8/13/2016
Objectives
• Describe the economic, clinical and humanistic impact of
poor medication adherence
Maximize Medication Adherence by
Minimizing Barriers
• List multidimensional barriers affecting medication
adherence
• Review the profiles of therapeutic options and the
importance of appropriate medication selection
• Discuss the role of care teams in medication adherence
• Implement strategies to improve medication adherence
in patients with diabetes
Pre-test Question 1
Faculty
Katherine S. O’Neal, PharmD, MBA,
BCACP, CDE, BC-ADM, AE-C
Associate Professor
The University of Oklahoma College of
Pharmacy
The University of Oklahoma School of
Community Medicine: Internal Medicine
Tulsa, OK
Member and Supported by Harold Hamm
Diabetes Center
William H. Polonsky, PhD, CDE
Associate Clinical Professor
University of California, San Diego
President
Behavioral Diabetes Institute
San Diego, CA
Disclosure to Participants
•
Notice of Requirements For Successful Completion
•
Conflict of Interest and Financial Relationship Disclosures:
•
•
•
Learners must attend the full activity and complete the evaluation in
order to claim continuing education credit/hours
Presenter: Katherine S. O’Neal, PharmD, MBA, BCACP, CDE, BCADM, AE-C – Nothing to disclose
Presenter: William Polonsky, PhD, CDE - Served on Advisory
Boards for Novo Nordisk, Sanofi, Eli Lilly and Company, Intarcia
Therapeutics Inc., Dexcom, and Roche. He has also performed
contracted research for Sanofi, Dexcom, and Insulet Corporation.
•
Non-Endorsement of Products:
•
Off-Label Use:
•
•
Accredited status does not imply endorsement by AADE, ANCC,
ACPE or CDR of any commercial products displayed in conjunction
with this educational activity
Which of the following statements is TRUE regarding
patients with diabetes and medication adherence?
A. With poor adherence, patients are 4 times more likely to
be hospitalized due to diabetes
B. Improved adherence to diabetes medications could
save $5 billion annually
C. A 10% increase in adherence corresponds to a 0.05%
decrease in hemoglobin A1C
D. Poor adherence to diabetes medications increases
mortality risk by 2.5 times
Pre-test Question 2
Please rate your ability to implement strategies to improve
medication adherence in patients with diabetes?
A. Excellent
B. Good
C. Fair
D. Poor
Participants will be notified by speakers to any product used for a
purpose other than for which it was approved by the Food and Drug
Administration.
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Pre-test Question 3
A 57-year old woman with a 13 year history of T2DM visits you for
her first diabetes education session. She has been successfully
managed on metformin 1000mg/sitagliptin 50mg twice daily. In the
past year, her A1C has jumped to 10.3%. She has private insurance
and is the CFO of a large national bank. Six months ago, her PCP
started her on 20 units basal insulin + 5 units bolus insulin with each
meal. Her detailed blood sugar log shows a blood glucose range of
200-260 at all times of the day. A1C today is 10.6%. Which one of
the following multidimensional barriers is most likely contributing to
the patient’s poor glycemic control?
A. Social Factors
B. Healthcare System
C. Therapy Related Factors
D. Economic Factors
Adherence Statistics
• Half of all patients do not take
their medications as prescribed
For every 100 prescriptions written…
• More than 1 in 5 new
prescriptions go unfilled
• To save money, 8% of adults
don’t take their medication
• Average medication adherence
71%
• Adherence is lowest among
patients with chronic illnesses
• Diabetes medications 43-73%
Are filled
at the
pharmacy
Are picked
up from
the
pharmacy
Are
taken
properly
Are refilled
as
prescribed
Claxton, et al. Clin Ther. 2001;23(8):1296-1310. Osterberg L, et al. New Engl J Med, 2005;353(5):487-97.
Fischer MA, et al. Am J of Med, 2011; 124(11):1081.e9. Sokol MD, et al. Med Care, 2005;43(6):521-30.
Image: www.healthworkscollective.com
Medication Adherence
DAWN Study
“Not taking medication as prescribed – taking either
too little, or too much, for too short, or too long a
period, at the wrong time or in an ineffective way – can
have negative consequences for patients, healthcare,
and the economy.”
