Fostering and Assessing Adherence to Treatment

Fostering and Assessing Adherence to Treatment Your name Institution/organization Meeting Date International Standards 9, 17

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

Fostering Adherence to Treatment Overview: • General concepts • Adherence factors and interventions • Comparison of traditional care vs. collaborative care • Strategies to improve adherence International Standards 9, 17

Fostering Adherence to Treatment 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 assess and foster 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)

Standard 9: Fostering Adherence to Treatment Supervision and support should be individualized 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

Standard 9: Fostering Adherence to Treatment 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 treatment or DOT) and identification and training of a treatment supporter (for TB and, if appropriate, for HIV) who is acceptable and accountable to the patient and to the health system. Appropriate incentives and enables, including financial support, may also serve to enhance treatment adherence (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 Health system/ HCT-factors Social/economic factors Condition-related factors Therapy-related factors Patient-related factors HCT = healthcare team WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

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

Adherence: Social/Economic Factors • Age • Race • Gender • Poverty • Illiteracy/Education level • Unstable living conditions/homelessness • Social upheavals (wars, natural disasters) • Distance from treatment centers • Costs of care WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

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

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

Healthcare Team / System-Related Factors Elements of the healthcare system necessary to 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

Through the Eyes of Patients and Families 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 Sanou A, et al. IJTLD 2004;8:1479 (cited in Munro SA, et al. PLoS Medicine 2007;4:e238)

Healthcare Team / System-Related Factors Elements of the healthcare system necessary to 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

Healthcare Team / System-Related Factors 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 WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

Therapy and Condition-Related Factors Factors that affect adherence: Therapy • Dosing frequency • Side effects Condition • Effects of symptoms • Lack of symptoms • Effects on functional status • Associated depression WHO. Adherence to Long-term Therapies: Evidence for action. WHO. 2003

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

Through the Eyes of Patients and Families 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 Green JA. Cult Med Psychiatry 2004; 28: 401 (cited in Munro SA, et al. PLoS Medicine 2007;4:e238)

Through the Eyes of Patients and Families ….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 Ngamvithayapong J, et al. AIDS 2000;14:413 (cited in Munro SA, et al. PLoS Medicine 2007; 4:e238)

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

Standard 17: Support and Services (1 of 2) • All providers should conduct a thorough assessment for co-morbid conditions that could affect tuberculosis treatment response or outcome • At the time the treatment plan is developed, the provider should identify additional services that would support an optimal outcome for each patient and incorporate these services into an individualized plan of care

Standard 17: Support and Services (2 of 2) This plan should include assessment of and referrals for treatment of other illnesses with particular attention to those known to affect treatment outcome, for instance care for diabetes mellitus, drug and alcoholtreatment programs, tobacco smoking cessation programs, and other psychosocial support services, or to such services as antenatal or well baby care

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

Traditional Care vs. Collaborative Care Bodenheimer T,et al. JAMA. 288: 2002, 2469-2475

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

Fostering Adherence to Treatment 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 individualizing 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]

Summary: ISTC Standard Covered* Standard 17: All providers should conduct a thorough assessment for co-morbid conditions that could affect TB treatment response or outcome. • The treatment plan should identify additional services that would support an optimal outcome for each patient and incorporate these services into an individualized plan of care. • This plan should include assessment of and referrals for treatment of other illnesses with particular attention to those known to affect treatment outcome (diabetes mellitus, drug and alcohol programs, tobacco smoking cessation programs, and other psychosocial support services, or to such services as antenatal or well baby care). *[Abbreviated version]

Alternate Slides

Purpose of ISTC

ISTC: Key Points • 21 Standards (revised/renumbered in 2009) • 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

ISTC: Key Points • 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

Questions

Fostering Adherence to Treatment 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? 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 Talk to her about directly-observed therapy as a way to help her succeed with treatment and support her closely 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 All of the above

Fostering Adherence to Treatment 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: 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 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 Provide written educational material for patients in appropriate languages, and consider a peer-assistance program. 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

Fostering Adherence to Treatment 3.To develop a patient-centered system of care for TB, all of the following would be good to consider except: The patient may be involved in deciding which TB medications they prefer to take in order to individualize treatment regimens The patient’s needs and expectations regarding TB care should be explored, looking for ways to improve adherence, and thus, treatment outcomes 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 Promote patient self-management through appropriate education and support. Support should be individualized and tailored to the cultural context

Fostering and Assessing Adherence to Treatment