Approaches to Patient Education: Emphasizing the Long-Term Value of Compliance and Persistence

Article Outline

• Abstract
• Goals of patient education to improve compliance
• Attributes of successful patient education initiatives
  • The Successful Educator
  • The Compliant Patient
  • The Healthcare Setting
• Barriers to effective patient education
• Does patient education work?
• Impact of monitoring and feedback on adherence
• Is self-management the future of patient education?
• Targeting interventions
• Summary
• References
• Copyright

Abstract 

Approximately 50% of patients with chronic disease do not obtain optimal clinical benefit from treatment because of poor compliance with medication regimens. Lack of compliance is associated with poor clinical outcomes, increased hospitalizations, lower quality of life, and higher overall healthcare costs. Although poor compliance and persistence are common across many disease states, they may be particularly poor in treatment for asymptomatic chronic diseases such as osteoporosis. Patient education has been demonstrated to significantly improve compliance with medication across a broad range of conditions and disease severities. In a study in which patients received educational materials, referral for bone densitometry, and physician consultation, 67% were compliant with treatment after 6 months. Patient satisfaction with treatment has been linked to compliance with therapy; by improving patient care through fulfilling expectations for physician visits and providing frequent feedback, the healthcare provider can dramatically improve compliance. Self-management programs focusing on day-to-day management of chronic diseases have been shown to significantly improve heath behaviors and health status. Regardless of the strategy used, attention must be directed to identifying the patients least likely to persist with treatment and to providing the education and support these patients need to adhere to osteoporosis therapy.

Keywords:  Bisphosphonates , Compliance , Patient education , Persistence , Self-management

The benefits of compliance and persistence with medication have been demonstrated across disease states. Among patients with osteoporosis, proper compliance with medication has been demonstrated to substantially reduce the risk of fracture. In 1 study, patients who were highly compliant with therapy—defined as having drug available to cover >80% of prescribed doses—had a 16% lower fracture rate compared with those who were less compliant with therapy.¹ This result may be an underestimate of the true impact of compliance with therapy because only prescription fulfillment, and not dose-taking, was assessed.²

The healthcare provider has a responsibility to implement interventional strategies to improve compliance with therapy. Many obstetricians/gynecologists and other primary care providers, including nurses and nurse practitioners, have long-term, trusting relationships with patients; this bond between the healthcare provider and the patient promotes communication and patient confidence in the recommendations made for the patient’s care. Therefore, the primary care provider is ideally placed to proactively convince patients to persist with medication and to monitor them long term to identify compliance and persistence issues. Such provider behaviors increase the likelihood of an optimal response to treatment.

To improve the probability of optimal outcomes among patients with osteoporosis, attention must be directed toward providing education about the disease state and the consequences of noncompliance. For agents with complicated dosing guidelines, such as bisphosphonates, patients must be taught to take their medication in accordance with instructions to reduce the likelihood of adverse effects. The primary care provider can play a role in all aspects of this patient education, promoting compliance with medication and thereby improving bone health.

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Goals of patient education to improve compliance 

Regardless of disease state or severity, the goals of patient education remain consistent. First, an educational effort should increase patient knowledge and clarify misconceptions about his or her medical condition, integrating information about the diagnosis, risk factors, consequences, treatments, and prognosis.³ Increasing knowledge and clarifying misconceptions are particularly important for patients with asymptomatic conditions (such as those with osteoporosis who have not yet experienced fracture) to highlight the urgent need for treatment and the consequences of poor compliance. Second, patients must understand the importance of each step that must be taken for the prevention of fracture—including lifestyle changes, medication management, and fall prevention. Patients must also understand how to implement each of these behaviors in accordance with healthcare provider instructions. Third, patients with existing fractures should learn strategies to manage both the physical and psychosocial burdens imposed by disability.⁴ Coming to terms with common psychosocial reactions to disability and deformity—anxiety, depression, and social isolation—may help the patient adapt to behavioral changes that may reduce risk of fracture.⁵

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Attributes of successful patient education initiatives 

Successful patient education initiatives require a number of important attributes on the part of the educator, the patient, and the healthcare setting.

