Conferencia dictada en el XVII Congreso Latinoamericano de Alergia, Asma e Inmunología, Cartagena, 2012

1. Adherence to Treatment
Adherencia al Tratamiento
Antje-Henriette Fink-Wagner, PhD
Executive Director
Global Allergy and Asthma Patient Platform GAAPP
Antje-Henriette Fink-Wagner, 2012 1

2. Statement of Interest
No conflict of interest!
Antje-Henriette Fink-Wagner, 2012 2

3. Content
or what you will take home from this presentation
– Status of Health Literacy as relevant issue to be adherent/
concordant
– Patient advocacy as 1st step to empower patients and to
increase adherence/concordance for better patient compliance
– Integral meaning and consequences of compliance
– Model of patient behavior
– Integration of all stakeholders to change patient behavior
Examples: – Physician – Family and friends
– Nurse – Policy Makers
– Pharmacist – Pharmaceutical industry
– Insurance/funds – Patient associations
– Conclusion
Antje-Henriette Fink-Wagner, 2012 3

4. Health Literacy
a precondition to achieve acceptable adherence/concordance
– Literacy and misunderstanding prescription drug labels.
Annals of Internal Medicine 2006 :
Take two tablets twice daily.
How many patients can follow this direction?
Antje-Henriette Fink-Wagner, 2012 4

5. Health Literacy
a precondition to achieve acceptable adherence/concordance
– Literacy and misunderstanding prescription drug labels.
Annals of Internal Medicine 2006 :
Take two tablets twice daily.
How many patients can follow this direction?
Only 34 % of patients were able to accurately follow this!
Antje-Henriette Fink-Wagner, 2012 5

6. Patient advocacy as 1st step to empower patients and
to increase adherence/concordance for better patient
compliance
– Advocacy empowers patients
– Empowered patients are more willing to feel responsible
for their therapy
– Patients who feel responsible want to understand
therapy opportunities, which means they request
education
– Educated patients are able to adhere to doctors‘ advice on
a level of concordance
– Concordance
will increase compliance
Patient advocacy will increase compliance
Antje-Henriette Fink-Wagner, 2012 6

7. Reality of non-compliance
Compliance is the main challenge for optimal treatment of
patients in general
Source: Antje-Henriette Fink-Wagner, 2012 7

8. Adherence to new medication:
Patients‘ problems with new medication
for chronic conditions
Still taking medication at 10 days Still taking medication at 4 weeks
(n = 226/239) (n = 171/197)
Adherent 159 (70%) 128 (75%)
Non-adherent
Partial non-adherence 67 (30%) 43 (25%)
Complete non-adherence 49 26
18 17
Source: N. Barber, J. Parsons, S. Clifford, R. Darracott, R. Horne; Qual Saf Health Care
2004; 13: 172-175, doi: 10.1136/ qshc.2003.005926 Antje-Henriette Fink-Wagner, 2012 8

9. Example
Compliance with and without help taking
medication in Hp eradication therapy
Source: F.A. Al-Eidan et al. J Clin Pharmacol 2002, 53, 163-171 Antje-Henriette Fink-Wagner, 2012 9

10. … without any problems?
Valerie uses her spray
twice daily –
without any relief!
Antje-Henriette Fink-Wagner, 2012 10

11. Model of patient behavior
Levendahl, et al. stated 1992:
Patients personal ideas These can be thought of
about their illness are often as the answers to five basic
organized around five questions about the illness
components: or health threat:
– Identity – What is it?
– Timeline – How long will it last?
– Cause – What causes it?
– Consequences – How will it/has it affected me?
– Control/cure – Can it be controlled or cured?
People form a mental model or representation of the illness,
which is made up of their answers to these questions.
Antje-Henriette Fink-Wagner, 2012 11

12. How can patient behavior be changed
Physician
Conclusion
Antje-Henriette Fink-Wagner, 2012 12

13. Physician
Motivational interviewing: Ask open questions in Physician
Patient friendly language
What changes would you most like to talk about?
What have you noticed about…….?
How important is it for you to change…?
How confident do you feel about changing…?
How do you see the benefits
BMJ 2010
Source:
Antje-Henriette Fink-Wagner, 2012 13

