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… and solutions from experts
Diabetes is a silent disease-most of these patients feel fine, even if their sugar levels are dangerously high. Because they don’t feel ill, many diabetic patients aren’t motivated to change their lifestyles or follow prescribed medical treatment.
In fact, as few as 60% of patients with type 2 diabetes take prescribed medications, according to a study in the American Journal of Managed Care. Another study, in Diabetes Therapy, showed that less than 50% of diabetic patients achieve recommended glycemic goals.
Furthermore, direct risk reduction for diabetes-related kidney disease, stroke, heart disease, and amputation were estimated for 100% compliance with diabetes treatment, as reported in a study in Innovations in Pharmacy. Risk, case, and yearly cost reduction calculated for 100% compliance with diabetes treatment were 13.6%, 0.9 million, and $9.3 billion, respectively.
Given this, it’s obvious that adhering to treatment protocols can significantly benefit diabetes patients. So how can providers-who are ultimately responsible for motivating patients to improve compliance-achieve the goal of better compliance among diabetic patients? Here, experts offer solutions for some common noncompliance issues.
First and foremost, patients need to understand how the long-term implications of not taking care of their diabetes. “Educating patients and their families about what diabetes does to the body, and how medication counters those effects, is critical to inciting behavior change,” says Diana O’Keefe, RN, CDTC, CDE, clinical coordinator, Diabetes and Endocrine Institute, Morristown Medical Center, Morristown, New Jersey.
Serge Jabbour, MD, FACP, FACE, professor of medicine and director, Division of Endocrinology, Diabetes & Metabolic Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, believes discussing American Diabetes Association (ADA) guidelines in regard to HbA1c, lipids, and so forth with patients is important. “When patients learn that a national association recommends specific goals to achieve based on major studies, their compliance improves, especially when they hear that achieving target goals would lower complications regarding kidney disease, eye disease, nerve disease, heart attack, and stroke,” he says. In addition, providers can improve patient compliance by setting realistic goals and expectations. For example, when discussing weight loss, patients should be reminded that results are expected over months rather than days or weeks.
A focus on the individual patient is also imperative. “Providers need to understand who their patients are and the factors that may influence their compliance,” says Deena Adimoolam, MD, assistant professor of medicine, Endocrinology, Diabetes, and Bone Disease, at the Icahn School of Medicine at Mount Sinai, New York, New York. “These might include socio-economic limitations, educational background, cultural differences, and language barriers.” Treatment plans and goals should be tailored to patients based on their unique circumstances including their age, underlying medical conditions, and risk for hypoglycemia.
HendersonKristi Henderson, DNP, NP-BC, FAEN, chief telehealth and innovation officer, University of Mississippi Medical Center, Jackson, Mississippi, stresses the importance of using technology to interact with patients daily to encourage adherence to treatment plans. “Health coaches and nurses can provide education, motivation, and tools to empower patients to manage their health through text messaging, video chats, and electronic health sessions delivered on the phone, tablets, or computers so it is convenient and easy to access,” she says.
Poor health literacy is a major barrier to medication adherence, Adimoolam maintains. Health literacy is a patient's ability to accurately comprehend medical information, and can be limited due to one’s level of education or inability to understand a non-native language.
AdimoolamAdimoolam assesses a patient’s health literacy with a simple survey. Then, she tailors patients’ treatment plans and clinic visits accordingly (e.g., would a patient benefit from more frequent follow-up visits or the help of a diabetes educator?).
Open communication is key when patients aren't taking medications as recommended, says Adimoolam. Ask the patient directly why his or her control is suboptimal, she says. “Some barriers to medication adherence may include inability to pay for medications, lack of understanding on how to take them, and social stressors."
Alan M. Delamater, PhD, professor of pediatrics and psychology and the director of clinical psychology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, says research shows that patients who have good relationships with their doctors better adhere to therapy regimens. “Physicians should use active listening techniques and work with patients on goal setting,” he says.
Providers can underestimate the important role education takes in medication adherence. At the Diabetes and Endocrine Institute, each patient is educated about each medication’s mechanism of action in layman’s terms. “If patients understand the basics of why their doctor prescribed their medication, they’re more apt to take it as prescribed,” O’Keefe says.
DelameterThe same technology that helps patient adhere to their treatment plans can also be employed to send reminders and alerts to support medication adherence. “Our technology has daily health questions that the patient answers telling us why he or she isn’t taking a medication (e.g., ran out of it, needs a new prescription, has bad side effects), so we can intervene appropriately,” says Henderson, who has seen compliance rates as high as 96% using the technology.
Adherence rates for diet and exercise are even worse than for taking medications, with studies reporting less than 65% and less than 20% respectively. “It’s easy to just take a pill, but changing your diet and exercising are much more obtrusive,” Delamater says.
Again, communication is the key to convincing patients to make lifestyle changes. “Providers should ask patients what types of exercise they enjoy,” Adimoolam says. “If patients are unable to engage in physical activity, find out why and uncover these barriers. Some patients may have significant pain limiting their ability to exercise. These patients should have their pain evaluated and treated to allow for improved mobility and exercise. If they have chronic pain that is difficult to control, providers should look for alternative forms of exercise that may be associated with less pain, such as aqua aerobics.”
JabbourRegarding diet, providers need to be realistic with expectations, and suggest patients eat less of certain bad foods rather than eliminate them completely. “Allow the patient to take time to make changes. Slow change is better than no change,” Adimoolam says.
Jabbour advises referring patients to a dietitian or diabetes educator. “By attending diabetes education classes, patients will better understand the importance of diet and exercise in the management of their diabetes and overall health,” he says.
Group classes can be incredibly motivating because everyone in attendance talks about the same issues and has the same challenges, O’Keefe says. It’s motivating for people to be with others who are also managing their disease.
Adimoolam educates patients on the importance of self-monitoring of blood glucose to help them understand and control diabetes in order to prevent complications from the disease. She also educates them on the importance of self-monitoring blood glucose to identify emergency situations such as experiencing hypoglycemia, which can be fatal.
The ADA recommends that type 1 diabetics on multiple-dose insulin or insulin pump therapy monitor blood glucose at least before meals and snacks, occasionally postprandially, at bedtime, prior to exercise, after treating low blood glucose (until glucoses are normal), and prior to certain tasks such as driving. Not all type 2 diabetics require frequent self-monitoring; the frequency depends on the severity of the diabetes and treatment goals.
Adimoolam empowers patients to believe that by understanding their fingerstick readings they will be able to gauge how their body will respond to certain foods, situations (such as exercise or stress), and hypoglycemia. “When a patient understands their body, he or she can better predict what to expect in different scenarios,” she says.
Adimoolam explains to patients the reasons for needing to have regular visits. “The goal is to optimize their diabetes treatment in order to prevent complications,” she says. “The frequency of their appointments will be higher when their condition is poorly controlled. Once they are stable, we can decrease the frequency. That way, there is an end in sight.”
O’Keefe believes that check ups should offer multiple benefits. “We schedule visits to ensure that each patient is also able to meet with a diabetes educator, so they can get a better understanding of a medication or discharge instructions. By providing this added educational benefit, patients want to come back to learn more,” she says.
Diabetes is a complex disease. The key to compliance is education and open communication. “Providers need to listen to their patients to understand their struggles in not achieving optimal diabetes control,” Adimoolam says. “When they listen with an open mind, they can identify key issues that need to be addressed first. Medications aren’t always the answer.”
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.