Lo básico que el Médico debe saber para prescribir medicamentos
en forma SEGURA, EFICAZ Y EFICIENTE.
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lunes, 21 de enero de 2013
11. Verificación de la adherencia terapéutica
Antecedentes
El número de personas con enfermedades crónico-degenerativas como la diabetes o la hipertensión se ha incrementado en años recientes. Esto representa un grave problema de salud pública. El Gobierno del D.F., ha identificado que el manejo tradicional de los pacientes con estos padecimientos ha sido insuficiente para lograr un control adecuado y evitar las complicaciones, el desarrollo de otras enfermedades y la muerte prematura. Es por esto que ha creado el proyecto Adherencia Terapéutica en la Secretaría de Salud del Distrito Federal, que parte de un nuevo enfoque de atención, centrado en el paciente, donde la persona con diabetes o hipertensión se involucra de manera más activa en su tratamiento.
¿Qué es Adherencia Terapeútica?
Además de seguir las indicaciones médicas, se requieren una serie de cambios en los hábitos, en el estilo de vida, en los pensamientos y en las habilidades de la persona con diabetes o hipertensión para llevar de mejor manera el tratamiento y obtener como resultado una mejor calidad de vida. Eso es Adherencia Terapéutica.
La falta de Adherencia Terapéutica genera grandes pérdidas en lo personal, lo familiar y lo social:
En lo personal, la enfermedad produce complicaciones que traen consigo sufrimiento, limitaciones físicas progresivas e incontrolables.
En lo familiar, provoca crisis y problemas entre sus integrantes.
En lo social, implica enormes costos para las Instituciones de Salud.
Factores relacionados con la falta de adhesión terapéutica
Los factores que afectan la Adherencia Terapéutica se pueden dividir en tres grupos: los relacionados con el paciente; los propios de la enfermedad y los generados por el equipo de salud.
Factores relacionados con el paciente
Poco o ningún conocimiento acerca de la enfermedad y su tratamiento.
Ideas equivocadas relacionadas con la enfermedad o su tratamiento.
Actitudes negativas o molestia del paciente, o sus familiares, hacia el tratamiento.
Falta de habilidades, destrezas o práctica para involucrarse en su tratamiento.
Falta de apoyo familiar.
Problemas emocionales o de personalidad como: tristeza, angustia, enojo, apatía, evasión, etc.
Factores relacionados con la enfermedad
Estados emocionales (enojo, depresión o angustia, etc.) inducidos por la diabetes o la hipertensión.
Malestares físicos por los efectos secundarios de los medicamentos.
El paciente siente el tratamiento como muy demandante y complicado.
Factores relacionados con el equipo de salud
Excesiva carga de trabajo para médicos, enfermeras, trabajadores sociales, etc.
Falta de recursos como: medicamentos, análisis de laboratorio, etc.
Ideas equivocadas o desconocimiento acerca de lo que es Adherencia Terapéutica.
Actitudes negativas del personal que atiende al paciente.
¿En qué consiste el proyecto?
El Proyecto “Adherencia Terapéutica” de la Secretaría de Salud del D.F., contempla los factores de no adherencia y se propone apoyar a los habitantes del Distrito Federal que viven con diabetes y/o hipertensión. Mediante sesiones telefónicas se les proporciona educación para la salud, apoyo emocional y entrenamiento para mejorar sus habilidades sociales, de comunicación y autocuidado. El apoyo telefónico ayuda a disminuir la angustia que se presenta cuando se debe llevar un tratamiento complicado que no se comprende cabalmente. También se establece comunicación con los familiares para promover con ellos: el apoyo al paciente, una vida saludable para todos los miembros de la familia (alimentación, ejercicio etc.), y hábitos de prevención y autocuidado de la salud. El proyecto Adherencia Terapéutica está basado en un esquema de terapia breve, y diseñado para lograr las metas de tratamiento en corto tiempo, considerando siempre el propio ritmo del paciente. El orientador realiza una o dos llamadas por semana durante tres meses. Al terminar el proceso se da seguimiento por seis meses más.
¿Cómo me puedo inscribir?
Llame a Medicina a Distancia, Proyecto Adherencia Terapéutica al 51 32 09 09.
Results: 8 SEARCH STRING: adherence AND compliance AND definitions. JAN 2013
Temple University School of Medicine, Philadelphia, USA.