14. Physician
Motivational interviewing Physician
Develop Discrepancy
– How does current behavior
conflict with core values?
Minimize Unsolicited Advice
– Patients overcomes their own obstracles
– Dance not a wrestling match
Support Self-Efficacy
– Uncover and reinforce it
Usual Suspects
– Express empathy
– Good nonverbal listening skills
– Be a problem solving partners Antje-Henriette Fink-Wagner, 2012 14

15. Physician
Never forget the WRITTEN action plan! Physician
Red Zone: Stop! Danger!
Yellow Zone: Caution! Slow Down!
Green Zone: Go!
Antje-Henriette Fink-Wagner, 2012 15

16. How can patient behavior be changed
Nurse
Conclusion
Antje-Henriette Fink-Wagner, 2012 16

17. Example: Nurse Nurse
Phone Dialog
doctor – patient – nurse triangle
COPD case management
by National Jewish Medical
and Research Center
– Individualized by patient and physician
– Driven by action plans from physician
– Nurses handle calls based on
developed algorithms as kind of call center
– Inbound and outbound calls
through Case Manager (nurse)
– Physicians always notified
– Can be done every 12 or 24 hours and will be
less after few weeks
Antje-Henriette Fink-Wagner, 2012 17

18. Example: Nurse Nurse
National Jewish Medical and Research Center
COPD all plan members
12-month utilization data
1500 1383
Baseline
7 to 12 Months
p < 0.001
1000
756
582 -45.1%
500 -79.7% -58.9% 415
281 - 48.2% 239
164 -70.7% 245
127
48
0 Adult Days Missed ER Visits Hospitalizations Unscheduled Dr. Visits Oral Antibiotic Bursts
from Work
n = 272 n = 751 n = 751 n = 751 n = 746
Source: Data provided by David Tinkelman, vice president Health Initiatives NJC, December 2002 Antje-Henriette Fink-Wagner, 2012 18

19. How can patient behavior be changed
Pharmacist
Conclusion
Antje-Henriette Fink-Wagner, 2012 19

20. Example: Pharmacist Pharmacist
EFA Allergy Awareness Project 2011-2014:
Pharmacists are the first Health Care Professionals
seeing a patient on risk for allergies when asking for
OTC products.
Situation: People often “know” they have an allergy but
do not go for proper diagnosis.
Aim: Use pharmacists to motivate potential allergy
patients to visit a doctor for proper diagnosis and
therapy.
Pilot project planed in Austria and Germany to proof
positive role of pharmacists in 2013.
Antje-Henriette Fink-Wagner, 2012 20

21. Appetizer … Pharmacist
Voilà – Amuse gueule!
Antje-Henriette Fink-Wagner, 2012 21

22. How can patient behavior be changed
Insurance/
Funds
Conclusion
Antje-Henriette Fink-Wagner, 2012 22

23. Example: Insurance/Funds
Reminder service Insurance/
Funds
Reminder service for preventive measures
of members
– Dental prophylaxis
– Health check-up
– Cancer prophylaxis
– Preventive care for children and youths
– Smoking cessation
Telephone reminder or information by e-mail
as requested by the member
Source: Techniker Krankenkasse, 2005; www.tk-online.de Antje-Henriette Fink-Wagner, 2012 23

24. Example: Insurance/Funds
Diagnostic information for members Insurance/
Funds
– After online entry of a diagnosis (often provided in codes only),
a diagnosis text is displayed in patient friendly language
– including additional information, e.g. links to treatment guidelines
Source: Techniker Krankenkasse, www.tk-online.de, Januar 2005 Antje-Henriette Fink-Wagner, 2012 24

25. Insurance/Funds
The impact of co pay costs on non adherence Insurance/
Funds
Rates of cost-related non-adherence (black bars) by monthly out-of-pocket
inhaler costs in the Inhaler +/CPD+ group. There is a roughly linear increases in
cost –related non-adherence as the out-of-pocket costs of inhalers increases
(test for trend, P<.0001). Error bars represent SEM.
Source: Chest 2011 Antje-Henriette Fink-Wagner, 2012 25

26. How can patient behavior be changed
Family
and
Friends
Conclusion
Antje-Henriette Fink-Wagner, 2012 26

27. Example: Family and Friends
Smoking cessation
“Feel free to say no”,
an initiative of the European Union:
Testimonials presents the friends
of the target groups
Antje-Henriette Fink-Wagner, 2012 27