World Health Organization
Type 1
Type 2
Medication adherence
83%
78%
Keeping appointments
71%
72%
Exercise
37%
35%
Self-monitoring blood
glucose
Diet
70%
39%
64%
37%
Peyrot M, et al. Diabet Med. 2005;22(10):1379-1385. WHO. Adherence to Long-Term Therapies: Evidence
for Action, 2003.
Medication Adherence vs.
Persistence
Conforming to timing, dosage,
and frequency of medication
ADHERENCE
Start Medication
Days taking medication without
gap in coverage
Stop Medication
IMPACT OF POOR
MEDICATION ADHERENCE
PERSISTENCE
Adapted from: Cramer JA, et al. Medication Compliance and Persistence. Value in Health, 2008.
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Economic Burden
Adherence and A1C
• Morris and Colleagues
$100-300 billion/year
– Studied pediatric patients aged 9-22 diagnosed with type 1
for 4-12 years
– Adherence groupings (p<0.001)
•
•
•
•
Low:
Moderate:
Moderate-High:
High:
$2000/patient in
physician visits
A1c 9.44 ± 1.7
A1c 8.98 ± 1.5
A1c 7.85 ± 1.4
A1c 7.25 ± 1.0
10-25% hospital and
nursing home
admissions
• Schectman and Colleagues
– Studied 810 adult patients with type 2 diabetes
– Each 10% increase in adherence corresponded to a 0.16%
decrease in A1c (p<0.0001)
Morris AD, et al. Lancet. 1997;350(9090):1505-1510. Schectman JM, et al. Diabetes Care. 2002;25(6):10151021.
Adherence and Hospitalization
• Lau and Colleagues
– Studied data from administrative claims from a managed care
organization over 2 years
– 900 patients with age range 19-94
– 2.5 times more likely to be hospitalized
– Adherence groupings (p=0.01)
20
15
% of
10
5
0
5.2
4.1
100 (n=220)
11.9
10.3
99-80 (n=421) 79-60 (n=165)
MPR Grouping
59-40 (n=67)
14.8
2.5x increased risk of
hospitalization for
patients with diabetes
WHO. Adherence to Long-Term Therapies, Evidence for Action, 2003. DiMatteo MR. Med Care.
2004;42(3):200-209. Lau DT, et al. Diabetes Care. 2004;27(9):2149-2153.
Greater Adherence To Diabetes
Drugs Is Linked To Less
Hospital Use and Could Save
Nearly $5 Billion Annually
Change
US Population
Improving
adherence
Avoiding loss
of adherence
Total
Patients at
ED visits
Risk
Avoided
(millions)
<40 (n=27)
MPR = medication possession ratio.
Lau DT, et al. Diabetes Care. 2004;27(9):2149-2153.
Total
Inpatients Total Costs Total Costs Total Annual
Visits
of ED Visits of Inpatient
Economic
Avoided
($)
Visits ($)
Impact ($)
10.4
699,000
341,000
735 million
395 billion
3.9
383,000
277,000
403 million
321 billion
4.68 billion
3.61 billion
14.3
1,082,000
618,000
1.14 billion
7.16 billion
8.30 billion
4.3
290,000
141,000
377 million
1.84 billion
2.22 billion
1.6
162,000
116,000
208 million
1.50 billion
1.71 billion
Medicare Population
Improving
adherence
Avoiding loss
of adherence
Estimated Impact of
Improving Medication
Adherence in USA
5.9
452,000
257,000
585 million
3.34 million
3.93 billion
Jha A, et al. Health Aff (Millwood). 2012;31(8):1836-1846.
Adherence and Mortality
• Currie and Colleagues
– Studied data from The Health Improvement Network databased of
> 350 primary care practices in the UK
– 15,984 patients with type 2 diabetes age 50-76
– Clinic Non-attenders (1.16x increased mortality risk)
• Smokers, younger in age, higher A1c, higher morbidity (p<0.001)
– Medication nonadherence (1.58x increased mortality risk)
MULTIDIMENSIONAL
BARRIERS TO
MEDICATION ADHERENCE
• Women (p=0.001)
• Smokers (p=0.014)
• Higher A1c (p<0.001)
• Higher morbidity (p<0.001)
Osterberg L, et al. New Engl J Med, 2005;353(5):487-97. Currie CJ, et al. Diabetes Care. 2012;35(6):1279-1284.
