Medication Adherence:the Patient Perspective

Monika SaffordUniversity of Alabama at Birmingham

Disclosures

• Dr. Safford receives salary support from NIH, PCORI, Amgen, and consults for diaDexus, a lipid assay manufacturer

Outline

• Use diabetes as an example to discuss medication adherence• Review findings from the Encourage study• Review findings from studies of the patient perspective on

medication adherence• Patient-centered education strategies• Motivational interviewing to help patients move toward

adherence

Background• Diabetes self care requires ~2 hours daily1,2

• Medications:• Many!• Complicated• Costly

• 28% of total costs of diabetes are medications3

• Many patients can’t afford

1. Russell LB, Suh DC, Safford MM. Time requirements for diabetes self-management: too much for many? J Fam Pract 2005 Jan;54(1):52-6.

2. Safford MM, Russell L, Suh DC, Roman S, Pogach L. How much time to patients with diabetes spend on self-care? J Am Board Fam Pract 2005 Jul-Aug;18(4):262-70.

3. American Diabetes Association. Economic costs of diabetes in the US in 2012. Diabetes Care 2013;36(4):1033-1046.

The Setting

12010 Census; 22008 Alabama Department of Public Health and BRFSS; 3PCP=Primary Care Providers per 10,000 people, from Board of Medical Examiners of Alabama and Kaiser Family Foundation.

Population % Black1 % <Poverty1 Diabetes Prevalence2 PCP/10,0003

Counties Choctaw 15,922 44.4 24.5 13.5 3.4 Dallas 46,365 69.4 34.7 11.9 10.1 Lowndes 11,147 73.7 31.4 12.2 1.5 Marengo 20,692 52.0 25.9 11.7 5.5 Perry 11,861 68.8 35.4 17.5 4.3 Pickens 19,746 43.0 27.7 14.9 5.0 Sumter 14,798 73.6 38.7 12.2 3.6 Wilcox 13,183 72.2 39.9 12.2 3.1 ALABAMA 4,802,740 26.3 19.0 11.8 20.6 US 314,918,000 12.6 15.9 8.3 25.7

• Rural AL: mostly African American, high poverty, high chronic disease burden, low access to health care

Community Health Workers (CHW)• Peer support effective in improving health behaviors in patients

with chronic conditions1-4

• CHWs:• Link community, health care system• Understand challenges of day-to-day

management of diabetes• Develop realistic, feasible strategies;

provide social and emotional support

1. Piette JD, Resnicow K, Choi H, Heisler M. A diabetes peer support intervention that improved glycemic control: mediators and moderators of intervention effectiveness. Chronic illness. 2013;9:258-67.

2. Tang TS, Funnell M, Sinco B, Piatt G, Palmisano G, Spencer MS, et al. Comparative effectiveness of peer leaders and community health workers in diabetes self-management support: results of a randomized controlled trial. Diabetes care. 2014;37:1525-34.

3. Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenheimer TA. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Annals of family medicine. 2013;11:137-44.

4. Heisler M, Vijan S, Makki F, Piette JD. Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Annals of internal medicine. 2010;153:507-15.

Encourage Study1

• Peers for Progress• 424 individuals with diabetes living in the Black Belt• Randomized trial: peer coach + education vs. education• Weight loss, blood pressure lower, quality of life improved

1. Safford MM, et al. Peer coaches to improve diabetes outcomes in rural Alabama. Annals Fam Med 2015, in press.

Encourage Study

• Diet and exercise: 93%

• Medications and adherence: 0%

Living Well with Diabetes Study

• Funded by Patient-Centered Outcomes Research Institute

• Goals:• Understand patient perspective on medication adherence• From this perspective, collaboratively develop an

intervention designed to improve health and wellness while living with diabetes (including medication adherence)

• Test the intervention in a randomized trial

Living Well with Diabetes Study

• Funded by Patient-Centered Outcomes Research Institute

• Goals:• Understand patient perspective on medication adherence• From this perspective, collaboratively develop an

intervention designed to improve health and wellness while living with diabetes (including medication adherence)

• Test the intervention in a randomized trial

Marrero Medication Adherence Risk Assessment

• David Marrero, PhD• Inner city Indianapolis• Mostly African

Americans, high poverty

• Focus groups

Encourage

Generic medications• Generics don’t work as well as brands – not “real” medicines• Because they don’t work as well, you need to take higher

doses, therefore they have more side effects• Generics are OK for milder conditions, but not serious

conditions• Doctors must make $ from writing Rx’s – “pill pushers”• Poor people have to settle for generics

Sewell K, Andreae SJ, Luke E, Safford MM. Perceptions and barriers to use of generic medications in a rural African-American population. Prev Chronic Dis, 2012 Aug;9:E142.

Living Well with Diabetes

Focus groups: • Black Belt residents with diabetes• CHW’s/peer advisors

• Medications are a “quick fix”• Diet and exercise are the “real deal”• Expect to get off medications

• On days when morning blood sugar normal, I don’t need medicines• Limited understanding of diabetes• Limited understanding of role of medications

Reality• Diabetes is a bad disease• Hope?

• Medications reduce but don’t eliminate risks• Medications should be taken daily• Most people can’t get off medicine1

• Look Ahead study: randomized trial of intensive weight loss• 11.5% off meds and A1c in pre-diabetes range in year 1• 7.3% in year 4

1. Gregg EW, et al. Association of an intensive lifestyle intervention with remission of type 2 diabetes. JAMA 2012;308(23):2489-2496.

Reality• Diabetes is a bad disease• Hope?

