The Role of Patient Adherence in Successful Clinical Pathway Implementation

02/16/16
Issue
Affiliation

Richard Stefanacci: The Access Group, Berkeley Heights, NJ

Scott Guerin: The Access Group, Berkeley Heights, NJ

Disclosures

Dr. Stefanacci is the Chief Medical Officer for The Access Group, a managed markets agency for pharmaceutical companies. He has received speaking fees from Allergan and Pfizer; serves on advisory boards for AbbVie, the ASCP Foundation, and the AMDA Foundation; and has provided consulting services to AstraZeneca, Baxter, Boehringer Ingelheim, Lundbeck, Otsuka, and Leo Pharma. Dr. Guerin is the Senior Director for Government Policy System and Analytics for The Access Group, a managed markets agency for pharmaceutical companies. 

Key Words

When considering the development of clinical pathways, the pathway itself is only the beginning; optimum outcomes cannot be realized unless patients follow their prescribed treatments. Simply having prescribers write a script is not a guarantee that the best outcomes will be achieved. For proper treatment adherence, providers can employ one of the many principles and tools of health psychology. Three effective applications of this discipline are: targeted messaging that addresses barriers to adherence; motivational interviewing techniques to help patients change their behaviors prior to the start of treatment; and shared decision-making to help patients understand and consider the risks and benefits of available treatment options in order to make an informed treatment decision.


Most patient adherence programs start only after a patient has stopped taking his or her medication. For example, in typical medication adherence programs, patients who are identified as not refilling their scripts receive reminder emails, phone calls, and letters. Some health care organizations are beginning to realize that a better answer to nonadherence is to address each patient’s perceptions and beliefs about his or her illness and treatment much earlier in the patient journey. This is where the discipline of health psychology, when incorporated into a clinical pathway, can help patients commit and adhere to their treatment plan.

Decades of research show that there are psychological factors that are associated with patients’ adherence and nonadherence with medications across a wide range of conditions and treatments.1-3 An understanding of these factors can help in the development of effective educational materials and interventions.4 For example, when a person hears the word “marriage,” “mortgage,” or “maternity,” a host of thoughts and emotions may come into play. For some, maternity is a welcome event, whereas others may perceive the word with trepidation. In the same way, when some patients hear the word “medication,” some may act by resisting and not pick up their first script, whereas others may accept their diagnosis and comply with their treatment plan. As psychologists enter the discussion, patients’ perceptions move to the forefront. The emphasis shifts from the disease and treatment to how to best engage patients in their own treatment by targeting their specific barriers to adherence.

Implementing the principles and theories of health psychology can significantly increase patient engagement through the use of targeted messaging, motivational interviewing, and shared decision-making tools.

Targeted Messaging

Because barriers to adherence vary for different patients, it follows that certain messages will be more effective with some patients than with others. An excellent example of how targeted messaging can impact medication adherence is illustrated in a study using a text messaging intervention for patients with asthma.5 At the beginning of the study, subjects filled out a survey regarding their beliefs about their asthma and treatment. Personalized text messages were sent to one group of participants that addressed their key barriers to adherence identified in the survey. For example, participants who indicated that they did not think their asthma was chronic would get a message stating, “Your asthma is always there even when you don’t have symptoms.” Results of the study showed that the proportion of patients taking more than 80% of their medication in the intervention group increased 15% more than it did in the control group. Even more interesting was an assessment, conducted 9 months after the study ended and the text messages ceased, that showed that adherence continued to be higher in the intervention group than in the control group. This suggests that the intervention changed the beliefs of the patients, thereby impacting their long-term behavior. 

When research on the behavior of health care providers and patients in treatment settings is conducted through the theoretical lens of health psychology, specific barriers to patient adherence with treatments can be identified. Targeted messages can then be developed and incorporated into both physician and patient educational materials and programs in order to help improve medication adherence.

