Gerik L. The Other Side of the Prescription. Methodist DeBakey Cardiovasc J website. January 23, 2019. journal.houstonmethodist.org
adherence , compliance , diabetes , cardiovascular disease
Managing a chronic illness is a daily challenge for patients with diabetes and cardiovascular disease (CVD). Current guidelines recommend a multipronged approach to treating diabetes and CVD that includes both medications and lifestyle changes1—but patient self-management is the key to success.2 However, all too often, people with diabetes do not take their medication or follow through with lifestyle modifications as prescribed—and even the best treatments won’t help if the patient cannot maintain the plan. Although self-management ultimately lies with the patients, their providers can be allies to empower patients and help them achieve their management goals.
THE ADHERENCE CONUNDRUM
The incidence of poor medication adherence among patients with diabetes varies between 38% to 93%,3 and lifestyle interventions such as weight loss and exercise are also difficult to sustain.
The costs of poor adherence are staggering. The Medication Adherence Alliance reports that Medicaid beneficiaries with poor adherence have 1.8 times higher risk of CVD events than their high-adherence peers.4 Moreover, a single ER or inpatient visit resulting from low adherence will wipe out the short-term savings from avoiding expensive medication prescriptions.3,4 Nationwide, the costs of medication nonadherence exceeds $100 billion per year, and improving patient adherence could save each patient thousands of dollars annually.3-5
“We often see patients who are unable to follow through on their treatment plan. Even if it’s by choice, there’s always a barrier. Whether it’s logical or physical, there’s always something there,” says Maryanne Strobel, R.N., M.S.N., certified diabetes educator and diabetes program lead at Houston Methodist Willowbrook Hospital.
For many patients, the medications may be prohibitively expensive, the regimen too complex, or the side effects too severe.2 For others, the barriers are more subtle: perceived lack of benefit, beliefs and misconceptions, cultural practices, forgetfulness, health illiteracy, and lack of physician trust.3,5
BECOME AN ALLY
The challenge for providers is to look past the “noncompliant” or “nonadherent” labels and identify the barriers preventing the patient from maintaining their treatment—and then help the patient overcome them. Although providers are limited in how much they can effect patients’ daily behavior, research suggests that the most effective interventions combine a variety of approaches.
Higher levels of patient trust in their physicians is linked to higher medication adherence.3 In fact, in a small study of patients at Veterans’ Administration hospitals, Piette et al. found that patients with higher trust in their physicians were more likely to adhere to medication plans even with high out-of-pocket costs.6
The first step in building that trust and finding the root causes of nonadherence is to reframe the situation in nonjudgmental terms. Or, as Archana Sadhu, M.D., endocrinologist and director of the Houston Methodist System Diabetes Management Program, puts it: “Don’t make the patient feel bad if they haven’t been able or willing to take the medication.”
“Language is everything,” Sadhu says. “If you start off the conversation asking, ‘Are you taking your medication?’ patients respond with guilt or defensiveness, and you won’t learn the actual reasons for their actions. If you don’t know those reasons, you’re going to draw the wrong conclusions, make the wrong decisions, and lose the patient’s trust.”
Instead, Sadhu starts conversations that are nonjudgmental and friendly, asking open-ended questions that focus on why a patient may be missing medications and focusing on the barriers. This approach normalizes nonadherence to make patients feel more comfortable discussing the reasons they aren’t following the treatment plan.
Help the Patient Set Goals
“The best way to set goals is to let the patient set the goal,” says Jaime Louis (J.J.) Rodriguez, senior exercise physiologist for Houston Methodist Weight Management.
For both lifestyle and medication interventions, change is most likely when the patient takes ownership of the goal, so providers should work with patients to tailor objectives to the patient’s preferences and lifestyle. Breaking down long-term goals into small, measurable steps builds confidence and helps the patient see progress as they achieve targets.7
“Patients often don’t know what they’re supposed to achieve with a medication. If you tell them, ‘take your medicine and your sugars will get better,” that’s too nonspecific,” says Jawairia Shakil, M.D., endocrinologist at Houston Methodist Hospital. “Instead, I give them tangible goals like, ‘I want to see your blood sugar drop by this many points, and it will happen when you do this intervention.’ Using numbers helps patients see results.”
Goal-setting for weight management can be a touchy subject, but it is an essential element of diabetes and CVD care—and closely intertwined with medication adherence. In the SHIELD study, investigators reported that adults with type 2 diabetes who lost weight had significantly better medication adherence than those who gained weight.8
“The weight loss conversation can be fraught with stereotypes or judgments,” says Sadhu. “I rarely go to ideal body weight with my obese patients because that’s setting the target so high that it sets them up for failure. Instead, we start reasonable, 10 to 15 pounds over the next 3 to 4 months, not tomorrow.”
Ultimately, goal-setting is a coaching process, says Rodriguez, and providers can help guide patients to set achievable goals: “We’re not going to be able to change everything that patients do. But what’s one thing they can change that makes an influence in their lifestyle? That’s something we can work with.”
Adherence Resources for Healthcare Professionals
Cost is one of the most common reasons why patients stop taking their medication. In a nationwide survey of adults with chronic illnesses, a third of respondents who didn’t take a medication due to cost didn’t discuss the barrier with their provider.9 Minority and low-income patients are especially unlikely to raise the issue.5 The onus is on physicians to ask patients if they are cutting back on medications because of finances and make sure they are prescribing medications that the patient can afford.
Simple ways to lower cost include prescribing cheaper alternatives or generics and offering discount cards or information about prescription assistance programs.
“We want to give our patients the latest and greatest, but if they don’t take it, they’re worse off than giving them a less expensive but less efficacious drug,” says Sadhu. “It’s better to give patients a cheaper alternative than try to force them to do something that they really can’t afford.”
