Medication Adherence:
the Patient Perspective
Monika Safford
University 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
Population
Counties
Choctaw
15,922
Dallas
46,365
Lowndes
11,147
Marengo
20,692
Perry
11,861
Pickens
19,746
Sumter
14,798
Wilcox
13,183
ALABAMA
4,802,740
US
314,918,000
% Black1
% <Poverty1
44.4
69.4
73.7
52.0
68.8
43.0
73.6
72.2
26.3
12.6
24.5
34.7
31.4
25.9
35.4
27.7
38.7
39.9
19.0
15.9
Diabetes
PCP/10,0003
Prevalence2
13.5
11.9
12.2
11.7
17.5
14.9
12.2
12.2
11.8
8.3
3.4
10.1
1.5
5.5
4.3
5.0
3.6
3.1
20.6
25.7
• Rural AL: mostly African American, high poverty, high chronic
disease burden, low access to health care
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.
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.
2.
3.
4.
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.
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.
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.
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”
 A1c
 BP
 Cholesterol
 Eyes
 Feet
 Kidneys
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
Adherence
A community self-help model
Monika Safford, MD
University 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.
2.
3.
4.
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.
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.
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.
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 relationship
2. Find an alternative to direct persuasion
3. Reinforce CHANGE TALK
4. Build a foundation of listening
5. Roll with resistance
PHASE II: Encourage action, move to “how to change”
6. Assess readiness, make a plan, set a goal
7. 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
“That sounds like it
was hard”
“You must be pretty proud of
yourself for doing that despite all
those challenges”
• 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
“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?”
“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”
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