Strategies for enhancing patient adherence to medical recommendations

Parents' treatment of their children's pain at home: pharmacological and nonpharmacological approaches

INTRODUCTION

During childhood, pain often is experienced on a nearly daily basis. This study focuses on pain alleviation techniques provided by parents, because children's painful experiences are most often treated at home. Hypotheses addressed various factors that can influence use of pain alleviation techniques, including parents' level of catastrophizing about their children's pain, children's age, and conversations with health care professionals.

METHOD

A total of 756 parents of children ages 6 to 17 years completed an online survey regarding pain alleviation including use and effectiveness of pharmacological and nonpharmacological techniques, pain catastrophizing, and questions regarding dialogue with health care professionals.

RESULTS

Parents with increased pain catastrophizing used more pharmacological techniques, and child self-administration of pain alleviation techniques increased with the child's age. Parents were more likely to have spoken with their health care professional about pharmacological techniques.

DISCUSSION

This study provides information that can help health care professionals initiate conversations regarding treatment options and align recommendations with techniques that parents are likely to use, and it can help health care professionals provide supportive alternative recommendations.

Patient-reported measures of psychosocial issues and health behavior should be added to electronic health records

Recent legislation and delivery system reform efforts are greatly expanding the use of electronic health records. For these efforts to reach their full potential, they must actively involve patients and include patient-reported information about such topics as health behavior, preferences, and psychosocial functioning. We offer a plan for including standardized, practical patient-reported measures as part of electronic health records, quality and performance indexes, the primary care medical home, and research collaborations. These measures must meet certain criteria, including being valid, reliable, sensitive to change, and available in multiple languages. Clinicians, patients, and policy makers also must be able to understand the measures and take action based on them. Including more patient-reported items in electronic health records would enhance health, patient-centered care, and the capacity to undertake population-based research.

Communication patterns for the most serious poison center calls

CONTEXT. The communication demands faced by specialists in poison information (SPI) are unique in the health-care context. OBJECTIVES. (1) To describe SPI communication patterns for the highest risk poison exposure calls using cluster analysis, and (2) to describe variation in communication patterns or clusters. METHODS. A sample of 1 year of poison exposure calls to a regional poison control center with SPIs' perceived severity rating of major or moderate perceived was collected. Digital voice recordings were linked with medical records and were coded using the Roter Interaction Analysis System. Descriptive analyses were applied, and cluster-analytic techniques were used to assess variation in call communication and factors associated with that variation. RESULTS. Cases were described, and four communication styles were identified. The informational cluster represents calls with relatively high levels of SPI clinical information and caller questions. The Facilitative cluster represents calls with a pattern of relatively high SPI questions and caller information provision. The Planning cluster represents calls with relatively high levels of SPI relationship talk. The Emotional cluster represents calls with relatively high caller and SPI emotion. Further analyses revealed relationships between call characteristics, SPI identity, and cluster membership. CONCLUSION. This study provides a beginning step to understanding SPI communication behaviors. Our results suggest that SPIs are able to use a range of communication strategies that often involve not only information but also emotional responsiveness and rapport building. Findings also point to the opportunity for future communication training for SPIs to meet the needs of the heterogeneous caller population.

Improving adherence with inhaler therapy in COPD

Chronic obstructive pulmonary disease (COPD) is a major public health problem, associated with considerable morbidity and health care costs. The global burden of COPD morbidity is predicted to rise substantially in the coming decade, but could be moderated by better use of existing management strategies. Smoking cessation, medication therapy, and pulmonary rehabilitation have all been shown to diminish morbidity and improve patient outcomes. But each of these strategies requires adherence. Adherence is crucial for optimizing clinical outcomes in COPD, with nonadherence resulting in a significant health and economic burden. Suboptimal medication adherence is common among COPD patients, due to a number of factors that involve the medication, the delivery device, the patient, and the health professionals caring for the patient. Lack of medication adherence needs to be identified and addressed by using simplified treatment regimens, increasing patient knowledge about self-management, and enhancing provider skills in patient education, communication, and adherence counseling. This article reports some of the challenges of medication nonadherence faced by the clinician in the management of COPD, and suggests ways to evaluate and improve adherence effectively in primary care.

