- [Narrator] The University of Michigan
Division of Gastroenterology
and the Inflammatory Bowel Disease Program
hosts the IBD Visiting Professor Lecture Series
in Ann Arbor, Michigan.
The series presents the latest in clinical research
and basic science from IBD experts from around the world.
- Thank you all for joining me this early in the morning.
We're gonna talk about the importance of being earnest,
the issue of adherence in IBD
and I think that anybody in the room who doesn't do IBD
can certainly take away some of these messages
for their own practices and adherence
in whatever field of medicine that they practice.
So, okay, good thing I don't have to worry
about Kaspersky viruses today.
All right, so we're gonna talk about adherence.
We're gonna talk about some general data
regarding non-adherence.
We're gonna talk about IBD specific non-adherence
and I'm gonna walk you through a story,
particularly in ulcerative colitis.
I'm gonna avoid Crohn's today, it just gets too muddy,
and I am going to use brand names
and the reason that I'm gonna do that is because
it does become important in terms of the FDA indications
for certain things and how you dose them.
So, when I can, I will use generic names,
but other times, it's appropriate for me to use brand names.
So I'll just tell you that up front.
We're gonna talk about the implications of non-adherence
and then, just, I'm gonna wrap up
with my most recent work that I just presented at DDW
looking at, another way to look at non-adherence.
So, back in 400 BC, Hippocrates said,
"The physician must not only be prepared
"to do what is right himself,
"but to make the patient cooperate."
So back then, we recognized the importance
of patients trying, of doing what they say
and it was two millennium later
that C. Everett Koop, our esteemed surgeon general,
said, "Drugs don't work in patients who don't take them."
So when it's, when I say it, it's,
well, you know, no kidding,
but when he says it, it's, you know, deep philosophy.
So I think that this is the bad outcome
that we're all trying to avoid in our patients
and we think that the way to do that
is to have them take their medicine.
So, for you in the audience, why should you care about this?
Why is Dr. Kane up here and why did I come this morning?
Well, it turns out that the
Office of Ongoing Professional Practice Evaluation,
or the OPPE, have initiatives that are being developed
to include patient outcomes and adherence
in credentialing, in board re-certification
and in career benchmarking.
So these are terms and philosophies
that are coming to a neighborhood near you
and so, even if you don't do IBD, if you do something else,
that you're gonna have to prove that you've, at least,
discussed with your patients adherence, how to improve it
and the consequences of non-adherence.
So the National Quality Forum also, the NQF,
is now deeply involved in IBD,
but back in 2005, the official report came out
and was published and two of the goals of that
were to improve medication adherence by creating standards
to change the way that healthcare professionals interact
with patients and to develop standard performance measures
that could be implemented in patient care settings
to improve adherence.
And in speaking with Arden Morris yesterday,
she's actually got an R01 grant to look at
how surgeons interact with patients
and their behaviors towards getting chemotherapy,
which I thought was really fascinating.
So the recommendations, these are very lofty goals,
so the recommendations right now
were that adherence needs to be evaluated like a vital sign.
So we know that, you know, now, pain is another vital sign,
but maybe adherence needs to be
or every time the patient is seen,
either the nurse or the doctor
or whoever the healthcare professional is is asking,
are you taking your medications?
And how do you ask that?
Well, it's are you taking it,
how are you taking it and what's your dose?
So, we know that adherence is complex and multifactorial.
This is a brilliant review by Dr. Osterberg
published in New England Journal a few years ago
and I'm not gonna go through
every one of these little facets of the diagram,
but just to show you how many areas
you can actually get involved with
and that any one of these spokes off this wheel
could be an entire career,
just looking at one of these aspects of adherence.
So we're not gonna go too deeply
into any one of those things, but suffice to say
that we do a smattering of all of those things.
So let's start with a definition.
What is adherence?
So adherence is actually made up of two components.
It's compliance, which is what we're all used
to thinking about, which is medication consumption
as instructed, and it's basically
the percentage of pills that you take.
So, that's what we think about when we talk
about our patients being compliant,
but you can be compliant today,
but are you compliant three weeks from now?
So that's the concept of persistence.
So, you could be compliant for two weeks,
anybody could take two pills twice a day
when they have acute sinusitis,
but what about three months from now
when now your ulcerative colitis is not active
and you're being asked to take these pills,
that's persistence.
So adherence is compliance plus persistence.
So there's a time factor in there.
And we measure adherence, historically,
by this medication possession ratio, or MPR,
and that takes into account
both of these aspects of adherence.
So, the challenges that we face in adherence
really come down to a couple of things.
So, we have to understand, first of all,
that our patients are not gonna take everything
that we prescribe and that they're gonna decide
what they're gonna take on any given basis,
so that maybe, we have to be strategic
in our counseling of non-adherence.
So, you can't afford XYZ drug today,
okay, well, it's more important that you take X.
If you have to skip Y, then, you know, then do that.
And be mindful that this is reality,
that we need to try to systematically minimize the number
and doses of pills that the patients are taking
and that we wanna try to promote the use
of beneficial therapies and reduce the use
of less beneficial ones.
So, you know, the patients come in with their long list
of the supplements that they are taking,
so they're on 12 supplements
and can't possibly take one medication
that you wanna give them because it's just too many pills,
but they're already taking 12 on their own.
And then, this concept of poly pills,
where there's two or three medications
in the same formulation.
So, for example, Pylera for H pylori
contains metronidazole and a PPI,
so maybe you can combine a couple of things together
and make it simpler.
And then, there's improving communication
between the healthcare providers and the patients,
which, ultimately, comes down to awareness
of the problem by healthcare providers
and we're gonna talk about this concept of interval empathy
and how that really becomes important,
as I show you the data and these repeating signals
in the data.
And then health literacy.
So you can be very educated,
but you look at a prescription bottle
and you can interpret it several different ways,
and I'm gonna show a very good example
of health literacy in patients.
So, I hope this projects okay.
This is taken directly, with permission from the authors,
from an article that just appeared a couple of months ago
in Archives of Internal Medicine.
So what the investigators did
was they took a cohort of patients who were elderly
who had multiple medical problems
and were given a theoretical regimen
of seven different medications
that were all appropriate for that cohort
and there on the far left is the regimen
that was recommended based on the combination
of all of these seven medications
and the times that you're supposed to take them.
Okay?
So, that the recommended regimen is four times a day
that you are taking some number of pills.
That was the easiest way that you could combine seven pills
and then what you did was they asked the patients
to look at the prescription bottles
and figure out how they were gonna take
their seven medications,
and then they just plotted how they were gonna do this.
And so, if you look at patient number one,
they interpreted it that they were gonna need
to take some pill eight times a day.
Patient number two said 10 times a day.
Patient three, 12 times a day
and then, the far end is patient number four
who had to take something 14 times a day.
So, these are all patients who have support at home,
have some, at least, level of eighth grade,
if not twelfth grade education,
and they just can't understand the instructions
on the bottles and they're ending up taking a medication
basically every hour that they're awake during the day.
So, health literacy is a big deal.
All right, so in terms of communication with our patients,
there's this concept of interval empathy,
where, that it's important that a healthcare provider
be interacting with a patient on a regular basis,
even when the patient is well,
just so that there's communication on a regular basis
so that patient feels plugged in or tucked in to the system
and that they feel like their doctor cares about them.
And I'm gonna show you why this might be important
and depending on what disease you're talking about,
this interval empathy may be on a weekly basis,
it may be on a monthly basis, it may be on an annual basis.
So that's something that needs to be negotiated,
but I'm gonna show you where I think interval empathy
is helpful in ulcerative colitis.