Abstract
Adherence is defined as the extent to which a patient's behavior coincides with medical or prescribed health advice. Adherence is considered non-judgmental and is preferred over the term "compliance," which carries negative connotations and suggests blame for the patient. A major challenge in the field of psychiatry has been to understand why patients may or may not adhere to medication and other treatment recommendations. A comprehensive review of the literature on medication adherence among patients with psychiatric illnesses was conducted with the following objectives: (1) to better understand the impact of medication nonadherence, (2) to identify risk factors for medication nonadherence, and (3) to study interventions designed to improve patientadherence. The authors initially searched the Ovid Medline electronic database using the key words "medication adherence" and "compliance" to identify all articles written in the English language published through early 2008. This produced over 2000 references. The search was then narrowed to publications specific to psychotropic medication. The ultimate goal of the review was to increase awareness of this critical issue and to discuss strategies that the psychiatric clinician can implement to address patientadherence to prescribed medications. The authors chose to include articles that were deemed to be clinically useful to the practicing clinician.Studies that have specifically investigated adherence to psychiatric medications vary in the definitions of adherence and methodology that were used, making interpretation of results across studies difficult. Psychoeducational interventions have long been the mainstay of treatment for adherence problems. However, there is growing evidence that other approaches such as cognitive-behavioral strategies and motivational interviewing may be effective. Based on a comprehensive literature review, the authors recommend the following strategies for addressing adherence problems: focus on strengthening the therapeutic alliance; devote time in treatment specifically to address medicationadherence; assess patients' motivation to take prescribed medications; and identify and address potential barriers to treatment adherence.
College of Nursing, Brigham Young University, Provo, Utah. janicehrobinson@gmail.com
Abstract
PURPOSE:
The implementation of patient-centered care (PCC) has been hampered by the lack of a clear definition and method of measurement. The purpose of this review is to identify the fundamental characteristics of PCC to clarify its definition, propose a method for measurement of PCC, and recommend effective PCC practices.
DATA SOURCES:
Review of literature related to PCC, adherence and communication from Cinahl, PubMed Academic Search Premier, and Cochrane Library databases.
CONCLUSIONS:
Research has shown that patient-centered interactions promote adherence and lead to improved health outcomes. The fundamental characteristics of PCC were identified as (a) patient involvement in care and (b) the individualization of patient care. The use of a numeric rating scale to measure the presence of these characteristics allows quantification from the patient perspective. Effective PCC practices were related to communication, shared decision making, and patient education.
IMPLICATIONS FOR PRACTICE:
PCC is a measure of the quality of health care. Understanding the characteristics of PCC facilitates its implementation and measurement. Promoting PCC activities will improve adherence and encourage patient responsibility for health status.
Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia. enquire@chspr.ubc.ca
Abstract
BACKGROUND:
Long-term utilization of prescription drugs for chronic conditions such as hypertension and/or hypercholesterolemia is a reality for millions of individuals, yet therapies may be discontinued before they can exert their beneficial effect. Several studies have measured the mean duration of therapy (ie, persistence) using administrative health databases. However, the terminology and methodology used for measuring persistence varied across studies, making it difficult to compare persistence rates.
OBJECTIVES:
The objectives of this study were to identify currently used measures of persistence and to propose a standard operational definition for use in administrative database analyses of drug utilization.
METHODS:
MEDLINE was searched for English-language articles published between January 1997 and June 2005 that quantified the concepts of persistence, adherence, compliance, or continuity with statin or antihypertensive therapy using administrative prescription claims databases. The conceptual and operational definitions of persistence used in the identified studies were categorized and applied to prescription-refill data for a hypothetical patient to compare the durations of persistence resulting from each method.
RESULTS:
Thirty-one articles were identified and reviewed. Few of the studies explicitly stated the conceptual definition of persistence used. Five methods of measuring persistence were identified: anniversary models, minimum-refills models, refill-sequence models, proportion-of-days-covered models, and hybrid models. When these models were applied to data for the hypothetical patient, total persistence with drug therapy ranged from 7 days to >1 year.
CONCLUSIONS:
There continue to be inconsistencies in the definition of persistence and the methods by which it is measured. A standard operational definition of persistence should be 2-dimensional, quantifying not only the total duration of therapy, but also the intensity of medication-taking within this interval.
Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Foundation, Fallon Community Health Plan, Worcester, MA 01605, USA. sandrade@meyersprimary.org
Abstract
PURPOSE:
Our aim was to perform a systematic review of the methods currently being used to assess adherence and persistence in pharmacoepidemiological and pharmacoeconomic studies using automated databases.
METHODS:
A MEDLINE search of English language literature was performed to identify studies published between January 1, 1980 and March 31, 2004 that evaluated adherence, compliance, persistence, switching, or discontinuations of medications using automated dispensing data (pharmacy records). Two study investigators independently reviewed the abstracts and articles to determine relevant studies according to specified criteria.
RESULTS:
A total of 136 articles met the criteria for evaluation. The types of measures of adherence and persistence commonly reported include the medication possession ratio and related measures of medication availability (77 studies), discontinuation/continuation (58 studies), switching (34 studies), medication gaps (13 studies), refill compliance (7 studies), and retentiveness/turbulence (4 studies). Specific issues considered include the assessment of exposed time to drug therapy and specification of the follow-up period.
CONCLUSIONS:
The terminology, definitions, and methods to determine adherence and persistence differ greatly in the published literature. The appropriateness and choice of the specific measure employed should be determined by the overall goals of the study, as well as the relative advantages and limitations of the measures.
