Do Cognitive Therapy Concepts For Losing Weight Apply To Improving Compliance?
I’m convinced this Medscape interview with Judy Beck on a cognitive therapy approach to weight loss has straightforward implications for optimizing patient compliance. Rather than argue the case, however, I encourage you to check it out for yourselves. To facilitate this process, I’ve excerpted some of the portions of the interview that are pertinent to treatment adherence. I suggest reading through the selections once for a sense of Dr. Beck’s notions regarding cognitive therapy and weight reduction and then re-reading the same material, mentally transforming the goal from weight loss to patient compliance. I think you’ll find the exercise simple and enlightening.
Medscape: Do people become demoralized when they find out that dieting isn’t as easy as they had thought? Dr. Beck: Yes. That’s why it’s important to lay the groundwork with dieters first. In fact, I suggest that people spend a couple weeks learning certain skills before they even start. One skill is to compose and read every day a list of every advantage they can think of for losing weight. They’ll need to read this list for a very long time, so when they face temptation, these advantages will be firmly in mind. And they need to prepare in advance what to say to themselves when dieting gets harder, when they feel discouraged, when the scale hasn’t gone down, when they stray from their diet, and when they start to feel the injustice of food restriction.
Medscape: What role does distorted thinking play in unsuccessful efforts to lose weight? Dr. Beck: Dieters who fail to lose weight or fail to maintain their weight loss think differently from those who are able to lose weight and keep it off long term. They have a lot of all-or-nothing thinking:
* Being full (often overly full) is good; hunger is bad;
* They’re good if they follow their diets, but bad if they make 1 mistake;
* Their eating week was either good (relatively easy) or bad (even if they only struggled for several minutes on several days);
* Food is either good or bad even though we recommend that dieters plan in advance to modify their diets so they can eat small portions of whatever food they want as often as once a day; and
* Dieters who fail to lose weight also view themselves as either in control (100% perfect) or out of control. They often think that 1 mistake should give them license to eat whatever they want for the rest of the day and delay starting fresh until the next day. They also believe that people of ‘normal’ weight rarely restrict their eating and rarely get hungry. They think that once they lose weight, they should be able to return to their old way of eating.
Medscape: How do you get people to recognize these kinds of ideas and what do you suggest they do about them? Dr. Beck: We use standard cognitive therapy techniques, teaching them to ask themselves what’s going through their minds when they feel hunger and craving, when they are disgruntled about not eating, when they are tempted to eat something they haven’t planned. Then they read ‘response cards’; index cards that contain compelling answers to their thoughts. They read these cards at least once a day, usually in the morning; then pull them out again on an as-needed basis, sometimes several times a day toward the beginning of their diet.
Medscape: Can you give an example of a response card? Dr. Beck: We make them up idiosyncratically with dieters. Some common ideas are: Even though I really want to eat now, I haven’t planned to. If I eat, I’ll strengthen my ‘giving-in’ habit, which means in the future I’m more likely to give in. If I don’t eat, I’ll strengthen my ‘resistance’ habit, which makes it more likely that in the future I’ll be able to resist. I can tolerate not eating now. I’ll be very glad in a few minutes when the desire goes away. I shouldn’t give myself a choice about this. After all, I’d rather be thinner. I can’t eat whatever I want AND also be thinner. I have to make a choice. Every time matters.
Medscape: What about emotional eating? Dr. Beck: Dieters give themselves permission to stray from their diet for any number of reasons. They’re upset, happy, tired, stressed, celebrating, traveling, busy, at a party…the list is endless. They think, ‘It’s okay to eat because…. everyone else is; it’s only a small piece; no one is watching; the food is free; I rarely get a chance to eat this kind of food.’ They need to learn the same skills to avoid straying from their plan, no matter what the reason. They have to grasp the fact that they can either eat what they want, when they want, for whatever reason they want (including being upset) — or they can be thinner. But it’s impossible to have it both ways.
Medscape: What do you suggest people do when they’re tempted by food that they’re not supposed to eat? Dr. Beck: As I keep saying, they have to prepare in advance for these times. They need to continually remind themselves (often by reading response cards) of the reasons to lose weight, that they can tolerate the discomfort of not eating (after all, they’ve tolerated much worse discomfort in their lives), that they’ll be happy in a few minutes when the desire to eat passes that they didn’t eat and they’ll be very unhappy in a few minutes if they give in to temptation. They also need a list of things they can do when they feel tempted — such as reading a diet book, surfing the Web for diet-related sites, taking a walk, calling a friend, brushing their teeth, writing emails, and so forth. We help dieters create a list of about 20 activities or so and urge them to try 5 of them each time they’re tempted.