The more complex or inconvenient a regimen, the less likely patients are to adhere.4 The New York Department of Health and Mental Hygiene’s supplement on adherence advises providers to minimize complexity by reconciling patient medications (and eliminate unnecessary medications, if appropriate), simplifying dosing schedules, and streamlining refills by prescribing 90-day supplies.5 Shakil notes that technologies such as automated glucose testing can simplify routines and make it easier for patients to manage their blood sugars.
Discuss Medication Effects and Side-Effects
Patients often cite side effects as the reason they stop taking a medication, so clear and candid communication about what patients can expect is key.5
“Patients are often afraid of adverse effects from medication, especially with what they see in the news or on social media,” says Shakil. “We have to discuss the risks and benefits and go over the literature in terms patients can understand.”
Those early discussions can help patients recognize which symptoms are side effects tied to a new drug. Shakil and Sadhu stress the importance of asking about medication tolerance at follow-up visits. Often, patients are unsure whether they are experiencing a side effect or if the medication is working and are hesitant to bring it up on their own.
It can be equally difficult to encourage asymptomatic patients to stick with a medication when they don’t feel an effect—good or bad. Therefore, physicians may need to get creative to explain the urgency of continuing medications; for instance, some patients may need to see visual proof that the medication is working, perhaps by comparing test results or imaging from before and after they started the treatment.10
Address Misconceptions and Beliefs
Beliefs and misconceptions about an intervention can also be barriers to adherence. However, Rodriguez points out, most of these beliefs are predictable—believing that type 2 diabetes is inherited, that people with joint problems can’t exercise, that insulin causes kidney failure—so providers can come to appointments prepared.
“I see the same trends in misconceptions over and over, so I try to have resources available when I meet patients. It could be as simple as a handout or a video,” he says. “I present information to contextualize the belief where they can see that it isn’t accurate rather than saying something belittling like, “No, that isn’t true.’ It’s about putting the patient in control so that they see and accept the facts.”
Reconcile Psychosocial Barriers
Psychosocial barriers to adherence can be more difficult to recognize. For instance, patients with depression are three times as likely to not follow treatment plans,5 and 25% of patients with diabetes experience depression,11 so Sadhu recommends screening patients for depression if they are not taking their medications or seem unmotivated to make lifestyle changes.
Social barriers such as taking care of sick relatives or relying on someone else for cooking can make it difficult for patients to keep up with their diabetes treatments. Asking open-ended questions can help identify these barriers; then, providers can help the patient devise coping strategies.
“Patients sometimes tell me, ‘We have a lot of family events, and food is part of our bonding experience.’ I go to portion size. If it’s rude to refuse, make sure the portion is very small because you know how it will affect your health. Don’t go to every party, but choose one or two of the most important ones,” Sadhu says.
She encourages patients to talk to the family cook about how to modify ingredients and sends home literature with diabetes-friendly recipes. It’s also important to take the patient’s culture into account, perhaps discussing how to adjust practices instead of replacing them altogether.
“Cultural awareness has become a big topic,” Sadhu says. “If the patient does not feel like you understand their background and lifestyle, your recommendations will fall on deaf ears.”
Connect Patient with a Support Network
Although limited to what they can do within their office walls, providers can help patients build a support network outside the physician’s office. Shakil and Sadhu refer patients to certified diabetes educators (CDEs) like Strobel, exercise physiologists like Rodriguez, and nutritionists and mental health professionals as needed.
“Physicians can help get their patients into a ‘cradle of care,’” says Strobel. “If a CDE is too expensive, they can refer the patient to an outpatient support group, preferably outpatient diabetes education. That way patients can go to classes and benefit from the logical knowledge and life experiences of their classmates.”
Ultimately, adhering to treatment is up to the patient, but providers can be effective allies to make sustained behavioral changes a little easier.
As Sadhu says, “We can’t intrude into patient’s daily lives. They have to take some ownership of what they’re willing to do. But we have to show that we understand the issues and that we want to work with them.”References
- Qureshi M, Gammoh E, Shakil J, Robbins R. Update on Management of Type 2 Diabetes for Cardiologists. Methodist DeBakey Cardiovasc J. 2018;14(4):273-80.
- Schechter CB, Walker EA. Improving Adherence to Diabetes Self-Management Recommendations. Diabetes Spectrum. Jul 2002;15(3):170-5.
- Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence. 2016;10:1299-307.
- Adherence Facts. Medication Adherence Alliance. http://managingyourmeds.org/adherence-facts/
- Improving Medication Adherence. City Health Information. The New York City Department of Health and Mental Hygiene. July 2009;23(suppl 4):1-8.
- Piette JD, Heisler M, Krein S, Kerr EA. The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Arch Intern Med. 2005 Aug 8-22;165(15):1749-55.
- Koenigsberg MR, Corliss J. Diabetes Self-Management: Facilitating Lifestyle Change. Am Fam Physician. 2017 Sep 15;96(6):362-70.
- Grandy S, Fox KM, Hardy E; SHIELD Study Group. Association of Weight Loss and Medication Adherence Among Adults With Type 2 Diabetes Mellitus: SHIELD (Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes). Curr Ther Res Clin Exp. 2013;75:77–82.
- Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med. 2004;164(16):1749-55
- Schwartz SK. Patient Compliance Techniques That Work. Physicians Practice. March 2011. http://www.physicianspractice.com/patient-compliance-techniques-work
- Curry A. The Diabetes and Depression Connection. Diabetes Forecast. May 2018. http://www.diabetesforecast.org/2018/03-may-jun/the-diabetes-and-depression.html