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Patient Factors
• Low socioeconomic status
• Psychological (e.g.
knowledge, perceived
risk/benefit of treatment,
confidence, motivation,
alcohol/substance abuse,
or frustration)
• Cultural
• Low levels of education
• High stress levels
• Depression
• Physical (e.g. visual or
cognitive impairment,
limited mobility)
• Eating disorders
• Forgetfulness
WHO. Adherence to Long-Term Therapies, Evidence for Action, 2003. American College of Preventive
Medicine: Medication Adherence. http://www.acpm.org/?MedAdherTT_ClinRef. Delamater AM. Clinical
Diabetes. 2006;24(2):71-77.
Five Dimensions of Adherence
“Modifiable” Factors
Disease beliefs
56
24
.006
36
19
.03
Symptoms of diabetes are minimal
39
16
Don’t need diabetes medicines when sugar is normal
• Access to care
• Continuity of care
• Patient education
material not written
in plain language
• Restricted
formularies
53
17
25
.03
.003
.02
42
18
.001
Medicines are hard to take
74
18
.001
Other
46
25
.04
Little confidence in ability to control diabetes
48
18
.001
Diabetes interferes with social life
43
22
.01
Significant depressive symptoms
System
40
Worried about side-effects of medicines
Worried about addiction to medicines
Healthcare System
P Value
Consequences of diabetes are low
Medication beliefs
WHO. Adherence to Long-Term Therapies: Evidence for Action, 2003. American College of Preventive
Medicine: Medication Adherence. http://www.acpm.org/?MedAdherTT_ClinRef
% who are poorly
adherent if disagree
with belief
Have diabetes only when sugar is high
Have low control over diabetes
Condition
related factors
% who are poorly
adherent if agree
with belief
40
23
.03
Mann D, et al., J Behav Med. 2009;32(3):278-284.
Condition/Therapy Factors
Team
• Lack of empathy
• Lack of positive
reinforcement
• Disparity between beliefs
of provider and patient
• Relationship
• Communication skills
WHO. Adherence to Long-Term Therapies: Evidence for Action, 2003. American College of Preventive
Medicine: Medication Adherence. http://www.acpm.org/?MedAdherTT_ClinRef
• Duration of disease
• Frequent changes in
regimen
• Treatment requiring
mastery of technique
• Fear of needles
• Adverse effects
• Co-morbidities
• Lack of immediate
benefit
• Medications with social
stigma
• Concerns about longterm medication use
• Inconvenience
• Complexity of regimen
WHO. Adherence to Long-Term Therapies, Evidence for Action, 2003. American College of Preventive
Medicine: Medication Adherence. Delamater AM. Clinical Diabetes. 2006;24(2):71-77. National Council on
Patient Information and Education Enhancing Prescription Medicine Adherence, 2007.
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What is Health Literacy?
Impact of Dosing Frequency
• The degree to which people obtain, process, and
understand basic health information and services in order to
make appropriate health decision (Institute of Medicine)
Cultural and conceptual
knowledge
Overall
p<0.001
Oral literacy
Print literacy
Claxton AJ, et al. Clin Ther. 2001;23(8):1296-1310.
Economic/Social Factors
Economic
• Health insurance
• Medication cost
• Transportation
Social
• Limited English
proficiency
• Lack of family or social
support
• Listening
• Speaking
• Writing
• Numeracy
• Reading
Nielsen-Bohlman L. Health Literacy: A prescription to end confusion, 2004.
Health Literacy Proficiency of Adults
36% of the
population has
limited health
literacy
skills
90 million adults
lack the needed
health literacy skills
to effectively use the
health care system
• Unstable living conditions
• Web-based information
• Low health literacy
WHO. Adherence to Long-Term Therapies, Evidence for Action, 2003. American College of Preventive
Medicine: Medication Adherence.