Motivational Interviewing

Another way to engage patients is by motivating them to change their behavior prior to the onset of their treatment plan. Motivational interviewing can accomplish this by helping patients to explore and resolve any psychological issues surrounding their illness and treatment.6 This approach works by activating a patient’s own motivation to adopt healthy behavior and remain adherent to his or her treatment.7 Numerous studies show that motivational interviewing can increase adherence, reduce health care costs, reduce the risk of hospitalization, and improve patient satisfaction and autonomy.7-10

A variety of health care providers can administer components of motivational interviewing, ranging from directive counseling techniques to tools that help patients to identify barriers to healthy behaviors. In general, motivational interviewing techniques are designed to help the health care provider exchange information with patients through two-sided conversations that encourage the patients to drive the discussions throughout the process.11 Motivational interviewing techniques can also be administered through patient tools such as the “readiness ruler,” which evaluates a patient’s readiness to change his or her behavior, as well as treatment diaries and medicine pocket trackers.  Motivational interviewing can be an effective means of helping a patient move from unhealthy to healthy behavior. 

Shared Decision-Making

Another approach that can further impact patient engagement and commitment to a specific treatment is shared decision-making. Shared decision-making emphasizes the importance of patients’ values, preferences, and experiences as they relate to clinical interactions and treatment decisions. This is accomplished by helping patients to understand and consider the risks and benefits of available treatment options in order to make an informed treatment decision, in consultation with their health care provider.12

Much of shared decision-making is accomplished through the use of decision aids. These are tools that help walk the patient through relevant treatment options. These options can include surgical, medication, and lifestyle options from which a patient can choose, depending on the illness and available treatments. Decision aids can range from simple one-page checklists to comprehensive brochures that provide details of surgical options and the pros and cons of all available medications. As the emphasis on patient-centered approaches to health care has increased, so has the use of shared decision-making programs. Evidence of this can be seen with the exponential increase in publications regarding shared decision-making over the past 15 years.13 In addition, large health care organizations like Mayo Clinic and Massachusetts General Hospital have implemented extensive resources and programs to encourage the use of shared decision-making among their health care providers.14,15

Motivational interviewing and shared decision-making use similar approaches to changing behavior. They both require health care providers to engage the patient through building relationships, respecting autonomy, asking questions, and listening. The difference is that motivational interviewing helps patients move away from risky behavior via behavior change, whereas shared decision-making helps patients to move from considering options to making decisions (Figure 1).12

Utilizing the components of health psychology—including the approaches of targeted messaging, motivational interviewing, and shared decision-making—can improve patients’ treatment adherence, optimize outcomes, and help to implement clinical pathways effectively. 

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References

1.    Horne R, Chapman SCE, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the necessity-concerns framework. PLoS One. 2013;8(12):e80633.

2.    Belloc NB, Breslow L. Relationship of physical health status and health practices. Prev Med. 1972;1(3):409-421. 

3.    Marks DF, Murray M, Evans B, Estacio EV. Health Psychology. Theory, Research and Practice. 3rd ed. London: Sage Publications Ltd; 2011.

4.    Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.

5.    Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol. 2012;17(1):74-84. 

6.    Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York, NY: The Guilford Press; 2002.

7.    Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press; 2008.

8.    Golin CE, Earp J, Tien HC, Stewart P, Porter C, Howie L. A 2-arm, randomized, controlled trial of a motivational interviewing-based intervention to improve adherence to antiretroviral therapy (ART) among patients failing or initiating ART. J Acquir Immune Defic Syndr. 2006;42(1):42-51. 

9.    Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521-530.

10.    Pollak KI, Alexander SC, Tulsky JA, et al. Physician empathy and listening: associations with patient satisfaction and autonomy. J Am Board Fam Med. 2011;24(6):665-672.

11.    Vlasnik JJ, Aliotta SL, DeLor B. Evidence-based assessment and intervention strategies to increase adherence to prescribed medication plans. Case Manager. 2005;16(2):55-59. 

12.    Elwyn G, Dehlendorf C, Epstein RM, Marrin  K, White J, Frosch DL. Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. Ann Fam Med. 2014;12(3):270-275. 

13.    Blanc X, Collet TH, Auer R, et al. Publication trends of shared decision making in 15 high impact medical journals: a full-text review with bibliometric analysis. BMC Med Inform Decis Mak. 2014;14:71. 

14.    Mayo Clinic Shared Decision Making National Resource Center. Mayo Clinical website. http://shareddecisions.mayoclinic.org/. Accessed December 10, 2015.

15.    Informed Medical Decisions Foundation. Demonstration sites. Informed Medical Decisions Foundation website. www.informedmedicaldecisions.org/shared-decision-making-in-practice/demonstration-sites. Accessed December 10, 2015.