• Medications reduce but don’t eliminate risks• Medications should be taken daily• Most people can’t get off medicine1

• Look Ahead study: randomized trial of intensive weight loss• 11.5% off meds and A1c in pre-diabetes range in year 1• 7.3% in year 4

• Patients don’t like medicines• Strong interest in diet and exercise• Strong belief that most people can get off medicine

1. Gregg EW, et al. Association of an intensive lifestyle intervention with remission of type 2 diabetes. JAMA 2012;308(23):2489-2496.

Strategy

• Provide what people want first• Diet and exercise

• Integrate medications and messages around medications

Strategy

• Provide what people want first• Diet and exercise

• Integrate medications and messages around medications

Strategy

• Provide what people want first• Diet and exercise

• Integrate medications and messages around medications

Question

• On average, how long have people already had diabetes at the time of their diagnosis?

Strategy

• It takes years to develop diabetes

Strategy

• Familiar analogies: “look under the hood”

A1cBPCholesterolEyesFeetKidneys

Education is not enough!

Motivational interviewing• Client-centered counseling technique• Proven effective for behavior change• Can be applied to all types of health behaviors• Substance use (smoking, alcohol, other)• Medication adherence• Diet• Exercise

• Helps clients explore, resolve their own ambivalence

Role of community members

• Understand challenges faced by others in their communities• Familiar with realistic solutions• Coach, cheer leader, friend• Can help link clients into community resources, health care

team

Break

Peer-to-Peer AdherenceA community self-help modelMonika Safford, MDUniversity of Alabama at Birmingham

Objectives

• Become familiar with community health workers• Become familiar with basic principles of motivational

interviewing• Practice setting a SMART goal for exercise• Learn a simple technique for reducing stress

Community Health Workers (CHW)

• Peer support effective in improving health behaviors in patients with chronic conditions1-4

• CHWs:• Link community, health care system• Understand challenges of day-to-day

management of diabetes• Develop realistic, feasible strategies;

provide social and emotional support

1. Piette JD, Resnicow K, Choi H, Heisler M. A diabetes peer support intervention that improved glycemic control: mediators and moderators of intervention effectiveness. Chronic illness. 2013;9:258-67.

2. Tang TS, Funnell M, Sinco B, Piatt G, Palmisano G, Spencer MS, et al. Comparative effectiveness of peer leaders and community health workers in diabetes self-management support: results of a randomized controlled trial. Diabetes care. 2014;37:1525-34.

3. Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenheimer TA. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Annals of family medicine. 2013;11:137-44.

4. Heisler M, Vijan S, Makki F, Piette JD. Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Annals of internal medicine. 2010;153:507-15.

Motivational Interviewing

• Client-centered counseling technique• Proven effective for behavior change• Can be applied to all types of health behaviors• Substance use (smoking, alcohol, other)• Medication adherence• Diet• Exercise

• Helps clients explore, resolve their own ambivalence

Motivational Interviewing

Ambivalence• Normal part of change process• Does not imply resistance to change• Think about a time when you were asked to change a behavior• Were you sure you wanted to change?• Were you sure you were able to change?

• Motivational interviewing: • Support ambivalence• Help client find motivation

What is NOT Motivational Interviewing?

• Arguing with a client about change• Direct advice or solutions • Without client permission• Without encouragement or choice

• Use of an authoritative stance• Client is passive

• Unidirectional conversation• Lots of talking by the counselor

• Labels client with a problem• Punitive or coercive speech

Seven Steps to Success for MI

PHASE I: Listen, figure out “why change”1. Build a power sharing relationship2. Find an alternative to direct persuasion3. Reinforce CHANGE TALK4. Build a foundation of listening5. Roll with resistance

PHASE II: Encourage action, move to “how to change”6. Assess readiness, make a plan, set a goal7. Teach, negotiate collaboratively

Motivational Interviewing

• Power sharing• Don’t tell the client what to do• Don’t judge – avoid “right” or “wrong”

• Behavior change talk• Open-ended questions• Affirmations• Reflective listening• Summarize

Motivational Interviewing

Open-ended questions• Put the reins in their hands• What about your health concerns you?• How has diabetes gotten in your way?

• Assessing readiness• How important is it for you to change?• How confident are you that you can make changes?• You are not very confident, can you tell me what makes you lack

confidence?

Motivational Interviewing

• Affirmations• Make it real • Lots of affirmations before moving to harder topics• Keep it positive

• Reflective listening• More effective than questions• Use change talk• Reflect emotions

• Summarize

“That sounds like it was hard”

“You must be pretty proud of yourself for doing that despite all those

challenges”

“So you are worried about exercising

because when you do, you always get pain in your legs, is

that right?”

“Despite the fact that you have had

pain, you would like to learn more about

how to exercise safely”

“Let me be sure I’ve understood; you would like to exercise because it will

keep your diabetes under control, but you worry about the pain exercise

seems to cause, is that right?”

Motivational Interviewing

Setting goals• Specific• Measurable• Achievable• Realistic/relevant• Time-bound

Quiz

• I will exercise more

Quiz

• I will exercise more• I will walk for exercise

Quiz

• I will exercise more• I will walk for exercise• I will walk every day for 10 minutes

Quiz

• I will exercise more• I will walk for exercise• I will walk every day for 10 minutes• I will walk the dog every day after

supper for 60 minutes

Quiz

• I will exercise more• I will walk for exercise• I will walk every day for 10 minutes• I will walk the dog every day after

supper for 60 minutes• Starting tonight, I will walk the dog

every day after supper for 10 minutes

Quiz

• I will exercise more• I will walk for exercise• I will walk every day for 10 minutes• I will walk the dog every day after

supper for 60 minutes• Starting tonight, I will walk the dog

every day after supper for 10 minutes

Set your own SMART exercise goal

• Group activity

Stress reduction