İlaç Uyumu: Farklı Bir Halk Sağlığı Sorunu
Özet
Kronik hastalıklarda kanıta dayalı tedavilerin başarısız olmasındaki temel nedenlerden biri olan ilaç uyumsuzluğu; sosyal, ekonomik, hasta, tedavi, komorbid durumlar ve sağlık sistemi gibi beş farklı katmandan etkilenen karmaşık bir halk sağlığı sorunudur. Literatürde kompliyans, aderans ve konkordans gibi kavramlarla açıklanan bu durum, hastanın tedaviye kasti veya kasti olmayan nedenlerle uymamasını kapsar. Uyumsuzluğun arkasında unutkanlık, bilgi eksikliği, yan etkiler, düşük sağlık okuryazarlığı ve düşük öz yeterlik gibi hasta kaynaklı faktörlerin yanı sıra, hekimlerin yetersiz bilgi aktarımı ve çoklu ilaç kullanımlarından doğan yüksek katkı payı maliyetleri yer almaktadır. İlaç uyumunu ölçmek amacıyla doğrudan (biyolojik indeksler, denetimli dozlama) ve dolaylı (öz bildirim ölçekleri, eczane kayıtları, hap sayımı, elektronik monitörler) yöntemler kullanılsa da henüz tam bir altın standart bulunmamaktadır. Uzun süreli tedavilerde uyumu artırmak için basit müdahaleler yetersiz kalmakta; dozaj rejimlerinin basitleştirilmesi, elektronik sağlık kayıtlarının etkin kullanımı, mali teşvikler ve hekim-hasta arasında motivasyonel görüşmelere dayalı güçlü bir iletişim kurulması gerekmektedir. Her hastaya uyan tek bir strateji olmamakla birlikte, sağlık çalışanlarının farkındalığı ve teknolojik entegrasyon bu sorunun çözümünde kritik öneme sahiptir.
Medication nonadherence, one of the primary reasons for the failure of evidence-based treatments in chronic diseases, is a complex public health issue influenced by five distinct dimensions: social and economic, patient-related, therapy-related, comorbid conditions, and healthcare system factors. This phenomenon, explained in literature through concepts such as compliance, adherence, and concordance, encompasses both intentional and unintentional nonadherence. The underlying causes of nonadherence involve patient-related barriers like forgetfulness, lack of information, side effects, low health literacy, and low self-efficacy, alongside physician-related deficiencies in communication and financial constraints arising from out-of-pocket copayments for multiple medications. Although direct methods (biological indicators, directly observed therapy) and indirect methods (self-report scales, pharmacy refill records, pill counts, electronic monitors) are utilized to evaluate medication adherence, no single method is accepted as a gold standard. Simple interventions remain insufficient for long-term therapies; thus, enhancing adherence requires simplifying dosage regimens, leveraging electronic health records, utilizing financial incentives, and establishing strong provider-patient communication based on motivational interviewing. While a one-size-fits-all strategy does not exist, healthcare provider awareness and the integration of technological advancements into clinical care are highly critical to addressing this public health dilemma.
Referanslar
Sabaté E, Sabaté E. Adherence to long-term therapies: evidence for action. World Health Organization; 2003.
Osterberg L, Blaschke T. Adherence to medication. New England journal of medicine. 2005;353(5):487–97.
Sabaté E, Sabaté E. Adherence to long-term therapies: evidence for action. World Health Organization; 2003.
Benner JS, Glynn RJ, Mogun H, et al. Long-term persistence in use of statin therapy in elderly patients. Jama. 2002;288(4):455–61.
McCarthy R. The price you pay for the drug not taken. Business and health. 1998;16(10):27–8.
Cramer JA, Roy A, Burrell A, et al. Medication compliance and persistence: terminology and definitions. Value in health. 2008;11(1):44–7.
Jackevicius CA, Li P, Tu J v. Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction. Circulation. 2008;117(8):1028–36.
Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. Jama. 2007;297(2):177–86.
Cramer JA, Spilker B. Patient compliance in medical practice and clinical trials. 1991;
Haynes RB, Taylor DW, Sackett DL. Compliance in health care. 1979;
Literacy H. A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004.
Wilson FL, Racine E, Tekieli V, et al. Literacy, readability and cultural barriers: critical factors to consider when educating older African Americans about anticoagulation therapy. Journal of clinical nursing. 2003;12(2):275–82.
Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. Jama. 2002;288(19):2469–75.
Jerant AF, von Friederichs-Fitzwater MM, Moore M. Patients’ perceived barriers to active self-management of chronic conditions. Patient education and counseling. 2005;57(3):300–7.
Bayliss EA, Steiner JF, Fernald DH, et al. Descriptions of barriers to self-care by persons with comorbid chronic diseases. The Annals of Family Medicine. 2003;1(1):15–21.
Pound P, Britten N, Morgan M, et al. Resisting medicines: a synthesis of qualitative studies of medicine taking. Social science & medicine. 2005;61(1):133–55.
Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Archives of Internal Medicine. 2006;166(17):1855–62.
Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. Jama. 2007;298(1):61–9.
Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Archives of internal medicine. 2004;164(16):1749–55.
Piette JD, Heisler M, Krein S, et al. The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Archives of internal medicine. 2005;165(15):1749–55.
Doshi JA, Zhu J, Lee BY, et al. Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans. Circulation. 2009;119(3):390–7.
Soumerai SB, Pierre-Jacques M, Zhang F, et al. Cost-related medication nonadherence among elderly and disabled medicare beneficiaries: a national survey 1 year before the medicare drug benefit. Archives of Internal Medicine. 2006;166(17):1829–35.
