How to improve medication adherence among dialysis patients

Editor's note: Medication compliance among ESRD patients is a concern for the entire renal care team. In the August issue of NN&I, Larry Krevolin, DO, and Justin Ilagan highlight obstacles for medication adherence among dialysis patients, and recommend steps nephrologists can take to improve compliance. Below, Krevolin and Ilagan explain what medications ESRD patients have the hardest time taking, and how the renal care team can address patient fears and help patients overcome adherence obstacles. -by Rebecca Zumoff

NN&I: In your own experience, are there any specific medications given to ESRD patients that you see the most compliance issues with?

Krevolin, Ilagan: In my experience, medications that most effect ESRD patients are within the phosphate binder families. Typically there are an inordinate number of pills patients have to take which can depend on brand. Aside from their chalky taste, it can cut into digestion and eating as well as having an influence on constipation. In addition, some anti-hypertensive drugs can influence libido, which in turn impacts a patients overall well-being as well as how they may perceive themselves.

NN&I: How can nephrologists address a patient's fear of side effects? Do you think prescribing physicians spend enough time explaining the medications they prescribe? Do you think warning about side effects can be counterproductive?

Krevolin, Ilagan: Nephrologists can effectively discuss side effects in a one on one setting in order to answer more personal questions a patient may have.

Unfortunately, as physicians we sometimes do not spend enough time explaining the medications patients are prescribed to. This can be due to a number of reasons; one being there is not enough time to go through every detail. If concerned, a patient should take time on their own, to research the prescription and look forward to specific answers being answered.

When dealing with medications, it can, at many time be difficult to elucidate benefits versus side effects. Side effects can be so enormous that at many times it may be counter productive to even prescribe them to patients. Furthermore, many times there is a lack of privacy typically within the dialysis unit, which can make it difficult for discussion of more in depth side effects the patient may not feel comfortable talking about in front of others.

NN&I: You mention illiteracy as an obstacle to medication adherence, how can this be addressed?

Krevolin, Ilagan: Literacy can be addressed by giving patients information about their medications in the most basic of terms. Solutions that may help bridge the gap can include explanations in different languages such as Spanish, Polish or whatever their native language so that it may improve their understanding. In addition, a major key is involvement of family members to assist in communicating the literature that may be more difficult for a patient to understand.

NN&I: In a 2003 report on medication adherence, the World Health Organization quoted a statement by Haynes et al that said “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.” How do you think this relates to ESRD?

Krevolin, Ilagan: One major aspect of medicine is the proactive treatment of disease before ESRD. It is always crucial information to know the history of the patient whether it is blood pressure, metabolic bone disease, number of hospitalizations and number of adverse complications patients have. Knowing alternate pieces of information regarding the patient’s health allows for a more effective treatment in attempting prevention of ESRD.

NN&I: Dori Schatell wrote a post on the Home Dialysis Central blog titled "Nephrology needs more compassion, not compliance." In it she says "Instead of insisting that people must 'comply,' offering understanding and compassion—and, most of all, HOPE that a good life is possible even with kidney failure—may go much, much further toward helping people take on the self-management role that is so vital to long-term success with chronic disease."

Do you agree with this general sentiment? Do you think more can be done to empower patients to better manage their health?

Krevolin, Ilagan: I agree with the statement in the sense that offering compassion and understanding will positively effect ones confidence of living life with kidney failure; however, that can only go so far. One effective strategy in addressing adherence to a patient is to show proof of others who have found success when having went through a similar case. It is one thing for a doctor to discuss or lecture a patient, but to have a patient share their success story goes far beyond the empathy doctors and nurses can offer. It is a very powerful tool to show living proof that people can do well with chronic disease.

NN&I: How important is a nephrologist's bedside manner in influencing patient compliance?

Krevolin, Ilagan: Nephrologists cannot be adversarial when it comes to compliance and treatment. It is of the utmost importance to be understanding of each patients lifestyles and make allowances for their specific lifestyle as it not only goes with medications but also treatments. Always a top priority of nephrologists is to attempt to find applicable solutions and ways of incorporating treatment of patients without significantly altering their lifestyle.

NN&I: Can nephrologists use the care team, like nurses and social workers, to improve medication adherence?

Krevolin, Ilagan: Absolutely. One of the many studies that support this claim is a DOPPS study that demonstrates patients willingness to comply more often when patient care technicians and dieticians are integrated into the team of improving a patients health.

Tactics for increasing adherence in ESRD patients

These recommendations come from Dr. Krevolin and Mr. Mr. Ilagan's article "Improving medication compliance among ESRD patients."

In essence, clinicians can merge efficiency and the knowledge of the above factors into routine patient visits with- out greatly adding to the amount of time spent with each patient. To help reduce the likelihood of non-adherence, the dialysis team should address matters concerning adherence at the time for writing prescriptions or reviewing forthcoming lifestyle alterations and appointments. Give realistic short-term goals for the patient to achieve and feel more motivated.

Other steps can include:

Provide solid communication and bedside manner to develop trust. Clinicians should recognize positive traits that the patient has, and utilize it for their benefit in getting healthy. Furthermore, address fallacies concerning the illness, side effects of each medication, and fortify positive beliefs about treatment.

Apply motivational interviewing techniques where possible. This gives the patient a sense of empowerment and responsibility to get better. Moreover, it assists in illustrating value of consistently adhering to medication regimens.

Identify and address general barriers to adherence. Formal valuation of broad barriers do not need to be conducted with every patient; however, the caregiver should evaluate suspected cognitive deficiency with a mental status investigation and question psychopathology, including mood, coping, sleep, and appetite disturbance. Caregivers should always assess inspiration for treatment by asking why they want to undergo treatment, while encouraging them to have personal as well as medical reasons for treatment.

Urge the patient to acquire community support for treatment. When making lifestyle changes, family and friends can aid with praise and motivation during the action stage, and with stimulus control and reinforcement during the maintenance stage.

Search for support groups for others making similar changes (i.e., Alcoholics Anonymous), as they can be helpful in reinforcing positive health motivations and activities, and in providing good role models.

Frequent follow-up can be helpful—phone calls, letters, or e-mail from nurses or other clinic staff can advance adherence considerably by responding to patient questions, supervising and addressing patient-initiated cessation of treatment, and reinforcing motivation for persistent engagement in medical treatment or lifestyle change.

About Larry Krevolin, DO, and Justin Ilagan

Dr. Krevolin is a nephrologist with Clinical Nephrology Associates in Philadelphia. Mr. Ilagan is an undergraduate student at the University of South Florida at St. Petersburg.