28. Memory function …
Family
and
Friends
Paul, hurry!
You have to be at
the doctor’s
at eleven …
Antje-Henriette Fink-Wagner, 2012 28

29. How can patient behavior be changed
Public/
Conclusion
Policy Makers
Antje-Henriette Fink-Wagner, 2012 29

30. Policy Makers
Health Literacy: a precondition to achieve acceptable
adherence/concordance
European Health Award October 2012 : Public
Policy Makers
• Survey of the HLS-EU CONSORTIUM
About 12% of
respondents
have inadequate general
health literacy, and more
than one third (35%)
problematic health
literacy, thus nearly
every second respondent
shows limited health
literacy,
in the general sample.
8000 respondents from
8 countries.
Source: HLS-EU CONSORTIUM (2012): COMPARATIVE REPORT OF HEALTH LITERACY IN EIGHT EU MEMBER STATES. THE EUROPEAN HEALTH LITERACY SURVEY HLS-EU , ONLINE PUBLICATION:
HTTP://WWW.HEALTH-LITERACY.EU
Antje-Henriette Fink-Wagner, 2012 30

31. Public
World Awareness days
Public
Policy Makers
Joint messages in as many countries
As possible
Creates awareness about a special
disease to patients, public and Policy Makers
Antje-Henriette Fink-Wagner, 2012 31

32. How can patient behavior be changed
Pharma-
ceutical
Industry Conclusion
Antje-Henriette Fink-Wagner, 2012 32

33. Example: Pharmaceutical Industry
ZacPac
Pharma-
History ceutical
3 packages to eradicate Hp: Industry
PPI plus two different antibiotics
(French triple therapy)
Compliance friendly solution
Development of ONE compliance-supporting
medication package for all three drugs
– Received the international award
Antje-Henriette Fink-Wagner, 2012 33

34. Example: Technical Industry
Helping Hand™
– Electronic tool offered
Pharma-
by Bang & Olufsen ceutical
– Reminds patients to take Industry
medication correctly
– Helps patients to feel secure on
level of compliance
– In use for 4 indications
(CNS, cardiovascular,
osteoporosis, immune suppression)
– Improves compliance from
45 – 80% and 95% of doctors
believe patients benefit from it
– Increased persistence
affects market shares
(according to B&O)
Antje-Henriette Fink-Wagner, 2012 34

35. How can patient behavior be changed
Patient
Associations
Conclusion
Antje-Henriette Fink-Wagner, 2012 35

36. Patient Association
European Federation of Allergy and Airways
Diseases Patient Associations EFA Patient
Associations
– 32 Member organizations in 22 countries
– EFA Respiratory Allergy Awareness Project:
– Raise awareness of respiratory allergies (Rhinoconjunctivitis and
Allergic Asthma Rhinitis, Asthma) as serious chronic disease
– Call for
– Early identification of symptoms by target audience
– Early diagnosis and appropriate strategies including life style changes
and physical activities to manage and control allergic diseases to
– Avoid exacerbations of severe allergies
Antje-Henriette Fink-Wagner, 2012 36

37. EFA Call to Action
– EU policy-makers are called to coordinate actions to
1) Increase the political recognition of respiratory allergies as a
real and serious disease
2) Promote national programmes on respiratory allergies
3) Prioritize the management and control of respiratory allergies
4) Promote training in allergy for healthcare professionals to
improve accurate and early diagnosis
5) Align healthcare and reimbursement policies, to support
appropriate disease management
6) Improve indoor air quality
Invitation to sign the EFA Call to Action:
http://www.efacallaction.net/sign.aspx Antje-Henriette Fink-Wagner, 2012

38. Patient Association
Global Allergy and Asthma Patient Platform
Patient
– 24 member organizations on all Associations
Continents
– Sport Games for children with asthma to promote
adherence to sport for asthmatics (see first talk of this
session)
Antje-Henriette Fink-Wagner, 2012 38

39. Conclusion
Adherence / Concordance will improve
as the sum of individual advocacy initiatives
by all allied healthcare professionals and the
patients themselves.
Antje-Henriette Fink-Wagner, 2012 39

40. Thank You!
COMPLY –
OR DIE
Antje-Henriette Fink-Wagner, 2012 40