Tips for managing non-adherence

Recognising constraints and practical barriers is key to improving outcomes for patients.

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The issue of patient compliance is always a difficult problem to address and can involve many factors.

When broaching this subject, although “compliance” seems to be the most used term (in my experience anyway), “adherence” is probably preferable. Adherence refers to “the extent to which a person’s behaviour corresponds with the recommendations from a health care provider” whereas compliance implies that “healthcare providers give instructions, which patients passively follow”. Using the term “declines” rather than “refuses” when documenting in patient’s notes is also preferable.

It is known that non-adherence to DMARDs, in particular in patients with RA, can range from 58% to 82%, a level that can have serious consequences. Inadequate medication adherence can lead to increased RA disease activity, poorer function, risk of co-morbidities and early mortality. It is therefore vital to address any issues identified. 

Adherence to prescribed exercise in SpA is unclear, but probably reduces over time, and this, again, can affect patient outcomes. Exercise is essential in the management of SpA to maintain and improve mobility, strength, cardiovascular health, function and quality of life, and to limit spinal deformities.

To enable adherence to be considered in the clinical setting, reasons for non-adherence could be categorised into three groups: communication, cost (time and monetary) and psychosocial aspects.

Communication

Issues

• Poor literacy/lower level of education; that is, inability to understand/follow instructions.
• Lack of understanding; that is, fear of getting addicted, thinking medications will not help, implications of not taking medications/following exercise program etc.
• Patient/clinician related – lack of trust towards clinician, feeling controlled by clinician, not wanting to discuss their fears/worries as they are worried about what the clinician will think about them – that is, the perception of “being difficult”.

Solutions

• Use an individualised approach by acknowledging patient limitations and own beliefs; practise empathy and reflective listening; encourage patient empowerment.
• Spend time on education – use diagrams to explain concepts; show patients results/imaging rather than just telling; address any concerns using open-ended questions and allow time for questions; explain side effects and risks of non-treatment; give trusted websites/information.
• Utilise the multi-disciplinary team – nurses are well placed to address many of the communication issues; other health care professionals such as GP/pharmacist/physiotherapist/exercise physiologist/podiatrist etc can play an important role in reassuring patients and reiterating information.

Cost

Issues

• Monetary costs include not being able to afford medications; difficulty accessing scripts; difficulty working/loss of income due to time off work for treatments/appointments.
• Time pressures (work/life balance); difficulty “fitting in” exercise programs; inconvenient dosing regimes/attending hospital for infusions; difficulty attending hospital appointments.

Solutions

• Explain to patients that using medications may be cost effective in the long term; that is, disease control can reduce time off work.
• Explain that exercise programs and taking medications should be part of everyday life/routine; give examples, such as stretching in shower etc.

Psychosocial

Issues

• Depression; feeling pessimistic/overwhelmed; fear of the future.
• Worried about medication side effects; not keen to take meds/trying lifestyle changes first.
• Poor memory/difficulty remembering when to take medications
• Younger age and shorter disease duration (better adherence in the older patient and those with longer disease duration).

Solutions

• Overlaps with communication, particularly reflective listening, asking open-ended questions and using all members of the health-care team.
• Address concerns with understanding; consideration of patient choices.
• Work out goals/values/purpose, what is important to individuals and how to facilitate achieving; appreciate patient goals may be different to the clinician’s.
• Encourage use of diaries, text messages as reminders, using apps and Webster-Paks.
• Utilise patient support programs/online support programs/information as appropriate; utilise chronic care management plans via GP (allied health access).

Other tips to consider are to ask how many doses have been missed rather than asking whether the patient is taking their medications. Dexterity with managing medications is a factor often forgotten but is very important – is the patient able to halve tablets, open the bottles etc? 

Managing everything can be very daunting for patients especially when first diagnosed.  Working out the individual’s priorities while ensuring best care is essential.

As healthcare professionals, if we can improve adherence by spending a little extra time with our patients, we can potentially improve patient outcomes and therefore costs to health care in the long term. Recognising constraints and practical barriers is key in managing this.

References

1. Brzezinska et al (2020) Adherence with methotrexate in Polish patients – survey research results.  Int J Clin Pract doi: 10.1111/ijcp.13677
2. Du et al (2020) Medication adherence in Chinese patients with systemic lupus erythematosus. J Clin Rheum 26 (3) 94-98
3. Hall et al (2003) Patient reported reasons for non-adherence to recommended osteoporosis pharmacotherapy.  J Am Pharm Assoc 57 (4) 503-509
4. McDonald et al (2019) Level of adherence to prescribed exercise in spondyloarthritis and factors affecting this adherence: a systematic review. Rheum Int (39) 187-201
5. Nurit et al (2009) Evaluation of a nursing intervention project to promote patient medication education. J Clin Nurs 18 (17) 2530-2536
6. Rubin et al (2017) Impact of a patient support program on patient adherence to adalimumab and direct medical costs in Crohns disease, ulcerative colitis, rheumatoid arthritis, psoriasis, psoriatic arthritis and ankylosing spondylitis. Journal of Managed Care and Speciality Pharmacy 23 (8) 859-867
7. Sun et al (2020) Investigating the safety and compliance of using csDMARDs in rheumatoid arthritis treatment through face-to-face interviews: a cross-sectional study in China. Clin Rheum doi: 10.1007/s10067-020-05458-w
8. Wohlfahrt et al (2018) Use of rheumatology-specific patient navigators to understand and reduce barriers to medication adherence: Analysis of qualitative findings. PLOS ONE 13 (7) doi.org/org/10.1371/journal.pone.0200886
9. Zwikker et al (2012) Development and content of a group-based intervention to improve medication adherence in non-adherent patients with rheumatoid arthritis. Patient Education and Counselling (89) 143-151