Improving adherence with inhaler therapy in COPD

Chronic obstructive pulmonary disease (COPD) is a major public health problem, associated with considerable morbidity and health care costs. The global burden of COPD morbidity is predicted to rise substantially in the coming decade, but could be moderated by better use of existing management strategies. Smoking cessation, medication therapy, and pulmonary rehabilitation have all been shown to diminish morbidity and improve patient outcomes. But each of these strategies requires adherence. Adherence is crucial for optimizing clinical outcomes in COPD, with nonadherence resulting in a significant health and economic burden. Suboptimal medication adherence is common among COPD patients, due to a number of factors that involve the medication, the delivery device, the patient, and the health professionals caring for the patient. Lack of medication adherence needs to be identified and addressed by using simplified treatment regimens, increasing patient knowledge about self-management, and enhancing provider skills in patient education, communication, and adherence counseling. This article reports some of the challenges of medication nonadherence faced by the clinician in the management of COPD, and suggests ways to evaluate and improve adherence effectively in primary care.

Nurse responsiveness to cancer patient expressions of emotion

OBJECTIVE

This theoretically based study examined nurse responses to cancer patient expressions of emotion using a videotaped, simulated cancer patient.

METHODS

This study used an experimental crossover design with a videotaped patient expressing anger, sadness, and neutral emotion to elicit nurse responses. Seventy-four nurses from eight sites participated. Responses were coded using Roter interaction analysis system. Correlations explored relationships between variables that impact communication (age, gender, work experience, trait anxiety, work stress, self-efficacy). Regression models explored the effect of variables on nurse affective responsiveness.

RESULTS

Patient expressions of sadness elicited more affective responses than anger. Expressions of anger or neutral emotion elicited more instrumental behaviors than sadness. Variables such as age, work stress and work experience were significantly correlated. No variables predicted affective responsiveness to patient expressions of anger or sadness.

CONCLUSION

Nurse communication showed significant variation in response to patient emotional expressions. Understanding the relationships between demographic, personality, and work variables, and identification of new variables that influence nurse-patient communication, has implications for interventional studies.

PRACTICE IMPLICATIONS

Over 90% of the participants indicated that the videotape simulation would be a useful method for teaching and practicing communication skills with patients expressing emotions.

[Therapeutic alliance, a stake in schizophrenia]

INTRODUCTION

Adherence to (or compliance with) a medication is one of the foremost issues in the assumption of patients with psychiatric illness and, in particular, in schizophrenia. Adherence to medication is generally defined as the extent to which patients take medications as prescribed by their health care providers. There is no consensus to define an acceptable compliance.

LITERATURE FINDINGS

The methods available for measuring adherence can be broken down into direct and indirect methods of measurement, each one having advantages and disadvantages. Clinical summations of studies were realized, the problem of poor adherence to medication concerned 25% of patients with schizophrenia and 74% of the 1493 schizophrenia patients recruited for the Catie study discontinued their assigned study medication before 18 months, a rate that was considered to be very high in a study in which the primary outcome measure was discontinuation of the study drug for any cause and approximately 30% stopped the treatment of their own motivation. In two thirds of cases, rehospitalisation is the result of complete or partial non-compliance. One year after first hospitalsation, 40% of relapse results from non-adherence to medication.

DISCUSSION

Medication adherence problems increase hospitalisation, morbidity and mortality. Social consequences, professional and family problems linked to hospitalisations lead to low quality of life for patients and high cost for society. Indicators of poor adherence to a medication regimen are a useful resource for physicians to help identify patients who are most in need of interventions to improve adherence. It is usual to identify quatre categories of factors causing disparity: 1: factors due to psychiatric disorders; 2: factors due to medication; 3: factors linked to patients; 4: factors depending on the therapeutic relationship with the clinician. Patients with psychiatric illness typically have great difficulty following a medication regimen, but they also have the greatest potential for benefiting from adherence. Some effective actions to improve compliance are described in reply to the factors influencing the adherence. The communication attitude of the clinician, therapeutic relationship and prescription use are main points of alliance. Information and communication with the patient, simplification of the therapeutic plan, consultation planning and account of side effect are simple and effective actions. Social support is very important for improvement of therapeutic alliance. Poor therapeutic alliance is common, contributing to substantial worsening of disease and more research on compliance and therapeutic alliance evaluation is needed. Information and tools must be proposed to practitioners.

