Fostering and Assessing Adherence to Treatment Your name Institution/organization Meeting Date International Standard 9

Fostering and Assessing Adherence to TreatmentYour name Institution/organizationMeetingDate

International Standard 9

ISTC Training Modules 2008

Fostering Adherence to Treatment

Objectives: At the end of this presentation, participants will be able to: Recognize that addressing a patient’s needs and

expectations, and fostering a relationship of mutual respect between patient and provider are key elements in promoting treatment adherence

Understand factors that may have a negative impact on patient adherence to treatment

Utilize interventions to improve adherence to treatment


International Standard 9


Overview: General concepts Adherence factors

and interventions Comparison of

traditional care vs. collaborative care

Strategies to improve adherence



Assuming an appropriate drug regimen is prescribed, tuberculosis treatment success depends largely on patient adherence.


Factors Likely to Improve Adherence

Increase visibility of TB programs in the community

Provide more information about the disease and treatment to patients and communities

Increase support from family, peers, and social networks

Minimize costs and inconvenience related to clinic visits

Munro S, et al. PLoS Medicine 2007; 4:e238


Suggestions to Improve Adherence

Increase provider flexibility and patient autonomy in choice of treatment support plan

Increase patient-centered focus of interactions between providers and patients

Address structural and personal factors; for example, through micro-financing and other empowerment initiatives

Provide more information about the side effects of medications

Munro S, et al. PLoS Medicine 2007; 4:e238


Standard 9: Fostering Adherence to Treatment

To foster and assess adherence, a patient-centered approach to administration of drug treatment, based on the patient’s needs and mutual respect between the patient and provider, should be developed for all patients.

(1 of 3)



Supervision and support should be gender-sensitive and age-specific and draw on the full range of recommended interventions and available support services, including patient counseling and education.

(2 of 3)



A central element of the patient-centered strategy is the use of measures to assess and promote adherence to the treatment regimen and to address poor adherence when it occurs.

These measures should be tailored to the individual patient’s circumstances and be mutually acceptable to the patient and the provider.

Such measures may include direct observation of medication ingestion (directly observed therapy–DOT) by a treatment supporter who is acceptable and accountable to the patient and to the health system.

(3 of 3)


Through the Eyes of Patients and Families

It just does not make sense as to why a grown person should be given medicines by someone else. I felt very awkward and tried to take my medicines myself.

—Male TB patient, Pakistan

Khan MA, et al. Health Policy Plan 2005;20:354

(cited in Munro SA, et al. PLoS Medicine 2007;4:e238)


Patient-Centered Care

Definition:Care centered on patients’ needs and expectations

Goal:Improving treatment outcomes through improved adherence


The Five Dimensions of Adherence

HCT = healthcare team

WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Health system/HCT-factors

Social/economicfactors

Therapy-relatedfactors

Condition-relatedfactors

Patient-relatedfactors


Interventions

General comments: Interventions must be tailored to the

particular situation and cultural context An approach developed in collaboration

with patient achieves optimum adherence Important: Treatment support measures,

not the treatment regimen itself, must be individualized to suit the unique needs of the patient


Age Race Gender Poverty Illiteracy/Education level Unstable living conditions/homelessness Social upheavals (wars, natural disasters) Distance from treatment centers Costs of care


Adherence: Social/Economic Factors


Housing Food / food tokens Transport to

treatment settings Peer assistance Mobilizing community-

based organizations Cooperation between/among services Education of the community and providers to

reduce stigma Family and community support

Interventions: Social/Economic Factors



Healthcare Team / System-Related Factors

Factors that affect adherence: Lack of awareness and knowledge about

adherence Lack of tools to assess adherence and address

poor adherence Lack of tools to assist with patient behavioral

change Suboptimal communication between healthcare

team and patients Access to care Gaps in provision of care




Elements of the healthcare system necessaryto deliver patient-centered care: Access and continuity:

Continuity of care and a good relationship with a clinician is a key factor in patient satisfaction

Coordination of care between/among settings: Identifying a specific care coordinator role within the healthcare team can improve communication

Patient participation:Patients should be given a meaningful role in determining treatment supervision



Sanou A, et al. IJTLD 2004;8:1479


The patients do not have adequate means to go to the health center to take their drugs. They just have camel, donkey or carts… and sometimes the state of some patients prevents them from using these.

—Male family member of TB patient, Burkina Faso



Elements of the healthcare system necessaryto deliver patient-centered care: Availability of self-management support:

Patients provide themselves with the vast majority of care they receive outside the hospital and should be equipped to do so

Use of a collaborative care model: Fostering a patient-provider partnership and sharing responsibility for care empowers patients to manage their illnesses more effectively



Interventions: Ensure access to care Provide information to patients Support local patient organizations/groups Manage disease in partnership with patient Collaborative, multidisciplinary care Intensive staff supervision and use of DOT



Factors that affect adherence:

Therapy Dosing frequency Side effects

Condition Effects of symptoms Lack of symptoms Effects on functional status Associated depression

Therapy and Condition-Related Factors



Therapy and Condition-Related Factors

Interventions: Education about tuberculosis and the need for

treatment adherence Education on use of medications and adverse

effects Use of fixed-dose combination preparations Agreements (written or verbal) to return for an

appointment or course of treatment Continuous monitoring and reassessment Tailor treatment support to needs of patients


Green JA. Cult Med Psychiatry 2004; 28: 401



I think that I feel healthy, my lungs are good, but I have a bit of fear that the sickness will return. But as I told you, I don’t want to take these pills because they make me sick, they hurt me….

