New Tool For Enhancing Medication Adherence in Diabetes

Poor drug adherence in patients with diabetes continues to plague clinicians, but new tools have been created to solve this problem by improving decision making. Physicians must change the nature of their conversations to ensure that the medication choices are consistent with the evidence as well as the values and preferences of patients.

Medication compliance in patients with diabetes has been a major barrier to achieving treatment goals in these individuals and has correlated with decreased benefits of medical care. When the cost of medications is not a factor, studies have shown that half of patients with diabetes still discontinue use of their drugs for the disease and other comorbid chronic conditions associated with it within 2 years. The burden of adherence significantly increases when cost of medication is a factor. “The impact of our advances in medical care and healthcare quality and delivery often become insignificant because so many patients lack access to or stop using potentially lifesaving medications,” says Victor M. Montori, MD, MSc. “Patients who understand the reasons behind their course of therapy are more likely to adhere to it. For that reason, physicians must change the nature of their conversations to ensure that the medication choices are consistent with the evidence as well as the values and preferences of patients.”

Dr. Montori and his colleagues initiated a patient-centered research program to positively impact drug adherence based on patients’ perspective of their health condition and treatments. They developed the Statin Choice decision aid, a quantitative, low-literacy tool that helps clinicians and patients discuss the importance of statin treatment and its potential risks and benefits in reducing coronary heart disease (CHD) risk over 10 years. “Many patients fail to associate medication adherence with a reduction in future risks of a heart attacks and strokes,” says Dr. Montori. “Typical physician-patient conversations focus on the disease and the role medication plays in lowering blood pressure and cholesterol, and controlling blood glucose. To an individual patient, however, these measurements are abstract numbers that do not seem to be relevant to their daily life. The Statin Choice decision aid is designed to help clinicians discuss the risks and benefits of treatment through the perspective of patients.”

In a study, Dr. Montori and colleagues evaluated the decision aid among 98 patients with diabetes. “Our results showed that short-term adherence in the intervention group increased by three-fold when compared with the control group,” explains Dr. Montori. “The decision aid helped improve patients’ accuracy in estimating their own CHD risk without medication and their risk reduction with statin therapy. Furthermore, it improved their overall knowledge about statins, which also assisted in their decisions to start, continue, or stop taking these agents.”

The Statin Choice Decision aid is a paper-based tool that includes four components  “The first component helps patients understand factors that were taken into consideration to estimate their 10-year CHD risk, the two most prominent factors being age and sex,” explains Dr. Montori. “The second component compares two illustrations, each comprised of 100 faces that are color coded to represent the proportion of people like the patient who will suffer a heart attack at any point during the next 10 years. One illustration shows how many individuals out of 100 people like the patient will and will not have coronary events in the next 10 years if they do not take statins; the other illustration represents the same information but among 100 people like the patient who decide to take statins.”

According to Dr. Montori, the visual representation of the potential benefits of statin therapy allows patients to better understand their risk of experiencing a coronary event without medication, as well as the portion of patients who will take medication needlessly. “This will produce different reactions from patients,” he adds. “Some will find the statistics encouraging, while others will find it disappointing. At that point in the discussion, if patients are still interested in pursuing statin therapy, the final two components explain the complications associated with the medication and determine the next move for patients. In our trial and practice, the entire discussion with the decision aid took about 3 minutes, on average.”

Physicians are constantly influenced by drug advertisements directed at them, quality-of-care parameters, and other pay-for-performance measurements, which indicate that all or a significant proportion of patients with diabetes must be prescribed statins. Pressure from marketing firms and the need to promote quality care combined with the ever-shrinking amount of time available in clinical visits can limit the opportunity physicians have to discuss important medication issues with patients. “The Statin Choice decision aid can open the lines of communication to encourage these critical discussions,” Dr. Montori says. “It provides a tangible intervention that may eventually gain support from quality-of-care organizations. Our hope is that physicians will eventually be provided with an incentive to use this tool and other similar tools rather than to simply prescribe a drug.”

Dr. Montori adds that more studies should assess means to better empower patients to feel well, do well, live long, and live out the life they want to lead without being overly burdened by their healthcare. “Using decision aids like Statin Choice can help clinicians develop a closer connection and deeper understanding of their patients’ preferences. It can also provide patients with a voice in their treatment.”

See this weeks Tools for Your Practice for a copy of The Statin Choice Decision aid

Weymiller AJ, Montori VM, Jones LA, Gafni A, et al. Helping patients with type 2 diabetes mellitus make treatment decisions: statin choice randomized trial. Arch Intern Med. May 28, 2007;167:1076-1082.

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FACT:

One-quarter of Americans 60 years and older had diabetes in 2007 and 3 million new diabetes cases in last two years:  Some 24 million Americans suffer from diabetes, an increase of more than three million in just the last two years, according to U.S. government figures.  New Data by the CDC showed that nearly eight percent of the U.S. population have the dreaded disease. About 57 million people are estimated to have ""pre-diabetes."" The CDC said that among diabetics, the number of respondents who did not know they had the disease declined from 30 percent to 25 percent compared to 2005. Diabetes is the seventh leading cause of death in the United States, claiming more than 200,000 lives a year. Although diabetes increased for all adults of both genders, the elderly were hit hardest. Rates of diagnosed diabetes were highest among Native Americans (16.5 percent), followed by African Americans (11.8 percent) and Hispanics (10.4 percent). For Asian Americans, the diabetes rate was 7.5 percent, while for whites it was 6.6 percent. 

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