Section 4. Challenges to Adherence
Even when patients are motivated to succeed, a number of barriers or challenges—many beyond the control of the patient or HCP—may negatively affect adherence (see Tool 5).
4.1. Assessing Patient Adherence
There is a lack of validated tools to assess patient adherence with medications, especially in oncology. One relatively simple tool that has been validated for patient adherence to medications for chronic conditions (Hahn et al., 2008) and can be self-administered by patients is the ASK®-20 survey.
ASK-20 is a valid and reliable self-administered survey for patients that can identify 20 specific barriers to medication adherence across a spectrum of chronic diseases. It has not been validated in the setting of oral cancer therapies. Use of this survey can help identify barriers and assist nurses with addressing barriers and provide direction for nurses when interviewing patients about their baseline and ongoing adherence. A shorter version, the ASK-12 survey, has been validated in patients with asthma, diabetes, and congestive heart failure but, again, has not been validated in patients with cancer (Matza et al., 2009).
4.2. Monitoring Adherence
Physicians and advanced practice nurses prescribe oral agents for patients with cancer, but the decision about who will monitor and follow the patient for adherence to therapy often remains unclear. Patients should be seen at least once per cycle for a physical assessment and laboratory tests. At that time, HCPs can address questions about adherence with the patient. Between clinic visits, HCPs can use the telephone and e-mail (if the practice permits electronic communication) to check in on patients.
Oral therapy requires a multidisciplinary team for optimal safety and adherence: The physician, nurse, and pharmacist jointly can provide oversight for patients on home-based oral therapies. Nurses have always been key players in teaching patients about IV chemotherapy; however, many nurse clinicians feel less involved in oral chemotherapy teaching. Nurses are patient advocates and should participate in adherence monitoring as part of the multidisciplinary team during the continuum of therapy to increase adherence, promote safety, and evaluate side effects (Winkeljohn, 2007).
Suggest a structured plan of care for these patients during the next patient care meeting. This should include the following:
- Assess and monitor adherence at each visit.
- Ask about missed doses.
- Assess for problems.
- Work toward resolution of problem or problems.
- Use telephone contact to monitor adherence of patients who visit the clinic less regularly, such as those receiving adjuvant long-term hormonal therapy or maintenance dosing.
- Manage side effects early.
4.3. Methods for Monitoring Adherence
Few randomized controlled trials have been conducted to identify a single adherence monitoring method that is superior to others. Most of the methods currently available (see Tool 6) are unreliable; for example, patient self-reports tend to overestimate adherence. Further research is still required to optimize adherence in this patient population. A meta-analysis of 61 studies of interventions to improve medication adherence demonstrated a relatively low increase in adherence of 4%–11% (Peterson, Takiya, & Finley, 2003). The investigators also concluded that no single strategy appeared to work best.
There are a number of direct and indirect techniques to monitor individual patient adherence to oral therapy, including pill counts, refill monitoring, patient self-report, and serum drug level assays. The techniques vary from free and noninvasive to invasive tests that involve an economic cost to the patient or healthcare system. The listing of monitoring techniques in Tool 6 can help HCPs and patients decide which method, if needed, would be most appropriate and provide the most accurate information.
4.4. Treatment Calendars
A relatively easy method to monitor and potentially improve patient adherence is to provide the patient with a personalized treatment calendar listing the dates and times medications are due to be taken. The patient can check off each dose and bring the calendar to appointments for review by the nurse. Tool 7 contains sample calendars for patients who are on combination chemotherapy-biotherapy for metastatic breast cancer.
Section 5. Strategies for Improving Adherence
Oncology nurses are in an ideal position to help patients identify their barriers to adherence and develop plans to deal with these barriers and improve adherence. Even when external barriers, such as access to medication, have been handled, patients may still face internal barriers such as lack of belief in the treatment or low motivation to stay on course through protracted or complicated medication regimens. Using appropriate interview techniques and helping patients recognize the need to change behavior are tools that oncology nurses can use to improve adherence.