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Putting prevention into practice (Green Book)

Issues and strategies to address patient adherence

Lack of acceptance of GP advice and nonadherence are common in the clinical setting. Patients often need to be encouraged to manage their own health, including lifestyle, health related behaviour, and chronic diseases in conjunction with the GP. This helps the patient understand their health condition, be involved in decision making, follow agreed plans for health care, monitor symptoms, and manage the impact of the condition.

GP factors

Strategies that promote better patient adherence include134,135:

  • regular clarification and summarising of health information
  • the use of empathy and humour
  • the use of motivational interviewing techniques
  • being receptive to patient questions
  • listening to patient concerns
  • clear, concise and nonjudgmental advice.

A large number of preventive activities are not offered to the patient because the GP either forgets or is unaware that the activity is recommended. Systematic strategies can be introduced to reduce this risk, including:

  • using computerised prompts at the time of the consultation to identify whether a preventive activity is due and to recommend activities
  • reviewing the patient prevention questionnaire (completed by the patient in the waiting room) and/or the patient’s health summary sheet
  • setting up a regular review and monitoring system
  • scheduling regular appointments for review with support from the PN have a significant influence on patient adherence
  • establishing common ground with the patient
    • what are the patient’s main concerns?
    • what do they think the problem is?
    • what are their expectations of the prevention activity/treatment?

Intervention factors

Some treatments may only have a modest impact (eg. changing diet to lower cholesterol) or may require more than one agent (eg. a medication for hypertension until adequately titrated or second antihypertensive added). Other treatments are designed to have an effect on an outcome that is extremely uncommon. For example, in women aged 30 years, the risk of dying from coronary heart disease is two deaths per 100 000 women (at age 50 this rises to 51 deaths per 100 000 women). There is only small benefit in prescribing a statin for a 30 year old woman who has a cholesterol level of 6.5 mmol/L and no other risk factors. To prevent one coronary heart disease death per year, one would need to treat 100 000 women with this profile. This is known as the number needed to treat (NNT). Appendix 3 describes the rationale for NNT and how it is calculated.

Be realistic about the impact and check whether factors other than the patient are contributing to a less than expected outcome (eg. inadequate or ineffective treatment). Routinely ask about adherence. Ask about NNT to help you (and the patient) identify and determine the likely benefit of intervention.

Patient factors

Patients are less likely to adhere to treatment if they perceive that there is little or no benefit to them. Uncover what the patient feels about the problem behaviour and the impact on their health. Explain to the patient the behaviour and its consequences. Patients vary in their understanding of what is required of them and only remember 3–4 main things from a consultation. Patient understanding is facilitated by opportunities to ask questions, sufficient time to digest the information provided, simple messages and use of diagrams, and reinforcement and support.136,137

Check what the patient remembers and understands. Reinforce key messages by:

  • repetition and summary (especially at the end of the consultation)
  • keep the messages simple
  • give handouts, drawings and leaflets to aid understanding (these may be personalised)
  • reinforce behaviour
  • link adherence to routine activities (eg. cup of coffee at breakfast, cleaning teeth)
  • encourage the use of patient held records (eg. immunisation card, personal health summary).

Patient adherence varies with the condition being treated. While adherence may be consistent across different therapeutic regimens, it is useful to check adherence with each different therapeutic regimen. If adherence requires a change in the patient’s behaviour, remember that behaviour change requires three main ingredients 138:

  • concern over the current behaviour
  • belief that change will be associated with benefits
  • belief in the ability to change.

Patient beliefs and expectations about the treatment are a potent influence on their adherence. Patients may also react to the GP ‘checking up on them’. While they generally acknowledge that such enquiry is part of the clinical process to see if things are improving, such enquiry may generate sensitivity, especially when the patient’s health related behaviour has direct impact on the illness (eg. smokers and patients drinking at hazardous levels). Ask about their beliefs and expectations. Explain how the patient’s behaviour is related to their condition without victim blaming. Put adherence on the agenda for discussion. Identify and acknowledge patient’s concerns.

If adherence is difficult, then the patient is less likely to adhere. Simplify the regimen:

  • divide into incremental steps
  • link the activities required to daily routine or key events such as the patient’s birthday
  • set achievable goals
  • achievement of even small steps helps to sustain the patient through the process
  • tailor the intervention to the patient’s circumstances and abilities
  • identify significant antecedents and consequences (eg. high risk situations for slip ups with smoking)
  • provide feedback regarding the benefit achieved.

Consider whether now is the right time for the patient to consider change. The context and timing of behaviour change can play a significant role in either impeding or facilitating change. Support has a strong impact on adherence. Enlist support from significant others. Provide support to the patient by regular follow up visits or contact with the PN. Decision aids, computer decision support systems and patient education/information material can all help to prompt the GP or practice staff to provide various prevention activities, reinforce key messages or facilitate the decision making process.

The reality pyramid

Discuss with staff

  • Can you identify how supportive your practice infrastructure is to the provision of preventive care within the consultation?
  • Does your IT system prompt you about patients eligible for preventive activities?
  • Do you have ready access to appropriate decision aids and patient education materials?
  • Is there an opportunity for provision of counselling by a PN?