What Does This Mean?
• The revocation by these Regulations of a saving on
the previous revocation of a provision does not affect
the operation of the saving in so far as it is not
specifically reproduced in these Regulations but
remains capable of having effect.
Statutory Instrument 1991 No 2680, The Public Works
Contracts Regulations 1991, Part 1, 2.4, page 4
Nielsen-Bohlman L. Health Literacy: A prescription to end confusion, 2004.
Why Care? With Diabetes…
• Drawing and measuring insulin with a syringe
• Identifying the correct dose on an insulin pen
• Working a glucometer
• Reading and comprehending blood sugars
• Reading education materials
• Calculating carbohydrates
• Calculating an insulin dose based on carbohydrates
• Understanding nutrition principles
• Understanding the role of exercise
• Medication adherence
• Taking medications appropriately
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Schillinger and Colleagues
• n=408
• 2 times more likely to have worse glycemic control
•
•
•
•
Diabetes
Self-Management
– A1c ≥ 9.5%(p=0.02)
ADA/EASD 2015 Guidelines cont’d
Dual Therapy
Metformin +
SU
Metformin +
TZD
Metformin +
DPP-4-I
Efficacy (↓A1C):
Hypoglycemia:
Weight:
Major side effect(s):
Costs:
high
moderate risk
gain
hypoglycemia
low
high
low risk
gain
edema, HF, fxs
high
intermediate
low risk
neutral
rare
high
Metformin +
SGLT2-i
intermediate
low risk
neutral
GUIs, DKA
high
Metformin +
GLP-1 RA
Metformin +
Insulin (basal)
high
low risk
loss
GI
high
highest
high risk
gain
hypoglycemia
variable
If needed to reach individualized A1C target after ~3 months, proceed to 3-drug combination
(order not meant to denote specific preference)
2 times more likely to have retinopathy (p=0.01)
3 times more likely to have cerebrovascular disease
2 times more likely to have nephropathy
2.5 times more likely to have a lower extremity
amputation
• 2 times more likely to have ischemic heart disease
Metformin +
SU+
Triple Therapy
or
TZD
DPP-4-i
or
SGLT2-i
or
Insulin
or GLP-1-RA
Combination
injectable therapy
Metformin +
TZD +
or
or
or
or
SU
DPP-4-i
SGLT2-i
GLP-1-RA
Insulin
Metformin +
DPP-4-I +
or
or
or
Metformin +
SGLT2-i +
SU
TZD
or
Insulin
or
SGLT2-i
Metformin +
GLP-1 RA +
SU
or
TZD
DPP-4-i
Insulin
or
or
SU
TZD
Insulin
Metformin +
Insulin (basal) +
TZD
DPP-4-i
or
SGLT2-i
or
GLP-1-RA
or
If A1C target not achieved after ~3 months of triple therapy and patient: (1) on oral combination, move to injectables,
(2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1 RA or mealtime insulin. In
refractory patients consider adding TZD or SGLT2-i.
Metformin + Basal Insulin + Mealtime insulin or GLP-1 RA
DPP-4-i = dipeptidyl-deptidase 4 inhibitor; SGLT2-i = sodium-glucose cotransporter 2 inhibitor; GLP-1 RA = glucagon-like
peptide-1 receptor agonists; GUI = genitourinary infections; DKA = diabetic ketoacidosis.
Adapted from American Diabetes Association. Diabetes Care. 2015;38(suppl 1):S41-S48. http://www.pdr.net/drugsummary/Farxiga-dapagliflozin-3427. Accessed December 26, 2015.
Schillinger D, et al. JAMA. 2002;288(4):475-482.