University of Oulu, University Hospital, Department of Nursing and Health Administration, Finland. helvi.kyngas@oulu.fi
Abstract
Compliance has been studied from a wide range of scientific perspectives including medicine, nursing, psychology and health economics. There is no agreement regarding a commonly accepted definition. Lack of consistency in the definition and measurement of compliance is a major problem in research which becomes more complicated in an international study. The response to the confusion over the term compliance has been to suggest and use alternative terms such as adherence, co-operation, mutuality and therapeutic alliance. These terms are ill-defined and often are used as synonyms. The purpose of this paper is to analyse definitions of the concept of compliance. Abstracts from MEDLINE have been analysed in order to identify the types of compliance research that have been carried out.
Department of Sociology, Bloomington, Indiana University, Indianapolis, USA. klutfey@indiana.edu
Abstract
The purpose of this study is to evaluate existing research in the area of patient "compliance," to endorse reconceptualizing "compliance" in terms of "adherence," and to discuss the benefits of such a change for medical practitioners. This study critically reviews existing medical, nursing, and social scientific research in the area of patient "compliance." We assert that the literature reviewed is flawed in its focus on patientbehavior as the source of "noncompliance," and neglects the roles that practitioners, the American medical system, and patient-practitioner interaction play in medical definitions of "compliance." The term "compliance" suggests a restricted medical-centered model of behavior, while the alternative "adherence" implies that patients have more autonomy in defining and following their medical treatments. We suggest that while the change in terminology is minor, it reflects an important paradigmatic shift for thinking about the delivery of health care. By enabling practitioners to more accurately identify patients' social and economic constraints and to provide them with more efficient educational and financial resources, this type of change will improve patient care. In general, by moving to a more social paradigm for understanding patientbehavior, practitioners can expand the types of explanations, and therefore the types of solutions, they have for therapeuticadherence.
Department of Psychiatry, Rush-Presbyterian, St. Luke's Medical Center, Chicago, Ill 60612.
Abstract
Issues surrounding treatment compliance can be considered for a number of clinical situations. For clinicians, compliance usually means "the extent to which the patient takes the medications as prescribed." Instead of "compliance," it has been suggested that the term adherence be used, which puts more of a burden on the clinician to form a therapeutic alliance with the patient, which thereby increases behavioral complianceand possibly enhances the therapeutic effect of the medication administered. The trend toward placing more responsibility on the clinician to obtain compliance or adherence to the prescribed treatment has resulted in several strategies. These include explaining the illness and the rationale for the use of medication for its treatment, inquiring into the patient's hesitation and fears concerning medication, and using various educational approaches with the patient and the patient's significant other concerning possible side effects. Different clinical settings and situations also may modify the emphasis needed to maximize compliance. The situation of continuation and maintenance treatment may require a different treatment procedure for maximum success. The emphasis must vary quite a bit from the patient who improves and needs education to be convinced to continue maintenance treatment to the patient who has a treatment-resistant depression and needs close support and maintenance of hope to continue treatment that, up until the present, has not yielded positive results. Shifting the focus of compliance from thepatient to the skill of the clinician refocuses the issue from a patient variable back to the art and science of good medicine.(ABSTRACT TRUNCATED AT 250 WORDS)
Clinicians face nonadherence as the norm in everyday medical practice. The literature suggests a number of techniques that are likely to increase adherence when incorporated into regular clinical practices and routines. Central to these guidelines appears to be the doctor-patientrelationship. For instance, the physician who uses understandable language, encourages open doctor-patient exchange, fosters participation by patients in their own medical care, and creates a friendly and efficient environment should increase the likelihood of adherence. Clinicians can also check adherence to medication regimens by requesting patients to bring in their pill bottles (or other prescription containers) for a discussion on how the medication appears to be working for them. This should elicit information from the patient about problems related to medication adherence. Since patient variables and social support affect adherence behaviors, eliciting information from patients about their understanding and beliefs regarding their particular illness and treatment, as well as enlisting the support of family and friends, may encourageadherence. Identifying what individual patients perceive as obstacles in following treatment regimens decreases their likelihood of nonadherence; these are difficulties that can be negotiated during the medical interview. Individualizing the treatment and minimizing its complexity may provide the solution that encourages adherent behavior. Frequent reeducation, reinforcement, and encouragement, as well as training in self-management and self-monitoring, will at the very least maximize the patient's comprehension of the illness and his or her motivation foradherence--an especially important requisite for living with a chronic condition. Some patients may even wish to openly solicit family and friends for help in the management and monitoring of their illness and treatment, and to structure their environment to support adherence. Education programs for the patient featuring handouts and pamphlets that provide information about the illness in written and illustrated form have been used successfully. Education programs such as patient-oriented package inserts to accompany the medications and brief written summaries of complex treatment plans may also be useful. The purpose of such patient education adjuncts to illness and treatment lie in the hope that they will enhance the likelihood of following treatment recommendations. Through their use, the reason for the treatment and its potential effectiveness will, it is hoped, be better understood (Ley 1988). Overall, significant advances have been made in adherence research. Measurement systems have become more finely tuned, and the definitions and criteria for adherent behaviors are more clear and precise.(ABSTRACT TRUNCATED AT 400 WORDS)
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