The contributing role of health-care communication to health disparities for minority patients with asthma

Asthma is a common, chronic illness with substantial morbidity, especially for racial and ethnic minorities in the United States. The care of the patient with asthma is complex and depends ideally on excellent communication between patients and health-care providers. Communication is essential for the patient to communicate the severity of his or her illness, as well as for the health-care provider to instruct patients on pharmacologic and nonpharmacologic care. This article describes evidence for poor provider/patient communication as a contributor to health-care disparities for minority patients with asthma. Communication problems stem from issues with patients, health-care providers, and health-care systems. It is likely that asthma disparities can be improved, in part, by improving patient/provider communication. While much is known presently about the problem of patient/provider communication in asthma, there is a need to improve and extend the evidence base on the role of effective communication of asthma care and the links to outcomes for minorities. Additional studies are needed that document the extent to which problems with doctor/patient communication lead to inadequate care and poor outcomes for minorities with asthma, as well as mechanisms by which these disparities occur.

Reducing racial bias among health care providers: lessons from social-cognitive psychology

The paper sets forth a set of evidence-based recommendations for interventions to combat unintentional bias among health care providers, drawing upon theory and research in social cognitive psychology. Our primary aim is to provide a framework that outlines strategies and skills, which can be taught to medical trainees and practicing physicians, to prevent unconscious racial attitudes and stereotypes from negatively influencing the course and outcomes of clinical encounters. These strategies and skills are designed to: 1) enhance internal motivation to reduce bias, while avoiding external pressure; 2) increase understanding about the psychological basis of bias; 3) enhance providers' confidence in their ability to successfully interact with socially dissimilar patients; 4) enhance emotional regulation skills; and 5) improve the ability to build partnerships with patients. We emphasize the need for programs to provide a nonthreatening environment in which to practice new skills and the need to avoid making providers ashamed of having racial, ethnic, or cultural stereotypes. These recommendations are also intended to provide a springboard for research on interventions to reduce unintentional racial bias in health care.

The use of adherence aids by adults with diabetes: a cross-sectional survey

Background

Adherence with medication taking is a major barrier to physiologic control in diabetes and many strategies for improving adherence are in use. We sought to describe the use of mnemonic devices and other adherence aids by adults with diabetes and to investigate their association with control of hyperglycemia, hyperlipidemia and hypertension.

Methods

Cross sectional survey of diabetic adults randomly selected from Primary Care practices in the Vermont Diabetes Information System. We used linear regression to examine the associations between the use of various aids and physiologic control among subjects who used oral agents for hyperglycemia, hypercholesterolemia, and hypertension.

Results

289 subjects (mean age 65.4 years; 51% female) used medications for all three conditions. Adherence aids were reported by 80%. The most popular were day-of-the-week pill boxes (50%), putting the pills in a special place (41%), and associating pill taking with a daily event such as a meal, TV show, or bedtime (11%). After adjusting for age, sex, marital status, income, and education, those who used a special place had better glycemic control (A1C -0.36%; P = .04) and systolic blood pressure (-5.9 mm Hg; P = .05) than those who used no aids. Those who used a daily event had better A1C (-0.56%; P = .01) than patients who used no aids.

Conclusion

Although adherence aids are in common use among adults with diabetes, there is little evidence that they are efficacious. In this study, we found a few statistically significant associations with adherence aids and better diabetes control. However, these findings could be attributed to multiple comparisons or unmeasured confounders. Until more rigorous evaluations are available, it seems reasonable to recommend keeping medicines in a special place for diabetic adults prescribed multiple medications.

Socioeconomic disparities in health: the impact of pharmacotherapy

Along with age and gender, socioeconomic status is a fundamental driver of health. This review discusses the meaning of socioeconomic status and how it influences health across a person's life. Particular attention is paid to the role of psychosocial stress and self-determination. Through various pathways, socioeconomic status may affect biologic aging. This review also discusses the implications of the socioeconomic status-health relationship for understanding international differences in population health such as differences in life expectancy. The review concludes with a discussion of the implications of these findings for national policies and the potential impact of pharmacotherapy.

