Commentary: Integrating Lessons from Evidence-based Assessment of Adherence into Clinical Practice

Abstract

In the past two decades, our appreciation of the complexity of disease management behavior has increased, and the methods now available to assess adherence behavior have advanced accordingly. Multiple methods are now implemented in research settings, including electronic monitoring devices, well-validated interviews, and procedures that allow real-time data collection of adherence behavior. Quittner and colleagues (Quittner, in press; Modi, Lemanek, Ieverse-Landis, & Rapoff, 2007) provide a comprehensive overview of the most current methods available to measure adherence behavior, and offer a compelling list of recommendations for future instrument development and research on adherence assessment. Reviewing the available methods not only provides us with a useful framework for approaching scientific inquiry in this area, but also naturally raises some larger issues in how health care professionals understand and use information regarding patients’ adherence to medical regimens. One practical limitation of measuring adherence behavior with state of the art methods is that the strategies that yield the most comprehensive picture of disease management behavior are generally also the most expensive and time-consuming, and may additionally require sophisticated data management procedures. This introduces substantial barriers for implementing these approaches into routine clinical care, where adherence assessment may be needed the most. Our colleagues in their busy primary care practice settings and emergency departments could benefit from a simpler, more targeted approach. What they want may not be possible—we know that you cannot capture the complexity of adherence behavior, particularly to complicated regimens, by asking a few quick questions or by ordering a simple blood test. There is no easy solution for nonadherence, and there is no simple measurement method to capture adherence behavior. Our increasing knowledge of findings from the growing body of adherence research does enable us to share perspectives that may have direct benefit for those on the front line in health care settings. First, expect that many patients will not adhere to treatment recommendations (Matsui, 2000), and that their report of how well they are following your instructions is likely to be “enhanced.” Research has consistently demonstrated that self-reports of adherence are inflated when compared to objective methods of monitoring (Riekert & Rand, 2002). As a result, reports of nonadherence are more likely to be accurate than reports of adherence. Second, be clear in your recommendations for disease management. Research on provider communication suggests that information provided to families is often inadequate, and as a result comprehension may be compromised (see DiMatteo, 2000, for a review). If families have difficulty understanding your directions, can they be following through on your treatment plan? As Quittner and colleagues point out, the increasing use of electronic medical records may provide an opportunity to systematize treatment plans, and in doing so provide clear written recommendations for families. Third, if you only have time for a few questions, consider reviewing issues and circumstances that are likely to arise and impede adherence. A further frontier in the measurement of adherence may be the development of practical methods and brief strategies to assess disease management behavior in clinical settings. With our increased understanding of the best practices to measure the complexity of adherence, we are beginning to develop “gold-standard” approaches against which briefer screening tools may be compared. Utilizing these sophisticated paradigms, in combination with briefer self-report instruments, may allow us to develop screening instruments to be used in clinical practice when more intensive, time-consuming approaches are not feasible. For example, it would be useful to determine a brief set of questions that could be used to identify families having significant adherence problems, or those at risk for deterioration of disease management. Implementation of well-validated screening tools for broad use in clinical practice will serve two useful functions, (a) it will raise the issues of adherence to the health care team in a more systematic manner, and (b) it will help identify families in most need of more intensive assessment and intervention. Through enhancing the health care team's awareness of typical barriers to adherence, the extent of nonadherence, and the need to address poor adherence as a multi-faceted clinical problem, we are likely to improve the overall care provided to all children and families. Conflict of interest: None declared.