Currently Available Antidiabetic Medications
Class
Biguanide
PROFILE OF THERAPEUTIC
OPTIONS IN DIABETES
MANAGEMENT
Drugs
Metformin
SU
Glyburide
Glipizide
Glimepiride
TZD
Meglitinides
AGi
Advantages
Extensive experience,
no hypoglycemia, ↓
CVD events
Disadvantages
Cost
GI A/E, lactic
acidosis, B12
deficiency
Low
Extensive experience,
↓ microvascular risk
Hypoglycemia, ↑
weight
Low
Pioglitazone
Rosiglitazone
No hypoglycemia, +
effect of lipids with
pioglitazone
Low
Repaglinide
Nateglinide
↓ Post prandial
glucose excursions,
dosing flexibility
↑ weight,
edema/heart failure,
fractures,
rosiglitazone ↑ LDL
and MI risk
Acarbose
Miglitol
No hypoglycemia, ↓
post prandial glucose
excursions
Hypoglycemia, ↑
weight, frequent
dosing
Modest A1c lowering,
GI A/E, frequent
dosing
Moderate
Low to
Moderate
ADA. Standards of Medical Care in Diabetes – 2016. Diabetes Care 2016; 39(1):S1-S112.
ADA/EASD 2015 Guidelines
Healthy eating, weight control, increased
physical activity
Initial drug
monotherapy
Efficacy (↓A1C)
Hypoglycemia
Weight
Side effects
Costs
Currently Available Antidiabetic Medications (Cont’d)
Class
Drugs
Advantages
Disadvantages
Cost
DPP4-i
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin
Vildagliptin
No hypoglycemia,
well tolerated
Angioedema/urticarial and
other immune-mediated
effects, ? acute
pancreatitis, ? Heart failure
hospitalizations
High
Colesevelam
No hypoglycemia, ↓
LDL
Dopamine2 agonists
Bromocriptine
No hypoglycemia, ↓
? CVD events
SGLT-2i
Canagliflozin
Dapagliflozin
Empagliflozin
No hypoglycemia, ↓
weight,
↓ blood pressure
Metformin
high
low risk
neutral / loss
GI / lactic acidosis
low
If needed to reach individualized A1C target after ~3 months,
proceed to 2-drug combination (order not meant to denote specific preference)
Adapted from American Diabetes Association. Diabetes Care. 2015;38(suppl 1):S41-S48.
BAS
Modest A1c lowering,
constipation, ↑ drug
interactions, TG
Modest A1c lowering,
dizzy, syncope, nausea,
fatigue, rhinitis
GU infections, polyuria,
↑ volume depletion /
hypotension / dizziness, ↑
LDL, transient ↑ SCr
High
High
High
BAS = bile acid sequestrants.
ADA. Standards of Medical Care in Diabetes – 2016. Diabetes Care 2016; 39(1):S1-S112.
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Currently Available Antidiabetic Medications (Cont’d)
Class
Drugs
Advantages
Disadvantages
Cost
GLP-1
agonists
Exenatide
Exenatide ER
Liraglutide
Albiglutide
Dulaglutide
No hypoglycemia, ↓
weight,
↓ post prandial glucose
excursions, ↓ some
cardiovascular risk
factors
GI A/E, ↑ heart rate, ?
Acute pancreatitis, c-cell
hyperplasia/medullary
thyroid tumors in
animals, injectable
High
Amylin
mimetic
Pramlintide
↓ weight, ↓ post
prandial glucose
excursion
Modest A1c lowering, GI
A/E, hypoglycemia
unless insulin is
reduced, injectable
High
Insulins
Variable
Nearly universal
response, theoretically
unlimited efficacy, ↓
microvascular risk
Hypoglycemia, weight
gain, injectable, patient
reluctance
Variabl
e
William H. Polonsky, PhD, CDE
Associate Clinical Professor
University of California, San Diego
President
Behavioral Diabetes Institute
San Diego, CA
ADA. Standards of Medical Care in Diabetes – 2016. Diabetes Care 2016; 39(1):S1-S112.
