Dr Susan Sawyer - Respiratory Paediatrician, Department of Respiratory Medicine & Deputy Director, Centre for Adolescent Health, Royal Children's Hospital
What stops patients from taking their medication as prescribed? Why do they 'forget' or stop treatment before recommended? Why don't they return for regular asthma review? These are questions that continue to baffle health professionals who manage people with asthma, as the best drug in the world is only as good as it is able to be correctly used.
Knowledgeable health professionals are easily able to understand the rationale for preventive treatment and can educate patients about the need for preventive medication. As health professionals we find it harder to truly understand the many barriers that limit adherence; harder to identify which patients are adherent with preventive medication; and harder to enter into true partnerships with patients that facilitate self-management, adherence and healthy outcomes. Strong communication skills are the key to unravelling the issues around adherence; we need to be as good communicators as we are diagnosticians and prescribers.
According to recent Newspoll research, one in two Australians with asthma who are prescribed preventive medication are not taking it as directed by their GP, with one in four only taking it when they feel out of control.1 This is nothing new, and it was Hippocrates who advised the physician "...to be alert to the faults of the patients which make them lie about their taking of the medicines prescribed and when things go wrong, refuse to confess that they have not been taking their medicine".2 In the 1990s, however, we recognise that poor adherence is far more than simply the patient's fault and it is now generally accepted that the responsibility for promoting better adherence lies with the health professional.
While there is no such thing as the 'adherent personality' or an adherent 'type' of person, some people find it easier to take their medication regularly, avoid triggers and obtain regular medical review than others. Actions requiring greater behaviour change are less likely to be adhered to than those involving minimal change to the daily routine. This means that people may be adherent to one part of an asthma management plan more easily than another.
While many patients are less than ideal at taking regular medication, health professionals are equally less than ideal at identifying which patients are adherent or not. Poor adherence affects most if not all patients with a chronic illness like asthma at some time, but often for different reasons and for different lengths of time. It is therefore important that health professionals implement strategies to improve adherence with all patients, all the time.
Before we can work at improving adherence we need to understand what medications are actually used. Framing questions about medication use in a way that normalises poor adherence in a non-judgemental way is the basis to obtaining an honest account - gather detailed information using open-ended questions; show warmth and empathy; follow up on verbal cues.
While actually remembering to take medication is part of the problem, it is also important to ensure that patients have a good understanding about what medications they are on and why. Asthma education without an asthma management plan is not sufficient.
Giving people the opportunity to raise concerns about medication is also important. This is consistent with research on the determinants of adherence which tells us that patients typically only follow recommendations they really believe in and those they actually have the ability to carry out.3 While many people, particularly parents of young children, may be concerned about possible side effects of medication, it is equally important to reinforce the possible risks of not taking medication. Providing opportunities for discussion and choice about medication type and delivery device is a strategy to encourage greater involvement in asthma self-management and improve adherence.
Adherence is best with the lowest number of medications and the lowest dosage intervals. Improve patient recall by providing written education material and a written record of medication names and doses. Encourage correct usage by checking aerosol technique. Positively reinforce specific efforts to improve adherence. Identify health beliefs around asthma and medication. Elicit family support.
It is often easy to blame a patient for not having check-ups or not keeping appointments with their doctor. But most of us need a good reason to visit our doctor which is why it is easier for people to visit only when they are sick. One way to encourage regular review is to focus on short-term goals while highlighting the long-term objectives. Short-term goals set around patient priorities such as sporting participation or fewer days off school or work are more likely to be successful than physiological goals such as peak flow. End points where patients know that reaching a certain goal will result in changes to medication may encourage regular review.
Some health professionals believe that scare tactics are the best way to make patients stick to their medication. However, disease severity per se is not clearly associated with better adherence and fear is not a lasting motivator for most people. Many people who live with severe asthma symptoms for a long time forget what good health feels like and accept a less than optimal health status. Indeed, six out of ten Australians with asthma wake at night with symptoms, believing this is a normal consequence of asthma.4 Emphasising disease severity will not necessarily make patients adhere better; helping them realise just how good they might feel is more likely to be successful.
So you think this takes time? Research suggests that this approach results in better health outcomes, more satisfied patients and shorter consultations.5 Promoting better adherence is based on health professionals' key skills and strategies - skills can be learnt but practice makes perfect.
References:
1 Newspoll Asthma Study; June/July 1998.
2 Hippocrates, Decorum c 200 BC.
3 DiMatteo MR. Enhancing Patient Adherence to Medical Recommendations. JAMA, January 5, 1994;Vol 271, No.l.
4 Reark Research Pry. Ltd. Market Research Report: Prevalence of nocturnal and exercise induced asthma in Australia, November 1994.
5 Clark NM, Gong M Schork MA, Evens D, Roloff D, Hurwitz M Maiman L, Mellins RE. Impact of education for physicians on patient outcomes. Pediatrics; 101(5): 831-6.
Content Updated July, 2001
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