1. Medication Adherence: the Patient Perspective Monika Safford University of Alabama at Birmingham

2. Disclosures Dr. Safford receives salary support from NIH, PCORI, Amgen, and consults for diaDexus, a lipid assay manufacturer

3. 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

4. Background Diabetes self care requires ~2 hours daily 1,2 Medications: Many! Complicated Costly 28% of total costs of diabetes are medications 3 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.

5. The Setting 1 2010 Census; 2 2008 Alabama Department of Public Health and BRFSS; 3 PCP=Primary Care Providers per 10,000 people, from Board of Medical Examiners of Alabama and Kaiser Family Foundation. Population% Black 1 % <Poverty 1 Diabetes Prevalence 2 PCP/10,000 3 Counties Choctaw15,92244.424.513.53.4 Dallas46,36569.434.711.910.1 Lowndes11,14773.731.412.21.5 Marengo20,69252.025.911.75.5 Perry11,86168.835.417.54.3 Pickens19,74643.027.714.95.0 Sumter14,79873.638.712.23.6 Wilcox13,18372.239.912.23.1 ALABAMA4,802,74026.319.011.820.6 US314,918,00012.615.98.325.7 Rural AL: mostly African American, high poverty, high chronic disease burden, low access to health care

6. Community Health Workers (CHW) Peer support effective in improving health behaviors in patients with chronic conditions 1-4 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.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. 2.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. 3.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. 4.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.

7. Encourage Study 1 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.

8. Encourage Study Diet and exercise: 93% Medications and adherence: 0%

9. 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

10. 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

11. Marrero Medication Adherence Risk Assessment David Marrero, PhD Inner city Indianapolis Mostly African Americans, high poverty Focus groups

12. 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.

13. 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

14. 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 medicine 1 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.

15. 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 medicine 1 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.

16. Strategy Provide what people want first Diet and exercise Integrate medications and messages around medications

17. Strategy Provide what people want first Diet and exercise Integrate medications and messages around medications

18. Strategy Provide what people want first Diet and exercise Integrate medications and messages around medications

19. Question On average, how long have people already had diabetes at the time of their diagnosis?

20. Strategy It takes years to develop diabetes

21. Strategy Familiar analogies: “look under the hood” A1c BP Cholesterol Eyes Feet Kidneys

22. 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

23. 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

24. Break

25. Peer-to-Peer Adherence A community self-help model Monika Safford, MD University of Alabama at Birmingham

26. 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

27. Community Health Workers (CHW) Peer support effective in improving health behaviors in patients with chronic conditions 1-4 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.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. 2.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. 3.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. 4.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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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?

34. Motivational Interviewing Affirmations 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 “That sounds like it was hard” “You must be pretty proud of yourself for doing that despite all those challenges” “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” “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?”

35. Motivational Interviewing Setting goals Specific Measurable Achievable Realistic/relevant Time-bound

36. Quiz I will exercise more

37. Quiz I will exercise more I will walk for exercise

38. Quiz I will exercise more I will walk for exercise I will walk every day for 10 minutes

39. 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

40. 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

41. 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

42. Set your own SMART exercise goal Group activity

43. Stress reduction