Cost of Antidiabetic Medications
Low Cost
Moderate Cost
High Cost
Biguanides (metformin)
500 mg (Qty 100) $71
1000 mg (Qty 100) $145
OR $4 ($10) lists
Metglitinides (repaglinide)
0.5 mg (Qty 100) $333
1 mg (Qty 100) $366
2 mg (Qty 100) $366
DPP-4i (sitagliptin)
25 mg (Qty 90) $1308
50 mg (Qty 90) $1308
100 mg (Qty 30) $436
Sulfonylureas (glipizide)
5 mg (Qty 100) $35
10 mg (Qty 100) $62
OR $4 ($10) lists
AGi (acarbose)
25 mg (Qty 100) $112
50 mg (Qty 100) $121
100 mg (Qty 100) $145
SGLT-2i (canagliflozin)
100 mg (Qty 30) $436
300 mg (Qty 30) $436
TZD (pioglitazone)
15 mg (Qty 30) $210
30 mg (Qty 30) $321
45 mg (Qty 30) $348
Insulin
Relion: Novolin N, R,
70/30
$25/vial
Insulin
Novolin N, R, 70/30
$153/vial
Humulin N, R, 70/30
$46/vial
GLP-1 agonists (exenatide)
5-10 mcg (1 pen) $694
Amylin mimetics (pramlintide)
1500 mcg (1 pen) $447
Insulin
1 Vial: $85-$322
1 Pen: $89-$220
Objectives
• Describe the economic, clinical and humanistic impact of
poor medication adherence
• List multidimensional barriers affecting medication
adherence
• Review the profiles of therapeutic options and the
importance of appropriate medication selection
• Discuss the role of care teams in medication adherence
• Implement strategies to improve medication adherence
in patients with diabetes
ADA. Standards of Medical Care in Diabetes – 2016. Diabetes Care 2016; 39(1):S1-S112; Lexi-Comp
Patient Assistance Programs
www.needymeds.org
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Two Key Interventions
• Addressing problematic beliefs about medications
• Enhancing patient-provider trust
Case Study: Mr. Reynolds
• Age 59, divorced, self-employed CPA
• T2D for 12 yrs, BMI 34, last A1C 8.8%
• After discussion, he admits that he
often “forgets” his OHA’s and insulin;
sees no reason to worry about this
• Rarely checks BG’s (“no point to it”)
• Knows diabetes can harm him, but has
many other things to worry about that
seem more pressing.
Patient Medication Beliefs
Perceived Costs
Adverse effects
Concerns about long-term
adverse effects
Represents “sickness”
Perceived Benefits
Rarely apparent
HCP may state that longterm risks are reduced
To Encourage Mr. R to Take His
Medications, Where to Start?
• “Have you been feeling down, depressed or hopeless
over the past few weeks?”
• “Don’t you understand that poorly controlled diabetes can
be very harmful to your health?”
• “What do you think about the medications that have been
prescribed for you?
• “What could be done that might help you to remember to
take your medications?”
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Challenging Harmful Beliefs:
Three Messages for Our Patients
Challenging Harmful Beliefs:
Three Messages for Our Patients
1. Out-of-control diabetes can harm you, even if you
feel okay
2. Treatment should not be delayed
Case Example
Back on Track Feedback
Tests
Usual
Goals
Your
Results
Your score
should be
A1C
Blood
Pressure
Lipids
7.0% or less
8.7%
130/80
125/75
100 or less
116
3. Discuss the critical “medication secrets”
Critical Medication “Secrets”
Name: Molly B.
• Taking your medications is one of the most powerful things
you can do to positively affect your health
FID #:
SAFE:
At or better
than goal
1. Out-of-control diabetes can harm you, even if you
feel okay
2. Treatment should not be delayed
NOT SAFE:
Not yet at
goal
x
• Your medications are working even if you can’t feel it
• Needing more medication isn’t your fault
• More medication doesn’t mean you are sicker, less
medication doesn’t mean you are healthier
x
x
A Diabetes Quiz
ROY takes 2 different diabetes pills and insulin, and his last
A1C is 6.8%. SAM hasn’t been prescribed any diabetes
pills, and his last A1C was 9.1%. Both patients have had
diabetes for the same length of time.
Who is doing better with his diabetes?
________________________________________
A. ROY. How healthy you are, and your risk of
complications, is not determined by the type of treatment
or how many pills you take. It is your metabolic results
that matter.
Even if you are not taking pills or insulin, high blood
sugars will likely lead to future problems.
