Jacqueline DunbarJacob Ph D RN FAAN Dean School

Jacqueline Dunbar-Jacob, Ph. D, 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? - 347 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

Clinical Impact of Poor Compliance 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

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 COSTS 100+ Emerging Issues In Pharmaceutical Cost Containment 6/92

Why Do Patients Fail to Adhere Effectively?

Why Prescriptions Are Not Filled Upjohn Survey 21% Thought 22% medication Concerned about Would Not Help Side Effects 20% Condition Improved 14% Cost AARP Survey 5% Not Available in Store 10. 5% Cost 10. 5% Other 21. 7% Did Not Want to Take 51% Did not need the medication 2. 8% Lost or Forgot It Task Force on Compliance (1994). Noncompliance with medications. Reproduced by permission of the Task Force for Compliance via the Copyright Clearance Center, Inc.

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

Reasons for Poor Adherence Patient Perspective t Forgetting t Symptom Management t Thought Medication Wouldn’t Help t Schedule Disruptions t Did Not Need Medication t Adequacy or Completeness t Did Not Want to Take It of Instructions t Multiple or Complex Regimens t Concerned About Side Effects t Condition Improved 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 = 3. 866 d¦ = 2 p =. 145 Regularity of Bedtime Routine x 2 = 5. 996 d¦ = 2 p =. 050

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

What Does Poor Adherence Look Like?

e c n e r e h d e l A b r a i o r o a P V a t n is e v E

Once a Day Dosing Prescription Actual Time 3 Extra Doses 12 pm 10 pm 8 pm 6 pm 4 pm 2 pm Noon 10 am 8 am x x x x x 4 am ¡Missed Doses x x x x x ¡ ¡ ¡ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Days of Observation x ¡ 21 22 23

Actual Time Twice a Day Dosing Prescription 5 am 6 am 7 am 8 am 9 am x 10 am 11 am 12 N 1 pm x 2 pm 3 pm 4 pm 5 pm 6 pm 7 pm x 8 pm 9 pm 10 pm x 11 pm x 12 M x x 1 am 2 am 3 Extra Doses ¡Missed Doses x x x x x x x x 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 Days of Observation

Actual Time Three Times a Day Dosing Prescription 5 am 6 am 7 am x 8 am x x 9 am x 10 am x x 11 am x 12 N 1 pm 2 pm 3 pm 4 pm 5 pm x x 6 pm x 7 pm 8 pm 9 pm x x 10 pm x 11 pm x 12 M x x x 1 am x 2 am 3 Extra x Doses x x x ¡Missed Doses x x x x x x x x x 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 Days of Observation x

Adherence Rates Medication Exercise Smoking Diet Smokers Relapse 1970’s 50% 50% 34. 4% 70 -80% 2000’s 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 t Loss in the Field of Therapeutic Effectiveness

Is This Likely to be Influenced By Measurement Method?

Relationship of Adherence to Cholesterol Change Adherence EEM 1 EEM 2 7 -Day EEM 1 7 -Day EEM 2 Pill Count 7 -Day Recall 1 7 -Day Recall 2 # pills 2 #pills in correct dosing interval 1 % D Total Cholesterol. 26. 18. 34. 26. 12. 20. 00 p-value. 043 NS. 009. 050 NS NS NS

Correlation (rs) Between Days Adherent and Clinical Outcomes Diary Pain FSI -. 091. 265* MPI. 151. 120 Diary -. 104 -. 108 Difficulty FSI -. 091. 172 Assistance FSI -. 029. 108 Symptom Rating Diary -. 111. 017 *p <. 05 (two-tailed) EEM RAC-1