1. PHCL 436 Lecture two

2. Objectives  The role of cognition in influencing adjustment to chronic conditions  What is medication adherence, prevalence, reasons, measurements

3. Facing an illness  What people thinks/do when adjusting to chronic disease?  What are the behaviours associated with managing chronic disease?

4.  Managing chronic disease ◦ @ social level ◦ @ individual level  Pharmacists ◦ What affects patients reaction to disease ◦ Pharmacists can help patients cope better

5.  Why chronic diseases???

6. Adherence ( Patients may pretend taking their medication) Hippocrates (Unpredictable responses to therapy due to low compliance) David Sackett, 1972

7. ( It is the extent to which the patient's behaviour matches agreed recommendations from the prescriber with emphasis the patients' freedom to decide whether to adhere to the prescriber's recommendations, and that failure to do so should not be a reason to blame the patient)* *National Institute for Health and Clinical Excellence (NICE) guideline

8.  1ry non-compliance ◦ patient fails to dispense the medication  2ry non-compliance ◦ don’t take the medication as directed Or  Intentional ◦ patient decides not to follow the treatment recommended  Unintentional ◦ the patient wants to follow the treatment recommendations but has practicality problemsI

9.  Studies showed that 33-50 % of patients in developed countries are non-adherent to their medication*  A quantitative review research from 1948 to 1998 found that the average percentage of non adherence is 24.8% Prevalence of non-adherence 9

10.  HIV, arthritis, and gastroenterology disease  pulmonary diseases, diabetes, and sleep disorders Prevalence of non-adherence 10

11.  40-50% of patients do not persist with their initial treatment for chronic disease more than 12 months  This proportion is higher in developing countries due to other reasons ◦ difficulties in accessing healthcare facilities, availability of medication, deficiency of education Prevalence of non-adherence 11

12.  USA, it been estimated to cost $100 billion each year, including ◦ 10% of hospital admissions and 23% of admissions to nursing homes, that is exclusive of indirect costs such as doctor's frustrations not accomplishing treatment outcomes  Canada, the cost of poor adherence has been estimated to be $7 to $9 billion per year because of avoidable negative outcomes not being prevented Consequences 12

13.  More than 200 variables have been identified to postulate the affect adherence ◦ positively i.e. variables that increase adherence ◦ negatively i.e. variables that decrease adherence Reasons for non-adherence 13

14.  Demographic data have been poorly correlated to patient adherence ◦ patient age, gender, social status, features of the disease, in addition to referral process*  negative effect ◦ Increasing psychiatric symptoms ◦ numbers of medications ◦ frequencies of medications ◦ complexity of the regimen ◦ Duration ◦ cost Reasons for non-adherence 14

15.  Very few variables were found to have positive strong correlation with adherence ◦ increasing the degree of disability ◦ administering parental medications Reasons for non-adherence 15

16.  Patients own beliefs and understanding about medicine and medication  Patient's unresolved concerns about disease  Effect of everyday life constraints  Effect of poor communication with health care provider  Effect of community and health care provider attitude  Effect of receiving conflicting information when health care provider do not adhere to diagnostic and therapeutic standard Reasons for non-adherence 16

18.  Variation in outcome and adherence relationship*  There are more factors affects accomplishing therapy outcomes by improving adherence ◦ nature of the disease studies, regimen complexity, tool to be used ◦ Improving medication adherence and outcome relationship should be initiated by using the appropriate technique Reasons for non-adherence 18

19. Direct observation Medication concentration in body fluids Direct Self reports Administration records Indirect Measures of Adherence 19

20.  Direct methods of assessing patient's behaviour of medication taking ◦ Directly observing the patient taking the medication, such as in tuberculosis direct observation therapy strategy (DOT) ◦ Direct measurement of metabolites, drug markers, or drug concentration in the patient's body fluids Measures of Adherence 20

21.  Indirectly measuring adherence either ◦ by using process measures of medication taking  self reports, tablet counting, prescription filling dates ◦ using outcome measures  therapeutic or preventive outcome measures Measures of Adherence 21

22.  Self report ◦ Widely used, general or specific ◦ Validation ◦ ex: ASK 20, MARS, ACT ◦ validation ◦ Semi-structured interviews Measures of Adherence 22

23.  Pill count ◦ Widely used ◦ Medication Event Monitoring System (MEMS) ◦ Cut-off 80% (HTN), 90% (HIV). Measures of Adherence 23

24.  Administration records ◦ Medication possession ratio (MPR), proportion of days covered (PDC) ◦ Cut-off? Measures of Adherence 24

25.  Drug Concentrations ◦ Increasing numbers of adherence studies are being conducted utilizes the advancement in the medication analysis technologies  Pain medication  Antipsychotic medication  Addiction therapy Measures of Adherence 25

26.  There is no ideal tool to assess adherence.  Many confounding factor affect each tool  using multiple measure with high sensitivity and the other with high specificity  Depth understanding of each patient factors is the only way to assess adherence and improving achievement of treatment outcomes Measures of Adherence 26

28. “illnesses that are prolonged, do not resolve spontaneously, and are rarely cured completely”

29. Domains of adjusting to a diagnosis of chronic disease interpersonalcognitiveemotionalbehavioural Physical components

30. Psychological adjustment to chronic disease themes:  It requires adjustment across different domains of life.  It happens over time.  There are marked differences in the way individuals adjust. Stanton et al (2007)

31.  What people do to adjust?  Adaptive task  Enhancement of self steam

32. Social factors Culture and ethnicity Gender Nature of the disease Interpersonal support Social recourse Social isolation

33.  Inherent optimism

34. Lazarus’s appraisal model Role of perception and thought in response to illness and people management of their chronic disease

35.  Lazarus’s appraisal model

38.  Leventhal’s common sense model of self regulation The model propose that patients will decides to cope with illness and the threat of illness in way that are consistent with their own understanding of the experience

39.  Heuristics (mental rules) associated with illness and illness representation ◦ Intuitive time and space representation ◦ Pattern of symptoms relating to previous experience ◦ Cultural beliefs and social experience ◦ Active social comparisons

41. Necessity of medication Concerns about medications

42.  pathways.nice.org.uk pathways.nice.org.uk  nice.org.uk nice.org.uk

43.  Haynrs et al 2008 Cochrane review Haynrs et al 2008 Cochrane review

44.  How people think and behave when they have chronic disease  It is difficult to adjust and adjusting is a dynamic process!  Coping is affected by inner thoughts and their surroundings  Lazarus’s stress and coping theory  Leventhal’s self regulation theory  Overwhelming impact on medication taking behavior

46.  Social and Cognitive Pharmacy. Donyai, Parastou. Chapter five.  Medicines adherence. Involving patients in decisions about prescribed medicines and supporting adherence. NICE guidelines 2009. http://guidance.nice.org.uk/CG76 http://guidance.nice.org.uk/CG76  Interventions for enhancing medication adherence (Review). http://www.cochrane.org/ http://www.cochrane.org/