How Do We Define Adherence? Improving Adherence to TB Treatment Lillian Pirog, RN, PNP Nurse Manager, Waymon C. Lattimore Practice NJMS Global Tuberculosis Institute What is adherence? A. Taking medication consistently B. Keeping clinic appointments C. Reporting for DOT D. Meeting a minimum percent for medications taken What is adherence? Broad View of Adherence Adherence to treatment means that a patient is following the recommended course of treatment by taking all prescribed medications and coming for scheduled exams and tests. Recognizes that adherence is not only about taking medication Actively engages patients in health care and treatment Adherence (or patient-centered compliance) refers to the involvement of patients working with health care providers in managing their treatment ** Adherence is preferred to compliance it portrays a more respectful and active role of the patient in disease management** ** Bulletin of the World Health Organization, 2008. Vol. 86 (No. 3) 161-240 1
Problems With Adherence To TB Medication Are Common Reasons for Non-Adherence to HIV Medications Simply forgot or busy (66%) Non adherence to medications: 20% to 80% (avg. of 50%) Rates comparable to treatments for other chronic diseases Williams & Friedland, 1997; Chesney, 2000; Eldin, 2001. Away from home (57%) Change in daily routine (51%) Fell asleep (40%) Illness (28%) Depression (18%) Privacy concerns (14%) Side Effects (12%) Bamberger, 2000 Reasons for TB non-adherence What is the most common reason patients where you work do not take their medications: A. Patients feel better B. Lack of understanding of treatment regimen C. Access to care D. Language barriers E. Lack of motivation F. Other health problems Reasons for Non-Adherence Patients feel better Lack of knowledge or understanding of treatment regimen Personal or cultural beliefs Lack of skills or resources Lack of access to care Language barriers Poor relationships with health care provider(s) Lack of motivation 2
Responsibility The patient is responsible for his/her adherence? A. True B. False 2003 TB Treatment Guidelines The healthcare provider is responsible for successful treatment, not the patient Prescribing appropriate regimen Ensuring successful completion of therapy Focus on patient-centered care utilizing case management and directly observed therapy (DOT) Case Management System is patient focused and involves: Assignment of responsibility Systematic review of patient progress Adherence plan Continuity of care Case manager should ensure: Treatment plan is established Patient is educated Therapy and follow-up are continuous Contacts are examined Provider-Patient Relationship Provide accurate, current TB health information Anticipated side-effects and management When and how to contact provider Communicate goals of medical care Reasonable and acceptable for patient Small steps over time Put it all on the table (no hidden agendas) Consequences of failing to adhere Anticipate and address other medical or lifestyle issues Ask about non-medical issues Support mechanisms and advocates 3
Promoting Adherence Directly Observed Therapy (DOT) The microbe is nothing...the terrain everything -- Louis Pasteur Terrain = circumstances surrounding each pt that may affect ability to complete Tx Effective TB case management + DOT identifies and characterizes terrain Adherence can be facilitated by positive or negative attributes related to health system, social/family issues, personal factors and drug factors (e.g., medication sideeffects are negative drug attributes) ** Involves providing anti-tb drugs directly to patient and watching as patient swallows each dose Preferred strategy for all patients with TB Consider for all patients Should be used for all intermittent therapy Can lead to reductions in relapse and acquired drug resistance ** Bulletin of the World Health Organization, 2008. Vol. 86 (No. 3) 161-240 DOT Priority If you had to prioritize DOT for TB patients, who would be your highest priority: A. Patient with inactive, prior TB disease B. 6-year-old child on treatment for LTBI (no known source case) C. Adult contact to MDR-TB case with positive TST result and normal chest x-ray D. Patient with HIV and lymphatic TB Prioritizing for DOT Pulmonary TB with + sputum smears Past treatment failure Exposure to drug resistant case Case of relapse Co-infected with HIV Current or prior substance use issues, psychiatric illness, memory impairment Non-adherence to therapy Children and adolescents Close contacts of case of TB disease Immunocompromised MMWR, June 20,2003 4