The Successful Educator 

A patient educator must have a high degree of familiarity with the subject for a patient to get the most value out of an intervention. Among the most important factors in ensuring compliance with therapy are the extent to which patients’ expectations about the office visit are met, their satisfaction with the cordiality of the physician–patient relationship, and their understanding of the diagnosis and causes of their illness. In 1 of the few studies to examine patient satisfaction with physician–patient communication, only 42% of interactions resulted in a high degree of compliance with therapeutic recommendations.⁶ The rate of compliance was directly related to the patient’s overall satisfaction with his or her interaction with the healthcare provider (Table 1).⁶ Among patients who were highly dissatisfied with their visit, only 16.7% were highly compliant, although compliance was <54% even in patients who were highly satisfied. These data suggest that the building of a strong, long-term, trusting relationship with the primary care provider is necessary, but not sufficient, to improve compliance.

Table 1. Relation between patient satisfaction with interaction with healthcare provider and compliance with therapeutic recommendations

Reprinted with permission from N Engl J Med.⁶

The Compliant Patient 

Patients are more likely to persist with therapy if they feel that it can help avoid a negative health condition, such as fracture. As suggested by the Health Belief Model—a psychological model that attempts to explain and predict health behaviors—failure to begin therapy is frequently related to a lack of perceived benefit regarding the therapy or medication.⁷

In a recent study conducted in patients with osteopenia or osteoporosis, nearly half did not initiate therapy because they felt that treatment was unnecessary.⁸ In striking contrast, adverse effects and dosing complexity were the most important causes of discontinuations among patients who were already taking therapy; <2% of patients who discontinued established therapy did so because they believed therapy was not necessary or was no longer needed. These data suggest that different approaches must be taken within the compliance process: the initiation of therapy and the continuation of therapy may require different educational approaches.

The Healthcare Setting 

One context in which patient education may be conducted is that of patient support groups or educational meetings. An unthreatening atmosphere may encourage patients to share information, legitimize acceptance of support services, and give healthcare providers the opportunity to update groups on advances in management of osteoporosis. Such support groups may be community based or located in an osteoporosis center and staffed by a healthcare team. The Building Strength Together program—a network of osteoporosis support groups developed by the National Osteoporosis Foundation (NOF)—is an example of a support group that focuses solely on patients with osteoporosis.⁹

Support groups have a long history in patients with serious disease (e.g., cancer), and have been shown to improve several dimensions of health-related quality of life and to reduce depression and anxiety.¹⁰ The influence of support groups on bone health has not been formally tested.

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Barriers to effective patient education 

Illiteracy is perhaps the most substantial barrier to successful patient education initiatives. A 1995 study conducted at 2 public hospitals showed that 26% of patients could not read their appointment cards, 33% of English-speaking patients could not read basic health materials, and 42% of patients were unable to comprehend directions for taking medication on an empty stomach.¹¹ Overall, 35% of English-speaking patients and approximately 62% of Spanish-speaking patients had inadequate or marginal functional health literacy. Any patient education initiative—regardless of format—should take into account the varying abilities of patients to understand written and verbal instructions. In addition, education of elderly patients may be more challenging because they frequently require more medications, may suffer from cognitive deficits, and may have physical limitations (e.g., failing eyesight and hearing).¹², ¹³, ¹⁴ Furthermore, some elderly patients view their condition as hopeless and believe that nothing can be done to improve their fracture outcome.¹⁵

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Does patient education work? 

Patient education has been demonstrated to improve medication compliance and persistence across a broad range of conditions and disease severity and should be considered an integral part of any disease management program. A variety of programs integrating different approaches to patient education have been tested across disease states.