Medscape: You mentioned that dieters need someone to be accountable to. Dr. Beck: Yes, we encourage everyone to find a ‘diet coach’: a friend, family member, coworker, neighbor, or maybe someone else who is trying to lose weight. Diet coaches don’t necessarily need to know much about dieting. But they do need to be highly supportive and encouraging. They also need to be willing to hunt down the dieter who has failed to keep his or her regularly scheduled weekly appointment (by telephone or email, or in person), reporting on how his/her weight has changed that week. Dieters don’t need to reveal their weight; only their change in weight. In addition, diet coaches need to be good problem solvers.
Medscape: What kinds of problems arise that dieters need help with? Dr. Beck: Common problems include practical ones, such as not enough time to schedule in dieting and exercise activities, and psychological ones, such as demoralization and discouragement. Some dieters need encouragement (and sometimes a little assertiveness coaching) to state their needs to family and coworkers. It’s surprising how many dieters are reluctant to turn down food that others offer or to ask that others bring only a single serving of overly tempting foods into the home, at least at the beginning. Ultimately, we want to build up dieters’ control so that they can keep any kind of food in the house and eat only small, planned-in-advance amounts.
Benjamen Brewer, MD, commenting in the 23 July 2008 Wall Street Journal on the effect the current economic problems have on his patients, describes this vignette from his practice:
A patient quit smoking so he could afford gas for the 40 mile commute to work in a packaging plant. He has been living paycheck to paycheck for years and his rent just went up. I was glad that something finally motivated him to stop smoking.
The bad news was that he came to the office with severe pneumonia two days after refusing to let an E.R. doctor admit him to the hospital. My patient was afraid of the expense and all the time he would go without pay from work.
To make matters worse, he didn’t fill the antibiotic prescription he was given either. The $50 co-payment was unaffordable, he said. This is a case when an insurer would have been better off picking up the antibiotic tab to avoid a larger expense. But there’s no easy way for a doctor to override a plan’s co-pay or to let an insurer know its rules are about to make something very expensive happen.
When the patient came to see me, his condition had deteriorated. I persuaded him to let me admit him to the local hospital. He was in such bad shape that he was soon transferred to the ICU of a large medical center. His care will end up costing tens of thousands of dollars.
Commentary
I suspect there are few physicians in clinical practice who could not relate similar stories these days. In addition to its poignancy, however, this episode is also instructive. Patient compliance rarely seems to hinge on a few dollars but our health system operates as a fiscally leveraged system in which huge costs and fees are pragmatically payable only through insurance and other third party payer plans. The loss of a job or a health benefit has consequences beyond a decrease in income or the dollar equivalent of a health benefit. Without insurance, the individual is vulnerable to costs that one can neither control or pay. One result is that financially dependent compliance is remarkably brittle. We should not be surprised that a downturn in the economy has a tremendously magnified negative impact on compliance.
This large (3359 patients) retrospective cohort study was designed to “determine the impact of depression on highly active antiretroviral therapy (HAART) adherence and clinical measures and investigate if selective serotonin reuptake inhibitors (SSRIs) improve these measures.”
Design & Results: (Excerpted)
[Researchers] measured the effects of depression (with and without SSRI use) on adherence and changes in viral and immunologic control among HIV-infected patients starting a new HAART regimen. HAART adherence, HIV RNA levels, and changes in CD4 T-cell counts through 12 months were measured. … [O]f 3359 patients … 42% had a depression diagnosis, and 15% used SSRIs during HAART. Depression without SSRI use was associated with significantly decreased odds of achieving =90% adherence to HAART (odds ratio [OR] = 0.81, 95% confidence interval [CI]: 0.70 to 0.98; P = 0.03). Depression was associated with significantly lower odds of an HIV RNA level <500 copies/mL (OR = 0.77, 95% CI: 0.62 to 0.95; P = 0.02). Depressed patients compliant with SSRI medication (greater than 80% adherence to SSRI) had HAART adherence and viral control statistically similar to nondepressed HIV-infected patients taking HAART. Comparing depressed with nondepressed HIV-infected patients, CD4 T-cell responses were statistically similar; among depressed patients, those compliant with SSRI had statistically greater increases in CD4 cell responses.
Commentary
Conclusions:
Depression significantly worsens HAART adherence and HIV viral control. Compliant SSRI use is associated with improved HIV adherence and laboratory parameters.
The conclusions1 drawn by the authors are straightforward, immediately useful to clinicians, and heartening, an all too unusual set of qualities for a clinical study dealing with patient compliance.
