Disclosures: Ritschl reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
December 31, 2020
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EULAR: All rheumatic, musculoskeletal disease providers should stress therapy adherence

Disclosures: Ritschl reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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All health care providers who assist in the management of rheumatic and musculoskeletal diseases should take responsibility for promoting adherence, according to EULAR “points to consider” published in the Annals of the Rheumatic Diseases.

“Thirty to 80% of people with rheumatic and musculoskeletal diseases (RMDs) do not follow the recommended treatment plan,” Valentin Ritschl, MSc, of the Medical University of Vienna, in Austria, and colleagues wrote. “Nonadherence equally affects medication, nonpharmacological interventions and keeping follow-up appointments and is associated with worse outcomes, increased risk of cardiovascular disease, decreased functioning and loss of health-related quality of life. Strategies to reduce nonadherence are thus essential to achieve an optimal outcome.”

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“Nothing can be done in terms of nonadherence without the help of the one who agrees, or not, to follow the treatment or exercises as prescribed. To engage him or her, we will need to attain basic effective communication skills and make [shared decision making] a reality,” Valentin Ritschl, MSc, and colleagues wrote. Source: Adobe Stock

“The problem of nonadherence is addressed in some EULAR recommendations on the management of specific health conditions or in the role of professionals, but none specifies interventions in or actual directions on how to improve nonadherent behavior,” they added. “All these recommendations focus on specific aspects of nonadherence and do not cover the multifaceted nature of this phenomenon, such as its detection or assessment.”

To develop a series of points to consider regarding the prevention, screening, assessment and management of treatment nonadherence among patients with rheumatic and musculoskeletal diseases, EULAR established a 22-member task force that included rheumatologists, nurses, pharmacists, psychologists, physiotherapists, occupational therapists and patient-representatives. A total of 12 European countries were represented.

Results from a systematic review of meta-analyses on existing strategies to prevent nonadherence were presented at the task force’s first meeting. Members also developed overarching principles and additional clinical questions during this meeting. Later, in a second meeting, task force members discussed the results of the systematic review and developed the points to consider. Statements were voted on and discussed using a three-round Delphi technique, while level-of-agreement and voting were scored anonymously on a scale of 0-10.

The final, third Delphi round of voting was completed online through Survey Monkey. Here, task force members were asked to give their final rating on every point to consider.

Ultimately, the task force approved four overarching principles and nine points to consider (PtCs). The overarching principles are:

  • Adherence impacts disease outcomes;
  • Shared decision making is key;
  • Multiple factors impact overall treatment adherence; and
  • Adherence is ever-changing and requires constant management.

According to the members, the points to consider reflect the “phases of action on nonadherence.” They include:

  • All providers who assist in the management of patients with rheumatic and musculoskeletal disease should take responsibility for promoting adherence;
  • Providers should use effective communication with patients to urge adherence;
  • Adherence barriers and facilitators for specific patients and treatments should be given appropriate evaluation;
  • Standard care for rheumatic and musculoskeletal diseases should include patient education;
  • Care should be tailored to patient preferences and goals;
  • Providers should examine which factors might reduce adherence, including cost and availability, as well as patient memory and concerns;
  • Providers should tailor adherence strategies to individual patients and their specific barriers; and
  • Specific expertise or interventions for adherence should be provided when needed.

The level of agreement ranged from 9.5 to 9.9 out of 10. In addition, members of the task force wrote that these points can be equally applied to cover exercises as well as medications, due to their generic nature.

“Regarding the implementation of these PtCs, the task force wanted to stress, on one hand the need to adopt a truly patient-centered approach and, on the other, the need to make system changes,” Ritschl and colleagues wrote. “Several PtCs involve the patient as main stakeholder in the issue of non-adherence. Nothing can be done in terms of nonadherence without the help of the one who agrees, or not, to follow the treatment or exercises as prescribed. To engage him or her, we will need to attain basic effective communication skills and make [shared decision making] a reality. The consequences will be a better outcome and higher odds of adequate self-management.”

“Similarly, if we do not evaluate periodically non-adherence at an organizational level, and address system barriers, many of which are modifiable, including improved staff training, we will not be able to make effective changes, or measure the impact of implemented strategies,” they added. “In summary, these PtCs can help [health care providers] to support people with RMDs to adhere to the agreed treatment plan, the basic scheme being minimize nonadherence by bonding with the patient and building trust, and by overcoming structural barriers, assess in a blame-free environment and tailor the solution to the problem.”