Patient and physician factors predict patients' comprehension of health information

While patients frequently do not comprehend health information, little is known about patient and physician factors that influence lack of comprehension. To assess effectiveness of health information exchange, 19 physicians and 145 patients were given post-encounter questionnaires to evaluate the preceding visit. We analyzed differences in beliefs between patients who comprehended health information and patients who did not, and whether physicians' attitudes and self-assessment of their educational abilities influenced this comprehension. Patients with insufficient comprehension were more likely to have schooling below college and cited language as a barrier. Physicians who believed health information delivery to be important had fewer patients with comprehension difficulties, while physicians who assessed themselves as very effective educators had significantly more patients with lack of comprehension, compared with physicians who did not feel as effective. Patients' comprehension of health information was associated not only with patient factors but also with physicians' attitude and self-assessment.

Communication in context: new directions in communication research

By focusing attention almost exclusively on a single encounter, researchers have adopted a rather restricted view on studying communication in health care. After all, communication does not take place in a vacuum but is influenced by the context in which it takes place. We would therefore strongly recommend to broaden the perspective of communication research. In this respect, four lines of investigation are proposed, each guided by different theories. In the first, context is determined by the goals or targets aimed at by both parties in the medical encounter. The second concerns the context of time, referring to the influence of previous and future medical encounters. The third is set up around the organizational context in which an interaction takes place and the last defines context by looking at a medical encounter as a meeting between two multifaceted parties. Studying a medical encounter in its broader context is expected to provide answers to intriguing questions such as why health care professionals do not always act in conformity with the general approved standards of high quality communication and how the factor time span can be used more effectively in the medical encounter. Eventually, a broader context view will bridge the existing gap between theory and practice.

Barriers to the effectiveness of any intervention in OA

One of the main barriers to the effectiveness of interventions in osteoarthritis (OA) is adherence to treatment interventions and advice. Estimates suggest that adherence to any intervention in OA is between 50 and 95% but many of these estimates are derived from clinical trials and the real levels in clinical practice may be much lower. The factors influencing adherence are complex and multifactorial and, although information is available from other diseases, little is known about the relative contribution of these factors in adherence to treatment in OA. Few interventions to improve adherence have been evaluated in OA, and such studies would be limited by the lack of an accurate method for assessing adherence.

From careless consumptives to recalcitrant patients: the historical construction of noncompliance

Thousands of articles on "noncompliance" have appeared since 1975. Yet the term has been criticized as paternalistic--as wrongly implying that patients should necessarily follow doctors' orders. This paper, which reviews how noncompliance has been constructed historically, argues that the problem with noncompliance is more than just one of terminology. Changing social and cultural factors during the 20th century have influenced the way in which uncooperative patients have been described. For example, resentment of poor immigrants in the early 1900s led doctors to describe tuberculosis patients who did not follow advice as "ignorant" and "vicious." Following World War II, patients who balked at taking new curative antibiotics for tuberculosis were called "recalcitrant." The term "noncompliance," popularized by Sackett and Haynes in the 1970s, reflected their early role in the field of research now termed "evidence-based medicine." While Sackett and Haynes had hoped that the new term would eschew earlier value judgments, noncompliance, through its association with the positivistic ethos of evidence-based medicine, has been conceptualized as a "tragic" problem potentially solvable by clinical research. Hence, noncompliant patients are still seen as deviant. With the growth of managed care in the United States, there is increasing pressure to get patients to follow medical recommendations. History suggests that labels such as "noncompliant" are invariably judgmental. Rather than seeing the provider's role as trying to get noncompliant patients to comply, we should emphasize the importance of negotiation and accommodation within the provider-patient relationship.

Patient decision making. The missing ingredient in compliance research

Medical noncompliance has been identified as a major public health problem that imposes a considerable financial burden upon modern health care systems. There is a large research record focusing on the understanding, measurement, and resolution of noncompliance, but it is consistently found that between one third and one half of patients fail to comply with medical advice and prescriptions. Critically absent from this research record has been the patient's role in medical decision making. For patients, particularly those with chronic illnesses, compliance is not an issue: they make their own reasoned decisions about treatments based on their own beliefs, personal circumstances, and the information available to them. The traditional concept of compliance is thus outmoded in modern health care systems, where chronic illness and questioning patients predominate.