Moreover, while the researchers are appropriately careful to limit these conclusions to those being treated for HIV, a disorder frequently accompanied by depression (a prevalence of greater than 30% in some studies in HIV-infected patients), it is certainly possible that depression and SSRI treatment have analogous effects on adherence to the treatments of other disorders. There is little evidence that depression associated with HIV is a different pathology than free-standing depression or depression associated with other diseases or that patterns of compliance and noncompliance with HAART are fundamentally different from adherence and nonadherence to other disorders.
Because adherence is a life or death matter for HIV patients and because the HAART regimen has been an especially rigorous and difficult protocol for patients to follow, clinicians and researchers working with this disorder have been long been concerned about compliance issues and their efforts have resulted in advances in clinical practice. My subjective impression is that the results of these labors have sometimes remained isolated to those working in this field. If so, perhaps it’s time for an organized effort to assure that patient compliance research is distributed across diagnostic and professional boundaries.
Footnotes
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In more expanded form, the conclusions read … depression negatively affects adherence and clinical parameters among HIV-infected patients taking HAART, including the odds of achieving at least 90% adherence over 12 months and achieving an HIV RNA level <500 copies/mL by 12 months. We found that improved SSRI adherence is associated with improved HAART adherence, leading to improved HIV RNA levels and CD4 T-cell counts approaching or even exceeding results seen with nondepressed HIV-infected patients. SSRI use is likely beneficial in depressed HIV-infected patients if they can be compliant with their SSRI medication.↩
What Does SEEDIE Have To Do With Patient Compliance?
First, one needs to know that SEEDIE is the Society for Exorbitantly Expensive and Difficult to Implement EHR’s, an organization that defines itself as “a healthcare IT standards organization that is completely funded and operated by a select group of proprietary electronic health record vendors.”
Further, “Unlike independent, objective, professional organizations created to help medical professionals select and implement interoperable EHR solutions, SEEDIE promotes healthcare IT systems that play well in the sandbox if, and only if, it is in the best interests of a particular vendor.”
SEEDIE also offers levels of certification for vendors that is exclusively fee-based.
So, what does SEEDIE have to do with adherence to treatment? Well, it should be obvious by now but here’s a clue from the home page of the SEEDIE site that features the graphic atop this post:
What does this little girl have to do with selecting an EHR? Absolutely nothing! But it does register 10 on the warm and fuzzy meter!
That’s right - SEEDIE also has nothing to do with patient compliance. Heck, AlignMap.com doesn’t even register on the warm and fuzzy meter.1
The home page for this organization can be found at ~ SEEDIE ~
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Hey, give me a break - it’s my first day back on the blog and I never could resist a clever parody.
Footnotes
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Should SEEDIE develop an affiliate web site program, however, I’d be willing to work on the warm and fuzzy thing.↩
After a prolonged hiatus caused by the illness and, finally, the death of a loved one, my posting on the AlignMap blog will begin again this week.
Kinda.
The Same But Different
All authors, whether writing novels, movie scripts, doctoral dissertations, limericks, advertising copy, pornography, epic poems, or blog posts, require two elements: time and money.
Creating and maintaining a non-revenue web site about patient compliance is gratifying as all get-out but unless I can finagle a scam to rake in some bucks from these idiosyncratic displays of literary semicolon-wielding scribblings, HTML manipulation, and footnoted snarkiness, I face the joy-draining prospect of earning an honest dollar.
Plus, as it turns out, I have a lot going on these days.
More about that later.
For now, I just want to alert readers that, while I intend to continue writing about patient compliance, the extent, focus, and format of this effort are up for grabs - or less colloquially, will evolve over time.
Credit Due Department: The nifty AlignMap word cloud atop this post was generated by The Wordle Web Site
In the preceding entry, Posting Suspended, routine blogging on and additions to this site were halted because of the illness of a loved one. That individual died yesterday. I trust readers will understand why I am not re-initiating work on the site immediately.
As it turns out, my long-scheduled annual vacation begins next week so the earliest date for the resumption of routine posting is sometime the week of June 26.
In the preceding post, I mentioned the illness of a loved one; unfortunately, this illness has become severe. Consequently, routine posting on AlignMap.com and AlignMap In Cites, as well as my personal blogs, will continue to be suspended. I will post any changes in this plan, including the resumption of blogging, here.
Given the dearth of recent posts to AlignMap, this is, I suppose, a clarification rather than a notification.