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Two Key Interventions
• Addressing problematic beliefs about medications
• Enhancing patient-provider trust
Communication and Refill Adherence
Prevalence of Poor Refill Adherence for Any Cardiometabolic Medication by Ratings
of Communication with Clinicians in a Cohort of 9377 DM Patients
Measure
Involved you in
decisionse
Mean Absolute Prevalence Rates
of Poor Refill Adherence,
% (95% CI)a
Lower
Ratingsc
Higher
Ratings4
Unadjusted Prevalence
Difference
% (95% CI)a
P Valuea
35(32 to 38)
27 (26 to 29)
8 (4 to 11)
<.001
Understood your
problems with
treatmente
38 (33 to 42)
27 (25 to 28)
11 (6 to 15)
<.001
Put your needs firstf
37 (33 to 41)
28 (27 to 30)
8 (4 to 13)
<.001
Confidence/trust in
PCPf
39 (34 to 44)
28 (27 to 29)
11 (6 to 16)
<.001
aWeighted to account for the survey design’s nonproportional sampling as well as survey nonresponse.
bAdjusted for patient characteristics (see article). cNever or sometimes. dUsually or always. eAdapted from
the Interpersonal Processes of Care Instrument. fAdapted from the Trust in Physicians Scale.
Ratanawongsa N, et al. JAMA Intern Med. 2013;173(3):210-218.
The KEY Message
What we have missed:
• In a significant number of cases, patients avoid or
quit medications because they are trying to be
healthy.
• Patients and HCPs have the same goal (and often
the same concerns) in mind, and we must take
advantage of that.
HCP-Patient Relationship
Consultation Variable
Trust in Physician Scale score
Continuity of care
UPC Index
Usual source of care
Length of care with same doctor
Importance of seeing same doctor
each visit
Enablement Index
Physician-patient concordance score
Unadjusted OR
(95% CI)
1.07 (1.02-1.12)
0.90 (0.97-1.01)
2.87 (0.86-9.60)
0.94 (0.74-1.19)
Adjusted* OR
(95% CI)
1.04 (0.99-1.10)
0.99 (0.97-1.02)
5.98 (1.88-19.03)
0.86 (0.68-1.09)
0.86 (0.56-1.30)
0.80 (0.51-1.25)
1.03 (0.99-1.08)
1.05 (0.98-1.12)
1.21 (1.05-1.39)
1.34 (1.04-1.72)
Kerse N, et al, Ann Fam Med. 2004;2(5):455-461.
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8/13/2016
What Does “Trust” Mean?
Thanks for Listening!
• To what extent do you think the doctor understands why
you came in today?
• How well do you think the doctor understood you today?
• To what extent did you and the doctor agree about the
main problem or need today?
• To what extent did you and the doctor agree about what to
do about the problem or need?
www.behavioraldiabetes.org
Post-test Question 1
Which of the following statements is TRUE regarding
patients with diabetes and medication adherence?
A. With poor adherence, patients are 4 times more likely to
be hospitalized due to diabetes
B. Improved adherence to diabetes medications could
save $5 billion annually
C. A 10% increase in adherence corresponds to a 0.05%
decrease in hemoglobin A1C
D. Poor adherence to diabetes medications increases
mortality risk by 2.5 times
Post-test Question 2
Please rate your ability to implement strategies to improve
medication adherence in patients with diabetes?
A. Excellent
B. Good
C. Fair
D. Poor
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8/13/2016
Post-test Question 3
A 57-year old woman with a 13 year history of T2DM visits you for
her first diabetes education session. She has been successfully
managed on metformin 1000mg/sitagliptin 50mg twice daily. In the
past year, her A1C has jumped to 10.3%. She has private insurance
and is the CFO of a large national bank. Six months ago, her PCP
started her on 20 units basal insulin + 5 units bolus insulin with each
meal. Her detailed blood sugar log shows a blood glucose range of
200-260 at all times of the day. A1C today is 10.6%. Which one of
the following multidimensional barriers is most likely contributing to
the patient’s poor glycemic control?
A. Social Factors
B. Healthcare System
C. Therapy Related Factors
D. Economic Factors
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