One educational program, conducted in 100 patients with rheumatoid arthritis treated with d-penicillamine, randomized patients to receive either no intervention or a patient education program that included information about the types of drugs used for rheumatoid arthritis, the disease process, physical exercise, joint protection, pain control, and coping strategies.¹⁶ Written information, including a patient information leaflet on d-penicillamine, was provided to both groups. Patient education was provided as part of 30-minute appointments conducted monthly by nurse practitioners over a 6-month period. Adherence was measured using a pharmacologic marker (phenobarbitone), which was encapsulated at a low dose with each dose of d-penicillamine; thus, measurement of phenobarbitone plasma levels correlated directly with the amount of d-penicillamine taken by the patient.

Patients randomized to the patient education group were substantially more compliant with treatment than were those of the control group. At 12 weeks, 86% of patients in the education group and 64% of those in the control group remained compliant with therapy (P = 0.01). At the end of the study, 85% and 55% of patients in the education and control groups, respectively, remained compliant (P = 0.01). Although patients in the education group were more likely to experience treatment-related adverse effects—perhaps as a result of greater compliance in this group—only 2 patients in this group withdrew as a result of side effects. In contrast, 12 patients in the control group withdrew because of side effects.¹⁶

Written information on the disease state and treatment—without personal attention on the part of the healthcare provider to other aspects of patient education—has little impact on rates of compliance and persistence with medication. Peveler and colleagues¹⁷ investigated the effectiveness of information leaflets combined with counseling in 250 patients starting treatment for depression with tricyclic antidepressants. Patients were randomized to 1 of 4 groups: usual care, receipt of an information leaflet, drug counseling, or both an information leaflet and drug counseling. The leaflet contained information about the drug and its adverse effects and what to do in the event of missing a dose. Drug counseling was provided by highly experienced nursing staff at weeks 2 and 8. Counseling consisted of education and advice about the importance of drug treatment, its potential side effects, and their management; the use of reminders and cues for therapy; the need for treatment continuation for up to 6 months; what to do in the event of missing a dose; depressive illness; and self-help and local resources.

A striking difference in compliance with medication was noted among the treatment groups at 12 weeks. A total of 63% of patients who received counseling remained on treatment, compared with only 39% of those who did not receive counseling. Treatment leaflets had no positive effect on persistence. Overall, there were no differences in treatment outcomes among the groups; however, when stratified by severity of depression, it was found that those patients with major depressive disorder who received dosages ≥75 mg/day, depression improved to a greater extent among those who received counseling than among those who did not.¹⁷

Although the this study suggests that minimal interventions are not useful in improving compliance, a study conducted by Schaffer and Tian¹⁸ shows that provision of written and audio educational materials—without further intervention on the part of the healthcare provider—may result in small, but significant, improvements in compliance. The study randomized patients with asthma to an experimental audiotape, a standard asthma management booklet, both tape and written materials, or no intervention. The 30-minute audiotape—“Bob’s Lung Story”—incorporated basic asthma facts, roles of medications, psychomotor skills related to therapy device use and self-monitoring, environmental control measures, and when and how to take rescue actions. After 6 months, compliance had increased by 15% to 19% in all 3 intervention groups and decreased by 22% in the nonintervention group. There were significant differences in pharmacy-verified compliance between the non-intervention and booklet group (P = 0.02) and between the nonintervention and tape plus booklet group (P = 0.04). Basic written or audio intervention strategies, if proved effective, have the advantage of minimizing the time and cost associated with 1-on-1 intervention with a healthcare provider.

Few studies have evaluated the impact of specific patient education on compliance and persistence with osteoporosis medication. In a study conducted by Cuddihy and colleagues,¹⁹ patients with forearm fracture received educational materials on osteoporosis, recommended calcium intake, and osteoporosis risk following fracture; a referral and appointment for bone densitometry testing; and consultation with a primary care physician. At baseline and after 6 months, participants were asked to complete a questionnaire regarding their experiences with these osteoporosis interventions and quality of life.