A convergence of family and business responsibilities, the illness of a close friend, and some relatively minor but time-consuming healthcare issues of my own make routine updating of this blog as well as AlignMap In Cites impossible.
The most likely scenario for the immediate future has me sporadically and unpredictably posting items when the opportunity arises.
My hope is to return to my original 3-5 posts per week schedule when the current tempests are quelled.
Patient Compliance Enhancement System Wins Columbia Business School Outrageous Business Plan Competition
According to With This Plan, Everyone Wins, a system for packaging a patient’s medication by dosing schedule (e.g., instead of dispensing a month’s supply of the patient’s five different medications each in its own bottle, the pharmacist would repackage the medications into that patient’s prescribed doses - 1 tablet each of medications A, B, and C on awakening, 2 tablets of medication D with breakfast, lunch, and dinner, and 1 tablet of medication E at bedtime) was adjudged the best entry in the Ninth Annual Outrageous Business Plan Competition,1 an honor accompanied by a $4,575 award.
The referenced post goes on to note that
Prescription noncompliance costs billions in healthcare dollars and thousands of lives each year. Geoffrey Reed ’09 saw the problem first-hand last summer when his grandfather mixed up his medications and ended up in the hospital. Now Reed and Eric Chesin ’09 have come up with a way for pharmacies to organize medications that increases the chance of compliance. The idea, Bluepak, recently won CBS’s 2008 Outrageous Business Plan Competition; their elevator pitch is below.
Commentary
As was the case with the MIT Yunus Challenge award,2 it is heartening to find patient compliance recognized as a problem worthy of the efforts of student competitors at these elite universities.
And, I think the idea is reasonable and and worthy of a trial. I am, however less certain a medication repackaging scheme warrants the “outrageous” tag.3 Hospitals have used this strategy for years, and some pharmacists have long provided the service for some patients. Heck, I’ve suggested this idea myself without one person in the audience retorting “That’s outrageous.”
More to the point, Bluepak appears similar to onePAC, a service featured recently on this blog,4 and the questions I asked about onePac (see previous posts) would apply to Bluepak. 5
Happily, being outrageous or even original, is not a prerequisite for a clinical valid, commercially viable program to enhance medication compliance. Those of us with vested interests in treatment adherence will be interested to see how Bluepak, onePAC, and similar ideas fare in the real world.
Footnotes
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From the Columbia Business School press release: To enter the competition, teams comprised of at least one Columbia MBA or EMBA student, submit an executive summary of their business plan and tape a two-minute elevator pitch. A panel of judges, comprised of executives from venture capital firms as well as several entrepreneurs who developed their own successful ventures while students at Columbia Business School, evaluated the pitches and narrowed the field down to five teams. In the final round of competition, each team delivered a formal 10 minute presentation to the judges and the audience. Based on these presentations, the judges decided how much money they would award each venture.↩
According to the previously noted Columbia Business School press release, “The competition, organized by the Columbia Entrepreneurs Organization and the Entrepreneurship Program, encourages students to develop and present creative entrepreneurial ideas that are sufficiently ambitious in scope and scale to be considered “outrageous.”↩
Patients will be scored on how closely they follow their doctor’s orders in taking their prescribed medications, in a move designed to lift adherence rates and improve outcomes for people with chronic conditions.
The article goes on to point out,
The scores will be expressed as a “mark” out of 100, and will be colour-coded to indicate increasing levels of concern as scores get lower. Pharmacists will be encouraged to help patients whose scores are slipping into the red, by packing multiple medicines into blister packs that make it easier to see which drugs are due to be swallowed at particular times. For more difficult cases, patients may be asked to see their GP for a home medication review, which is designed to simplify a patient’s drug regimen.
However, the scores are not designed to imply fault or blame, and no penalties or sanctions will apply to people with low scores. (Emphasis mine)
The basic mechanisms of the plan are outlined in these excerpts:
The new scheme will work by comparing the time it takes patients to return to a pharmacy to have a repeat script filled, with the time it would have taken them had they taken all the previous doses at the appointed times.
The MedsIndex scheme has been devised by the Pharmacy Guild, which has already run it as a successful four-month pilot, mainly in Victoria and Queensland.
