Nonadherence: Investing in Real Change

June 13, 2017

Medication reminder systems, simplification of dosing, medication organizers, and virtual assistants have all shown some effectiveness, albeit marginal, in improving adherence rates. Health care costs associated with nonadherence to medication regimens are now exceed $300 billion annually. And, despite the aforementioned interventions, the overall rate of nonadherence for the past 40 years has remained at over 50 percent for year two of chronic asymptomatic illnesses. This raises the question, “Where is the silver bullet?” The answer, of course, is there is no silver bullet. Dr. Bruce Berger has studied adherence for over 35 years. He offers the following; “While there are numerous types of technologies and interventions out there, adherence is done at the individual level. Until we explore what the problem is (lack of motivation, barriers, cost, forgetfulness, etc.), we simply cannot match an intervention to the needs of the patient. The intervention must fit the problem. It makes no sense to give a patient a medication reminder system when the problem is the patient doesn’t think he needs the medication. In a caring and supportive way, we must learn how to uncover each patient’s particular issues(s), respond with respect, reflect our understanding, and then offer insight, education, or a tool to invite the patient to reconsider.” Real change takes place when it is the patient’s decision. Ultimately, adherence is the patient’s decision and change must be associated with the individual’s goals or ideas about health. Being patient-centered is no easy task. Health care professionals (HCPs) have to resist the urge correct, persuade, or motivate the patient. Patients who are not ready to take a medication, lose weight or quit smoking resist correction and persuasive techniques. Motivational interviewing is a well-researched and highly efficacious patient-centered approach for improving adherence to health behaviors. MI does two important things. MI:

  1. accurately and nonjudgmentally reflects, explores, and uncovers the concerns and emotions of the patient, and
  2. provides insight or new information to address those concerns in a nonjudgmental and nonthreatening manner.

A skilled HCP, trained in motivational interviewing can effectively explore whether an adherence problem represents an importance issue (“I really don’t think I need the medication,” “I don’t think the medication is working”) or a confidence issue (“I’ve never given myself injections,” “I have a hard time remembering to take medications”) or an economic issue, or a combination of these issues. If a patient does not believe it is important to take a medication or lose weight, for example, it is unlikely he/she will engage. Relatedly, a patient may think it’s important to lose weight, but has been unsuccessful in keeping the weight off in the past. Being able to skillfully explore the patient’s issues at an individual level and work with the patient to devise solutions has been shown to be highly effectively when skills training has been of sufficient breadth and depth.

 

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