The rate of successful osteoporosis intervention following fracture was improved in this study, from 16% in the general population to 45% for the overall study population at 6 months. Among women who received treatment for osteoporosis, those newly advised to initiate therapy were less likely than those already taking medication (59% vs. 95%) to remain on treatment at 6 months. Interestingly, women with lower T-scores (<−1.5) had an 89% initial treatment rate, and 67% were compliant with treatment at 6 months; in contrast, 100% of women with borderline or normal T-scores (>−1.5) were compliant with treatment recommendations at follow-up.¹⁹ These data highlight the need for enhanced education initiatives among patients newly diagnosed with osteoporosis.

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Impact of monitoring and feedback on adherence 

Frequent monitoring and feedback may be the most effective strategies for improving medication adherence. In a study of elderly patients with hypertension, those who had their blood pressure checked regularly were more likely to adhere to medication than those who did not.²⁰ Because their blood pressure was monitored regularly, these patients were more aware of their irregularity and could see the effectiveness of the medications they were taking. Compliance with physician-recommended treatments for osteoporosis may be greater among women apprised of their fracture risk following bone densitometry testing. In a survey of women who received testing, those who reported that their bone density measurements were below normal were significantly more likely than women with normal results to begin the recommended preventive treatment (94% vs. 56%; P ≤0.01), to start hormone therapy (38% vs. 8%; P ≤0.01), and to take preventive measures to avoid falling (50% vs. 9%; P ≤0.01).²¹

Monitoring of bone turnover markers to provide patients with a measure of treatment success was evaluated in a recent study by Clowes and colleagues.²² A total of 75 patients with osteopenia were randomized to 1 of 3 treatment groups: no monitoring (usual care); nurse monitoring (a predefined interview consisting of 6 open questions without assessment of compliance); and marker monitoring (consisting of the nurse interview plus presentation of bone turnover marker test results with standard interpretation). Patients were treated for 1 year. Among patients who received nurse monitoring—with or without bone turnover monitoring—compliance increased 57% (P = 0.04) from baseline; in patients with no monitoring, compliance did not change. Persistence with therapy was 25% longer in monitored patients compared with those not receiving monitoring (P = 0.07); however, the addition of bone turnover monitoring did not affect compliance with therapy. It should be noted, however, that this study may not have been adequately powered to examine whether marker measurement improved compliance. Improved compliance was associated with a greater positive change in hip bone mineral density and a greater suppression of bone turnover markers.

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Is self-management the future of patient education? 

Self-management programs emphasize the central role of the patient in managing his or her own illness. These programs focus on helping patients with medical management, maintaining social roles, and managing negative emotions—such as fear and depression—that frequently accompany the limitations imposed by chronic illness. Self-management programs also offer the opportunity for patients to collaborate with healthcare providers in optimizing their care and provide a context in which patients can support each other.

To assess the impact of self-management programs in a real-world setting, Lorig and colleagues²³ enrolled patients with illnesses such as lung disease, heart disease, diabetes, and arthritis in a chronic disease self-management program. The program consisted of a series of 7 small classes (4 to 18 participants, 2.5 hours long) led by a pair of educators. Approximately 15% of classes were taught by professional leaders, 43% by peer leaders, and 42% by a combined team consisting of a healthcare professional and a peer. Class leaders followed a detailed manual to teach the program, which included 15 topics focusing on problem solving, decision making, and confidence building. The main outcome measures of the study were health behavior, the ability to deal with health problems, health status, and healthcare utilization, as assessed using a self-administered questionnaire.

