A simple tool to improve adherence communication in healthcare consultations

Non-adherence to medication for long term conditions averages around 50%¹, leading to poorer treatment outcomes², an estimated 200,000 premature death in Europe per year and an estimated €125 billion per year in avoidable hospitalisations, emergency care and outpatient visits³. Patients may not start treatment or take it as prescribed, and they may choose to discontinue their medication early⁴. There are many reasons that patients may not be adherent, and these vary between individuals and may vary in the same individual over time⁵.

Poor patient-healthcare professional (HCP) communication is a known barrier to adherence⁶, and HCPs should be trained in adherence¹. However, adherence is rarely discussed in routine consultations or may be broached in inappropriate ways that make it difficult for patients to “admit” non-adherence⁷.

Making Medicines Work for You (MMWFY)

Working with patients and clinicians at King’s Health Partners, as part of the Centre for Adherence Research and Education in London, I was involved in designing a brief screening questionnaire for patients to complete while waiting for their consultation (Making Medicines Work for You/MMWFY). The MMWFY asks whether the patient is experiencing one or more of seven problems with their medicine, drawn from recent evidence mapping the main drivers of adherence/non-adherence⁵. The screener also contains a free response box in which the patient can record issues they might have that are not captured by the questions. The answers can be used by their healthcare professional to prompt a conversation to overcome the patient’s barriers to adherence⁸. Although designed for pen and paper use, the screener could be adapted for use electronically in remote consultations.

MMWFY identifies adherence barriers

In a study of adult patients with type 2 diabetes we found that 88% of the sample indicated at least one medication-related issue, demonstrating that patients are willing to raise these issues when they are presented in this way.  Scores on the questionnaire were positively correlated with self-reported adherence (measured via the Morisky Medication Adherence Scale – MMAS4)⁹, meaning that patients who reported more issues also reported higher levels of non-adherence. In addition, scores were positively correlated with concerns about potential adverse effects of medication (measured via the Beliefs about Medicines Questionnaire (BMQ)-Concerns¹⁰), and negatively correlated with perceived need for treatment (measured via BMQ-Necessity¹⁰). That is, patients reporting more issues also reported higher concerns about potential adverse effects, and a lower perceived need for treatment⁸. Consequently, this brief, easily implemented screening questionnaire shows promise as a tool to improve discussion around adherence and adherence-related barriers in routine consultations.

MMWFY Lead, Prof John Weinman says “As we know that patients and practitioners find it difficult to discuss and resolve adherence problems in the consultation, there is huge potential in having a simple screener to start this process. Not only do patients find it easy to use but also it enables practitioners to see, at a glance, the individual challenges which each patient is experiencing and to focus their support on these in a personalised way. We have just finished a study using the screener in an outpatient sample of people with heart disease and found very similar results, and there is certainly scope now for using the screener routinely in all healthcare settings.”

References:

1. WHO (2003). Adherence to Long-Term Therapies, Evidence for Action. https://www.who.int/chp/knowledge/publications/adherence_report/en/

2. DiMatteo, M. R., Giordani, P. J., Lepper, H. S., & Croghan, T. W. (2002). Patient adherence and medical treatment outcomes a meta-analysis. Medical Care, 794-811.

3. Khan R. & Socha-Dietrich, K. (2018). Investing in medication adherence improves health outcomes and health system efficiences: Adherence to medicines for diabetes, hypertension and hyperlipidaemia. OECD Health Working Papers, No.105, OECD Publishing, Paris. https://dx.doi.org/10.1787/8178962c-en

4. Vrijens, B., De Geest, S., Hughes, D. A., Przemyslaw, K., Demonceau, J., Ruppar, T., … & ABC Project Team. (2012). A new taxonomy for describing and defining adherence to medications. British Journal of Clinical Pharmacology, 73(5), 691-705.

5. Jackson, C., Eliasson, L., Barber, N., & Weinman, J. (2014). Applying COM-B to medication adherence: a suggested framework for research and interventions. Eur Health Psychol, 16(1), 7-17.

6. Zolnierek, K. B. H., & DiMatteo, M. R. (2009). Physician communication and patient adherence to treatment: a meta-analysis. Medical Care, 47(8), 826.

7. Engel, T., Ungar, B., Ben-Haim, G., Levhar, N., Eliakim, R., & Ben-Horin, S. (2017). Re-phrasing the question: a simple tool for evaluation of adherence to therapy in patients with inflammatory bowel disease. United European Gastroenterology Journal, 5(6), 880-886.

8. Weinman, J., Ali, I., Hodgkinson, A., Canfield, M., & Jackson, C. (2019). Pilot testing of a brief pre-consultation screener for improving the identification and discussion of medication adherence in routine consultations. Patient Preference and Adherence, 13, 1895.

9. Morisky, D. E., Green, L. W., & Levine, D. M. (1986). Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care, 67-74.

10. Horne, R., Weinman, J., & Hankins, M. (1999). The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychology and Health, 14(1), 1-24.