate a series of behavioral/problem solving interventions to improve poor adherence

Setting: Specialty practice sites

An Intervention Study Designed to Improve Poor AdherersRAC-1

Group Differences Baseline To End Of Treatment

Average Change In Adherence x sdIntervention 4.30 + 24.7Usual Care -7.99 + 27.1 t = -2.02, p = .023

Proportion Greater Than 80% AdherenceIntervention + Maintenance = 29.7%Usual Care = 15.6% X2 = 2.25, df = 1, p = .065

RESULTS

Relationship of Change in Adherence and Functional Status

Tx F/U Adherence: Pain rs = .02 rs = -.22*

(n = 96) (n = 98)

Adherence: Difficulty rs = .04 rs = -.11 (n = 95) (n = 97)

Adherence: Assistance rs = .03 rs = -.12 (n = 96) (n = 97)

*p<.01 Changes in adherence were associated with changes in pain in carrying out activities of daily living, but no level of difficulty or assistance required

Predictors of Change

Baseline Correlates With Change Score

End of Treatment rs = -.20 p = .036Follow-up rs = -.32 p = .001

Session Attendance and Change ScoreFollow-up f = 9.07, df = 2, p = .0007

Compliance in Clinical Trials - An Induction Study

Purpose: To evaluate a minimal strategy designed to promote initial compliance

Setting: Single center randomized, clinical trial designed to study the psychological and behavioral effects of cholesterol lowering*

* M. Muldoon, the CARE Study

Group Differences in AdherenceACT

at 6 Months

n = 180 MEMS MEMS Pill Count(% days compliant) (% pills taken)

Usual Care (Mdn) 62.5% 85.7% 93.5%

Habit Training (Mdn) 67.9% 92.8% 96.1%

Habit Training (Mdn) 61.6% 90.2% 93.8%+ Problem Solving

p = NS NS NS

Summary

Poor Adherence is: Wide Spread Costly Hard to Identify Difficult to Predict Who Does Not Adhere

Few Studies Point to Interventions

Summary

Individuals vary in dosing adherenceMeasures to identify poor adherence need

to be sensitive to dosing patternsMinimal intervention does not appear to

improve long-term adherenceAdherence can be improved with intensive

interventions Improving adherence positively impacts

clinical outcomes

Recommendations

Address individual adherence patterns in clinical and research setting

Take careful account of method of assessment in interpretation of adherence data

Design/evaluate adherence interventions

Any Questions?Thank You!