Jacqueline Dunbar-Jacob, PhD, RN, FAAN Dean, School of Nursing University of Pittsburgh School of Nursing Center for Research in Chronic Disorders

“On Several Occasions I Have Been With My Brother Herodicus Or Some Other Physician To See One of His Patients, Who Would Not Allow The Physician To Give Him Medicine, Or Apply the Knife or Hot Iron To Him” - Plato (427? B. C.)

What is Poor Adherence? t Deviation from Optimal Prescription

Extent of the Problem

50% of Patients Fail to Adhere t To Pharmacotherapy t To Diet t To Exercise Programs

t Decline in health status t Increase in disease complications t Relapse t Unnecessary hospitalizations t Loss of transplanted organs t Development of disease resistant organisms t Death Clinical Impact of Poor Compliance

Impact of Poor Compliance on Research t Lack of Study Power t Increased Sample Size Needs t Overestimate of Safety t Underestimate of Risks, Adverse Effects t Underestimate of Effectiveness t Increased Cost

Costs of Non-Compliance $ BILLIONS Hospital Admissions 25 Lost Productivity 50+ Nursing Home Admissions 5 Premature Deaths ?? Treatment Costs In Ambulatory Patients ?? TOTAL COSTS100+ Emerging Issues In Pharmaceutical Cost Containment 6/92

Why Do Patients Fail to Adhere Effectively?

Why Prescriptions Are Not Filled Task Force on Compliance (1994). Noncompliance with medications. Reproduced by permission of the Task Force for Compliance via the Copyright Clearance Center, Inc. 5% Not Available in Store 51% Did not need the medication 10.5% Other 10.5% Cost 21.7% Did Not Want to Take 2.8% Lost or Forgot It 22% Concerned about Side Effects 21% Thought medication Would Not Help 14% Cost 20% Condition Improved Upjohn SurveyAARP Survey

Cognitions/Beliefs t Readiness (TTM) t Beliefs about Disorders and Treatments (CSM)

Reasons for Poor Adherence Patient Perspective t Forgetting t Symptom Management t Schedule Disruptions t Adequacy or Completeness of Instructions t Multiple or Complex Regimens t Concerned About Side Effects t Condition Improved t Thought Medication Wouldn’t Help t Did Not Need Medication t Did Not Want to Take It t Lost Medication t Cost t Not Available In Stores

Relationship of Regularity of Routine and Medication Adherence ACT (Days Compliant): Once a Day Medication Taken At Bedtime Regularity of Bedtime Hours x 2 = d  = 2p =.145 Regularity of Bedtime Routine x 2 = d  = 2p =.050

Most of These Reasons Have Been Identified by Self-Report with Adherence Also Evaluated by Self-Report

What Does Poor Adherence Look Like?

Poor Adherence is a Variable Event Poor Adherence is a Variable Event

Once a Day Dosing Prescription 12 pm 10 pm x 8 pm x 6 pm 4 pm 2 pm Noon x 10 am x x x x x 8 am x x x x x x x x x x x x 4 am x    Days of Observation Actual Time   Extra Doses  Missed Doses

Twice a Day Dosing Prescription 5am 6am 7am 8am x 9am x 10am 11am 12N 1pm x 2pm x 3pm x 4pm x 5pm 6pm x 7pm x 8pm 9pm 10pm x x x 11pm x x x x x x x x x 12M x x x x x x x x x x x x x 1am x x x x 2am Days of Observation Actual Time   Extra Doses  Missed Doses

Three Times a Day Dosing Prescription 5am x 6am 7am x x x x 8am x x x x x x x 9amx x x x x 10amx x x x 11am x 12N x 1pm 2pm 3pmx 4pmx x 5pm x x x x x x x x x x x 6pmx 7pm x 8pm 9pm x x x x x 10pm x x x x x x x x 11pm x x x x x 12Mx x x x x x x 1am x x 2am Days of Observation Actual Time   Extra Doses  Missed Doses

Adherence Rates Smoking Medication ExerciseDietSmokersRelapse 1970’s50%50% 50%34.4%70-80% 2000’s50%50% 50%22.7%70-80%

Adherence Refers to Multiple Behavioral Errors

Types of Behavioral “Errors” t Failure to Adopt the Regimen t Early Stoppage of Treatment t Reduction in Levels of treatment t Over Treatment t Variability in the Conduct of Treatment t Dosage Interval Errors t Performance Errors

How Much of a Behavioral Deviation or Error Constitutes Poor Adherence? t Standard in the Field t Loss of Therapeutic Effectiveness

Is This Likely to be Influenced By Measurement Method?

Relationship of Adherence to Cholesterol Change %  Total Adherence Cholesterol p-value EEM EEM 2.18NS 7-Day EEM Day EEM Pill Count.12NS 7-Day Recall 1.20NS 7-Day Recall 2.00NS 1 # pills 2 #pills in correct dosing interval

Correlation (r s ) Between Days Adherent and Clinical Outcomes Diary EEM Pain FSI * MPI Diary Difficulty FSI Assistance FSI Symptom Rating Diary *p <.05 (two-tailed) RAC-1

MEMs Cap and Monitor MEMs ELECTRONIC MEDICATION CAP ADHERENCE

Thus, Poor Adherence Refers to Multiple Behavioral Errors at Varying Levels Occurring in Varying Patterns Due to Varying Reasons

Most of the Adherence Research Treated Poor Adherence as a Single Behavior with a Stable Pattern That is Primarily Due to a Motivational Deficit