Of the 613 patients who were enrolled in the study, 489 had complete baseline and follow-up data. After 1 year, patients who participated in the program had significantly improved health behaviors—range-of-motion exercise (P ≤0.001), cognitive symptom management (P ≤0.001), and communication with physicians (P ≤0.001)—and their confidence to deal with disease-related problems (i.e., self-efficacy) was significantly increased (P ≤0.001). Participants in the program had significantly fewer visits to the emergency room (P ≤0.05) and a slight reduction in outpatient visits.²³

A recently developed program, (Procter & Gamble Pharmaceuticals, Inc., Mason, Ohio) Choices for Better Bone Health, extends these techniques of disease self-management to patients with osteoporosis.²⁴ This community-based program is intended to motivate patients to comply with long-term health behaviors that improve bone health. It consists of 5 sessions, 2 to 3 hours each, conducted over a 5- to 10-week period. Each session includes both lecture and discussion, and participants are asked to engage in both individual and group work. Sessions are led by 2 facilitators; 1 drawn from the healthcare professions (e.g., physical or occupational therapist, social worker, or physician) and 1 a patient with osteoporosis. Detailed facilitator notes were developed to serve as guidelines for facilitators and to standardize sessions. A detailed description of session contents is presented in Table 2.²⁴

Table 2. Choices for Better Bone Health^⁎ session contents

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Targeting interventions 

In this age of limited healthcare resources, patients most at risk for poor compliance should be identified and targeted for intensive educational intervention and enrollment in self-management programs in order to focus resources on those most in need.

Cognitive deficits—in patients of any age—may affect compliance negatively.¹⁴ Patients who experience drug-related adverse effects are more likely to discontinue treatment. In 1 study, 66.7% of patients who discontinued haloperidol for Tourette syndrome did so because of side effects. Other patients who discontinued treatment did so becase of perceived ineffectiveness of treatment or fear of drug-related side effects.²⁵ Drug-related adverse effects are of particular concern among patients taking bisphosphonates because they have complicated dosing requirements; failure to follow these guidelines substantially increases the risk of gastrointestinal side effects.

Studies have also identified predictors of compliance. Patients who closely monitor their disorders and notice consistent improvement are more likely to be satisfied with treatment and remain compliant with medication. Understanding the purpose of a prescribed drug and how it must be taken also enhances adherence.²⁶ A simple medication regimen—one that fits into the patient’s daily routine—should have a positive effect on compliance. Increasing the number of medications affects compliance negatively.²⁷

Compliance is significantly better in patients who report having social support.²⁸ In a substudy of the Coronary Primary Prevention Trial, highly compliant men had strong support systems; a partner who believed in the benefits of treatment had a positive impact on patient compliance with therapy.²⁹

In addition to psychosocial considerations, the impact of financial constraints on medication compliance must be considered. Patients who do not have insurance may discontinue medication because of inability to pay. In a study conducted by Col and colleagues,³⁰ patients in the highest income categories were substantially more likely to comply with medication than those with lower incomes. Patients who have financial constraints are also less likely to fill their prescriptions or refill them on time.²⁰

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Summary 

Poor compliance and persistence with therapy are common across disease states, especially those that are asymptomatic; approximately 50% of all patients do not obtain optimum clinical benefits from treatment because of poor medication compliance. Patient education initiatives and self-management programs are among several of the mechanisms that can be used to improve patient adherence.

Randomized and real-world studies indicate that educational initiatives—particularly when conducted in the context of patient support groups led by healthcare providers or peers—have a positive impact on health behaviors. Although few studies have examined the impact of patient education in individuals with osteoporosis, the results of the studies summarized here suggest that, regardless of disease state, patient education programs can have a positive impact on patient behaviors. Programs that include direct contact with the healthcare provider appear to provide the most benefit in terms of improving health behaviors, including compliance and persistence with medication. Studies indicate that simple monitoring and feedback protocols—which can be easily integrated into current practice paradigms—may result in substantial improvements in compliance with therapy.²⁰

It is also clear that the quality of the patient–healthcare provider interaction is a critical factor in compliance and persistence with therapy. Obstetricians/gynecologists and other primary care providers—including nurses and nurse practitioners—may have a substantial positive impact on patients’ treatment by ensuring that they receive the necessary information and support to maximize compliance and persistence with therapy.

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