Interventions for Adherence Many different types of interventions Can be tailored to address specific challenges patient may face Best approach is multi-level strategy that addresses: Patient Regimen Provider Meet Patients at Their Level Patient-Focused Interventions Individualize based on patient s knowledge, attitudes, and beliefs about TB Provide education and information Use interpreters, when possible Medication scheduling and cues (e.g., at meal times or when brushing teeth, etc.) Adherence gadgets (e.g., pill boxes, timers, etc.) 5
Regimen-Focused Interventions Manage side effects Reduce pill burden Dietary interventions Provide medication fact sheets Provide dosing instruction sheets Utilize tricks of the trade Peer support Pain management (e.g., parenteral administration) Tricks of the Trade 1 2 3 For babies & young children, pills can be crushed & dissolved in a teaspoon of water 4 This can then be mixed with a small amount of food such as apple sauce, mashed bananas, yogurt, etc. Provider-Focused Interventions Multi-disciplinary team with knowledge of TB management Adherence-related policies or protocols Prompt and frequent follow-up Medical advocacy Contracting between patient and provider Active patient role Progressive Interventions for Nonadherent Patients Advise patient on importance of adherence, consequences of failure to adhere, & possible implications (involuntary confinement) for nonadherence to TB treatment Learn the reasons for non-adherence Address identified problems of nonadherence (incentives, enablers) (DOT if not already on DOT) DOT agreement form Home isolation form Adherence Completion of OR treatment Voluntary orders Non-adherence Court-ordered DOT Adherence Completion of (optional) treatment Non-adherence Court-ordered involuntary isolation/confinement for inpatient treatment 6
Incentives & Enablers Incentives Small rewards given to patients to encourage them to adhere to treatment or keep appointments Enablers Things that make it possible or easier to receive treatment Both should be appropriate and valued by the patient Find sources of both (e.g., ALA, community groups, local stores, volunteers) Incentives Examples Enablers Washington State TB Services Manual Background (1) Case Study 32 y/o Ethiopian female diagnosed with pansensitive TB at a local hospital in NY Contact investigation identified 5 high-priority contacts residing in NJ One of the contacts is a 3 year old male 7
Background (2) Field visit made to family of the 3 year old contact Several attempts were made to have child skin tested Finally staff were able to arrange TST in field after clinic hours Background (3) TST results 5 positive, 1 negative 3 year old 12 mm CXR and medical evaluation 5 x-rays negative 3 year old male abnormal X-ray consistent with TB Background (4) 3 y/o seen by private pediatrician Diagnosed with suspected pulmonary/tb meningitis Treatment initiated with I, R, Z (DOT) Admitted to local hospital next day with c/o fever, cough, wt. loss, poor appetite, headache, stomach pain, listlessness, vomiting EMB added to existing regimen Cerebrospinal fluid smear negative Culture positive for M. tb Sensitive to R,I,P,E,S Background (5) MRI findings consistent with TB meningitis Gastric aspirate smear/culture negative Repeat CXR abnormal/no change Discharged from hospital and referred for outpatient care DOT initiated next day following hospital discharge 8
Concerns & Challenges Time & scheduling conflicts Language barrier Psychosocial aspects of TB diagnosis Difficulty administering medication Complaints of abdominal discomfort Spits out meds/sometimes vomits or gags Family member interference Attempted Resolution Arranged for DOT outside of regular clinic hours Solved scheduling conflict Arranged for father to be present for DOT Solved issues of language barriers Solved issues of interference from grandmother Used creative techniques to administer medication Peanut butter and grape juice Blow pops/magic tricks Twin brother pretended to be medicated also Outcomes to Date Using tricks of the trade was successful Patient playful/animated Completed one year of treatment with 100% DOT adherence Lessons Learned Importance of: Providing services outside clinic hours Reassuring parents that TB is treatable and curable The key to success Flexibility Patience Coordination Cooperation Persistence 9
Take-Home Points After this talk what change will you most likely implement: A. Use incentives/enablers B. Explore changing of dosing to patient convenience C. Implement case management system Individualize treatment plans to each patient s needs Recognize specific challenges of working with TB Use knowledge and tools to overcome challenges and to advocate for patients Carefully monitor for treatment failure even with DOT Explore opportunities to link with providers across disciplines to strengthen adherence support D. Change how DOT is implemented Other Summary Before. DOT + individualized case management + enablers/incentives = Best Treatment Results 10
After. 11