Hsu J, Price M, Huang J, et al. Unintended consequences of caps on Medicare drug benefits. New England Journal of Medicine. 2006;354(22):2349–59.
Thorpe KE. Cost sharing, caps on benefits, and the chronically ill—a policy mismatch. Vol. 354, New England Journal of Medicine. Mass Medical Soc; 2006. p. 2385–6.
Maciejewski ML, Bryson CL, Perkins M, et al. Increasing copayments and adherence to diabetes, hypertension, and hyperlipidemic medications. The American journal of managed care. 2010;16(1):e20-34.
Heisler M, Choi H, Rosen AB, et al. Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis. Medical care. 2010;48(2):87.
Zeber JE. The effect of a medication copayment increase on veterans with schizophrenia. University of Michigan; 2004.
Chernew ME, Shah MR, Wegh A, et al. Impact of decreasing copayments on medication adherence within a disease management environment. Health affairs. 2008;27(1):103–12.
Choudhry NK, Fischer MA, Avorn J, et al. At Pitney Bowes, value-based insurance design cut copayments and increased drug adherence. Health affairs. 2010;29(11):1995–2001.
Volpp KG, Troxel AB, Pauly M v, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360:699–709.
Volpp KG, John LK, Troxel AB, et al. Financial incentive–based approaches for weight loss: a randomized trial. Jama. 2008;300(22):2631–7.
Alcoba M, Cuevas MJ, Perez-Simon M-R, et al. Assessment of adherence to triple antiretroviral treatment including indinavir: role of the determination of plasma levels of indinavir. Journal of acquired immune deficiency syndromes (1999). 2003;33(2):253–8.
Wagner JH, Justice AC, Chesney M, et al. Patient-and provider-reported adherence: toward a clinically useful approach to measuring antiretroviral adherence. Journal of clinical epidemiology. 2001;54(12):S91–8.
Corrigan P. How stigma interferes with mental health care. American psychologist. 2004;59(7):614.
Choo PW, Rand CS, Inui TS, et al. Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy. Medical care. 1999;846–57.
Steiner JF, Prochazka A v. The assessment of refill compliance using pharmacy records: methods, validity, and applications. Journal of clinical epidemiology. 1997;50(1):105–16.
Rosen MI, Rigsby MO, Salahi JT, et al. Electronic monitoring and counseling to improve medication adherence. Behaviour research and therapy. 2004;42(4):409–22.
McHorney CA. The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease. Current medical research and opinion. 2009;25(1):215–38.
Raebel MA, Ellis JL, Carroll NM, et al. Characteristics of patients with primary non-adherence to medications for hypertension, diabetes, and lipid disorders. Journal of general internal medicine. 2012;27(1):57–64.
Stroupe KT, Murray MD, Stump TE, et al. Association between medication supplies and healthcare costs in older adults from an urban healthcare system. Journal of the American Geriatrics Society. 2000;48(7):760–8.
Stroupe KT, Teal EY, Weiner M, et al. Health care and medication costs and use among older adults with heart failure. The American journal of medicine. 2004;116(7):443–50.
Yang M, Barner JC, Worchel J. Factors related to antipsychotic oversupply among central Texas veterans. Clinical therapeutics. 2007;29(6):1214–25.
Thorpe CT, Bryson CL, Maciejewski ML, et al. Medication acquisition and self-reported adherence in veterans with hypertension. Medical care. 2009;474–81.
Rudd P, Ahmed S, Zachary V, et al. Improved compliance measures: applications in an ambulatory hypertensive drug trial. Clinical Pharmacology & Therapeutics. 1990;48(6):676–85.
Kimmerling M, Wagner G, Ghosh-Dastidar B. Factors associated with accurate self-reported adherence to HIV antiretrovirals. International journal of STD & AIDS. 2003;14(4):281–4.
Waterhouse DM, Calzone KA, Mele C, et al. Adherence to oral tamoxifen: a comparison of patient self-report, pill counts, and microelectronic monitoring. Journal of Clinical Oncology. 1993;11(6):1189–97.
Bosworth HB. Enhancing Medication Adherence: The Public Health Dilemma [Internet]. Springer Healthcare Limited; 2014. Available from: https://books.google.com.tr/books?id=i2ogBAAAQBAJ
Gourevitch MN, Wasserman W, Panero MS, et al. Successful adherence to observed prophylaxis and treatment of tuberculosis among drug users in a methadone program. Journal of Addictive Diseases. 1996;15(1):93–104.
Volmink J, Garner P. Interventions for promoting adherence to tuberculosis management. The Cochrane database of systematic reviews. 2000;2000(4).
Vermeire EIJJ, Wens J, van Royen P, et al. Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Cochrane database of systematic reviews. 2005;(2).
Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database of systematic reviews. 2004;(3).
Schedlbauer A, Schroeder K, Fahey T. How can adherence to lipid-lowering medication be improved? A systematic review of randomized controlled trials. Family practice. 2007;24(4):380–7.
Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing adherence to prescribed medications. Cochrane Database Syst Rev. 2008;(2):Art-No.
Sleath B, Roter D, Chewning B, et al. Asking questions about medication: analysis of physician-patient interactions and physician perceptions. Medical care. 1999;37(11):1169–73.
Sleath B, Tulsky JA, Peck BM, et al. Provider-patient communication about antidepressants among veterans with mental health conditions. The American Journal of Geriatric Pharmacotherapy. 2007;5(1):9–17.
Miller WR, Rollnick S. Motivational interviewing: Preparing to change addictive behaviour. New York: Guilford. 1991;
