Use these techniques to improve adherence
Use these techniques to improve adherence
By soliciting feedback from patients about their perceptions of treatment and helping them work though possible difficulties, physicians can greatly enhance adherence, says Martha Johns, MD, MPH, a family physician and medical director of health promotion and disease prevention for Centura Health, an integrated health system in Denver.
Johns offers the following techniques for physicians to improve adherence:
1. Keep the regimen simple.
"The more complicated something is, the more difficult it’s going to be for someone to adhere to it," she says. For example, time-release versions of some medications are now available, or dosing schedules can be arranged. The more often patients have to think about taking their pills, the more likely they are to forget a dose.
2. Write out the regimen for the patient.
This is especially important if the treatment plan is complicated or you’re dealing with an older patient who may have memory problems. But by human nature, patients will forget some of what you told them shortly after they walk out the door.
"Use your prescription pad to write down important points," suggests Johns. "I probably write as many wellness prescriptions or patient instructions prescriptions as I do medicine prescriptions."
Written instructions encourage change
This technique can be effective in encouraging patients to make behavioral changes. For example, Johns may write, "Walk 10 minutes, three days this week. Increase to four days, increase by five minutes each day."
"When I’m doing something like that I joke and say, This may look like a strange prescription for you, but it may be one of the most important prescriptions I’ll ever give you.’"
Johns uses a pad that has duplicate copies, which she can attach to the patient’s chart. If patients are making lifestyle changes, such as in diet or exercise, she may ask them to keep a diary. "If they’re not keeping the diary, you pretty much know they’re not doing it," she says.
If you use a pre-printed handout for instructions, Johns suggests you personalize it by writing the patient’s name on the handout and highlighting important points.
3. Motivate the patient.
Tell patients what benefits they will get from the medication or treatment and how long it will take to get them. For example, antidepressants won’t work until they build up in the patient’s system for a couple of weeks or more, she says. If patients aren’t made aware of the medication’s effectiveness time frame, they may decide the treatment isn’t working and stop taking the medication.
Sometimes Johns even gives patients a copy of a page from a calendar with dates marked indicating when they may expect to feel better.
Patients often stop taking medications, such as antibiotics, once they start feeling better. Physicians need to stress the importance of continuing the medication for the full prescribed course.
4. Prepare the patient for side effects.
Side effects are a common cause of non- adherence. Often, the patient won’t even tell the doctor about the side effects, Johns says. "The trick is telling them about the possibility of side effects without suggesting they will occur," she says.
For example, when prescribing erythromycin, Johns may say, "Some people will develop stomach upset with this medicine. I want you to be aware that’s a possibility. Most people don’t, and I doubt you’ll have any problem with it. If you do, please don’t stop taking it. Give us a call and we’ll change the medication for you."
You can think about side effects even for behavioral regimens, suggests Vaughn Keller, MST, associate director of education of the Bayer Institute for Health Care Communication in West Haven, CT.
"For a person who may not be exercising, one of the side effects in starting an exercise regime might be to get stiff," he says. A physician may tell the patient to expect some initial soreness, "and probably by the end of two weeks you’ll feel a little better because you’ve been exercising."
5. Identify and remove obstacles to the regimen.
Johns often suggests that patients take their medicines along with some other routine they do every day. For example, she had a healthy patient with a positive skin test for tuberculosis who would need to take prophylactic medication for a year.
At first, he kept the medicine in his work locker and took it when he changed clothes. With that system, he often skipped weekend doses. After some discussion with Johns, he decided to leave the medicine next to his coffee machine so he could remember to take it with coffee every morning.
6. Get feedback from the patient.
Johns asks her patients, "So that I can be sure I’ve made myself clear in explaining this to you, could you repeat back to me what our plan is?"
"Sometimes you’ll realize they have no idea," she says. "Then you know you need to go over it again."
Physicians also should ask patients at future visits how their treatment plan is working and whether they have experienced any difficulties. In some cases, nurses may make follow-up phone calls to see how patients are doing with their regimens.
Johns says she follows these overall techniques in her family practice and believes they work. "My sense is that it at least doubles my success rate," she says.
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