Methods to Improve Adherence

The significant health and economic impact of nonadherence have resulted in numerous interventions to increase patient adherence to treatment. These interventions are based on psychological theories of adherence, which include cognitive strategies (involving what the patient knows about the disease and treatment), behavioral strategies (involving reminders and rewards to influence medication-taking behavior), and social support (involving family and friends to help or hinder adherence). One example of applying these theories of adherence to construct an adherence promotion intervention can be shown through a study performed by Hoy. In this study, the adherence rates of patients receiving standard support were compared to that of patients receiving intensive support. Standard support consisted of a full explanation of the need for and benefits of the therapy (cognitive strategy). Intensive support consisted of providing initial education of the therapy in the patient’s home (cognitive strategy) with the involvement of the patient’s partner, convincing the partner of the need for the therapy and the importance of its continued use (social support). The therapy used in the study was continuous positive airway pressure (CPAP), a nocturnal-mask treatment for continuous use during sleep to alleviate the symptoms of patients diagnosed with obstructive sleep apnea.

In particular, we know that patients should be provided adequate education and support at the start of CPAP treatment. Recognizing the importance of this CPAP adherence information, the Veterans Health Administration has recently required that all CPAP machines distributed to its patients be equipped with these adherence monitors. In addition to evaluation of adherence-promoting interventions, electronic monitoring has allowed researchers to gain more insight on patient adherence, particularly in day-to-day variability and general patterns of adherence in chronic respiratory diseases such as asthma and obstructive sleep apnea.

The machines used for therapy record when the circuit is pressurized, i.e. when the machine is turned on and the patient is wearing the mask. Adherence rates were defined as the average nightly hours’ use of the therapy. Results showed that adherence rates were significantly higher in the intensive support group compared to the standard support group (5.4 ± 0.3 hours/night versus 3.9 ± 0.4 hours/night, p= 0.003). Evaluating successful and economical interventions, such as that described, can result in the integration of intervention and clinical practice, which may lead to increased adherence and positive health outcomes. The identification of these patterns may lead to a better assessment and understanding of adherence, perhaps allowing the intervention to be tailored toward a particular pattern to optimize the degree of improvement in adherence (i.e. a partially adherence patient might need less reinforcement to achieve sufficient adherence compared to a poorly adherent patient). Unfortunately, no studies of intervention evaluation or adherence pattern identification have been performed using objective adherence data for LTOT since there is no established method for objectively monitoring its adherence.