—Female TB patient, Bolivia


Ngamvithayapong J, et al. AIDS 2000;14:413

(cited in Munro SA, et al. PLoS Medicine 2007; 4:e238)


….When my husband went back home, he was angry with himself and he was upset about everything. He refused to eat and rejected his medicine. He threw his pills away. He did not take TB medicines at all.

—Female HIV+ TB patient, Thailand


Adherence: Age, gender Race/ethnicity Stigma Understanding of

disease and effects of treatment Cultural belief systems Altered mental status

(substance abuse, mental illness, other illnesses)

Adherence: Patient Factors




Interventions: Patient Factors

Interventions: Developing a collaborative

relationship Mutual goal setting Memory aids and reminders Incentives and/or reinforcements Reminder letters Telephone reminders or home visits for patients

who default


Bodenheimer T,et al. JAMA. 288: 2002, 2469-2475

Traditional Care vs. Collaborative Care

Issue Traditional Care Collaborative Care

Relationship between patient and provider

Providers are experts who tell patients what to do. Patients are passive.

Providers are experts about disease. Patients are experts about their lives.

Principal caregiver? The provider. Patient and provider

share responsibility.

What is the goal?

Compliance with instructions. Noncompliance is a patient problem.

Patient sets goals based on information from provider. Noncompliance is a problem of strategies.


Bodenheimer T,et al. JAMA. 288: 2002, 2469-2475

Traditional Care vs. Collaborative Care

Issue Traditional Care Collaborative Care

How is behavior changed?

External motivation

Internal motivation through increased patient understanding

How are problems identified?

By the providerBy the informed patient who can recognize problems

How are problems solved?

By the providerBy the informed patient with the provider



Overall Administrative Strategies

Developing a “patients first” attitude in the clinic Staff training, motivation, and supervision Defaulter action (example: home visits) Reminders mailed in advance of appointments Encourage staff to identify incentives, enablers Provide reimbursements for visit costs Directly observed treatment (DOT)



Summary: Consider patient’s needs Mutual respect between

the patient and provider is key

Consider all factors that may influence adherence

Support measures must be tailored to the individual


Summary: ISTC Standard Covered*

Standard 9: To foster and assess adherence, a patient-centered approach, based on the patient’s needs and mutual respect between the patient and the provider, should be developed for all patients.• Consider gender-sensitive and age-specific

interventions and support.

• Use measures that assess and promote adherence, and address poor adherence when it occurs.

• These measures should be tailored to the individual, mutually acceptable, and may include directly-observed therapy (DOT) of medication.

*[Abbreviated version]


Alternate Slides


Purpose of ISTC


ISTC: Key Points

17 Standards Differ from existing guidelines: standards

present what should be done, whereas, guidelines describe how the action is to be accomplished

Evidence-based, living document Developed in tandem with Patients’ Charter

for Tuberculosis Care Handbook for using the International

Standards for Tuberculosis Care


Audience: all health care practitioners, public and private

Scope: diagnosis, treatment, and public health responsibilities; intended to complement local and national guidelines

Rationale: sound tuberculosis control requires the effective engagement of all providers in providing high quality care and in collaborating with TB control programs

ISTC: Key Points


Questions



1. A 62 year-old patient has been taking TB treatment for three months. She has hypertension and has been your patient for ten years. Although she has always been good at listening to all of your advice in the past, she has missed her last two appointments, and her husband now informs you that he is worried because she is not taking her TB medications at home as directed. He states that she rarely goes out of the house now, and she avoids her friends. In addition to asking about possible side effects from the medications, what else would be good to address during her next appointment?

A. Ask how she is coping with the diagnosis, understanding that emotional factors such as fear, stigma, and depression may play a role in non-adherence

B. Talk to her about directly-observed therapy as a way to help her succeed with treatment and support her closely

C. Assess her understanding of TB disease and treatment, and ask her what she thinks might be interfering with her ability to take her medications as directed

D. All of the above



2. As a clinic caregiver and administrator, you note that the clinic has a high rate of TB treatment failure and default. Healthcare team and system interventions that could improve patient adherence and completion rates include all of the following except:A. Develop a joint case conference to discuss problem TB cases with

doctors, nurses, and other clinic healthcare workers involved with the TB patients, to put together all aspects of patient care and problem-solve jointly

B. Define a list of strict rules for adherence that patients must follow in order to receive care for tuberculosis at the clinic. Post the rules and enforce. All patients will see the same information, staff will not have to spend time reviewing issues with patients, and the clinic will run more efficiently

C. Provide written educational material for patients in appropriate languages, and consider a peer-assistance program.

D. Develop a reminder system to contact defaulters through letters and/or telephone, and consider a system of incentives or enablers that could help improve adherence



3. To develop a patient-centered system of care for TB, all of the following would be good to consider except:

A. The patient may be involved in deciding which TB medications they prefer to take in order to individualize treatment regimens

B. The patient’s needs and expectations regarding TB care should be explored, looking for ways to improve adherence, and thus, treatment outcomes

C. Foster relationships between patients and providers that rely on mutual respect and mutual responsibility toward a shared goal, rather than just offering expert advice and assuming passive compliance

D. Promote patient self-management through appropriate education and support. Support should be gender-sensitive and age-specific, and should be tailored to the cultural context

Documents

Fostering and Assessing Adherence to Treatment Your name Institution/organization Meeting Date International Standard 9