Pharmacy Guild president Kos Sclavos said research showed patients’ adherence to dosing schedules plunged rapidly in line with the number of daily medicines they were supposed to take. Among patients taking one pill per day, compliance was about 80 per cent, but fell to 72 per cent for those taking two pills — and to just 64 per cent among patients taking three pills every day. Sclavos said even an 80 per cent compliance raised concerns, as “drug manufacturers don’t confirm their drugs remain efficacious if you are missing one dose in five”. A score of 90 out of 100 suggested room for improvement, but Sclavos said the Guild would ask pharmacists to consider packing medicines in labelled blister packs for patients with scores below 80. “If it’s 75 or lower, they should be seeing their doctor about a home medicine review,” he said. Sclavos said the 200 patients involved in the pilot — which was run merely to ensure the IT systems worked properly — became obsessed by their scores and did not want to come off the scheme. “We’ve had patients coming back saying ‘Please measure me again’ — that’s how enthusiastic patients have been,” Sclavos said. Aaron D’Souza, a pharmacist in Brisbane’s CBD, helped devise and trial the scheme and described its reception by patients as “absolutely fantastic.” “A typical response (to a low score) is ‘Really? I knew I missed some medicines sometimes, but not that much’,” D’Souza said.
Commentary
I am wholeheartedly in favor of compliance with prescribed healthcare measures, including medications, being monitored - in theory. Simply put, noncompliance will not be recognized, let alone be rectified, unless ongoing, routine monitoring is in in place.
Heck, I think it is even possible that compliance monitoring can be accomplished in practice if sufficient care and planning is invested in the effort.
I do, however, have qualms about the proposal written up in The Australian.
First among them is the notion that “the scores are not designed to imply fault or blame, and no penalties or sanctions will apply to people with low scores.” I’m fully willing to believe that this statement reflects the intent of those responsible for the program.
It does not require much effort, on the other hand, to imagine scenarios in which certain parties would face temptations to change or illicitly abuse this principle.
Not being familiar with systems of Australian healthcare payment or the medico-legal system, I’ll give an example or two based on how the American healthcare system operates.
As healthcare expenses increase, somebody in the government, the insurance industry, or a payer (e.g., an employer) is going to have the epiphany that patients who don’t adhere to prescribed medication dosing cost more than those who do. Clearly it would be not only a cost-saving but also justifiable to reduce the benefits or increase the personal fees paid by this group, members of whom could be identified by an adjustment in the system.
Somewhere else, a lawyer defending a physician accused of malpractice will seek judicial leave to present the patient’s compliance score of 45 as evidence that the treatment failed because of poor adherence rather than the doctor’s error.
And, those justifications may indeed be legitimate. My point is only that there will be pressure to use these scores in ways not currently intended. And once recorded, this compliance rating will be vulnerable to the intrusions of politicians, lawyers, healthcare officials, and others.
My other area of concern is that this important change is predicated on a four month study of 200 patients - “which was run merely to ensure the IT systems worked properly” - and research that “showed patients’ adherence to dosing schedules plunged rapidly in line with the number of daily medicines they were supposed to take.”
While studies tend to show that decreased compliance is coupled with an increased number of doses per day, that research is not unanimous. Nor are the remedies listed, blister packs of medication and simplified drug regimens, both of which are reasonable responses and which are beneficial to some
patients, panaceas for all nonadherence. And, since most physicians try to minimize dosing for all patients, it is difficult to see how that measure will have a dramatic effect.
The enthusiasm demonstrated by some of those 200 patients notwithstanding, one wonders if the novelty of this program may not wilt after a few months with a corresponding decrease in interest by patients and clinicians.
There are other imperfections as well. The compliance formula, which “compar[es] the time it takes patients to return to a pharmacy to have a repeat script filled, with the time it would have taken them had they taken all the previous doses at the appointed times” has several built-in potential flaws, the most significant of which is perhaps that picking up ones prescriptions at the correct times is not synonymous with taking the medications as prescribed. In the US, it is not unusual for a patient to semi-surreptitiously obtain medications from other countries to reduce costs. Doing so would, I assume, bypass the monitoring system.
Perhaps the point of this jeremiad disguised as a post is that monitoring the compliance of all patients in a practice, an insurance group, or a country offers great opportunity to improve healthcare - but not if it addresses only one area of noncompliance with one set of responses, especially since it puts those those patients at some risk of their compliance records being used to make their healthcare more expensive or less accessible.
I received these responses on 26 March 2008 from Nanette Kirsch, Senior Director, Marketing Communication, Parata Systems, LLC
Q: If all of a patient’s prescriptions are processed and sold in 30-90 day bundles, how are changes in that patient’s medication regimen handled, both logistically and financially? A: That is being managed at the pharmacy level, although we expect to create a process specific to that issue in the near future.
Q: Is there research demonstrating that this type of packaging increases compliance? A: Not that we have conducted yet. But we anticipate collecting such data as we advance into the market and will keep you in the loop on those outcomes.
