1. Mason, Diana J. PhD, RN, FAAN
  2. Lewis, Laurie

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Doing What You're Told

Factors that influence adherence to chronic illness treatment regimens.

Adherence to treatment regimens presents a special challenge to chronically ill patients and the nurses who treat them. What factors influence a patient's adherence? Researchers from the University of Pittsburgh School of Nursing have been examining whether the existence of comorbidities influences treatment adherence. Their studies have focused on patients with different chronic conditions, including rheumatoid arthritis (RA), urinary incontinence, hypertension, and HIV.


Susan Sereika, PhD, was on a team of researchers examining whether comorbidities affect treatment adherence among people with RA. The patients had an average of almost five comorbid conditions (range, one to 16). Hypertension was the most frequent comorbidity, occurring in 34% of those studied. In addition to RA, 21% of the patients had anemia, which has been increasingly recognized as a common condition among people with chronic illnesses and is referred to as "anemia of chronic disorders." The participants took an average of 6.5 medications (range, zero to 18). The researchers found no relationship between the number of comorbidities and the percentage of prescribed doses of medication taken or the percentage of days of adherence to the prescribed regimen.


Researcher Sandra J. Engberg, PhD, RN, CRNP, suggested that it may not be the number of comorbidities that dictates adherence to treatment regimens, but the burden of other conditions on the individual. In a study funded by the National Institute of Nursing Research, Engberg found no relationship between the number of comorbidities among community-dwelling older adults with urinary incontinence and their adherence to a pelvic floor-muscle exercise regimen. Adherence to the exercise regimen was greater than was compliance with other strategies designed to reduce urge and stress incontinence.


Medication treatment adherence is particularly important among people with HIV who are taking antiretroviral medications because poor adherence has been associated with the development of drug resistance. Judith Erlen, PhD, RN, FAAN, studied 200 men and women with HIV infection and found that the average rate of adherence to daily drug regimens was 65%. The prescribed number of doses was taken only 44% of the time. Erlen recommended that future research examine whether adherence is influenced by depression, which is high in this population.


Although many people with chronic illnesses have multiple health problems, these studies suggest that the number of comorditities doesn't necessarily affect treatment adherence. Future research needs to examine depression, the burden of comorbidities, and other factors that might influence treatment adherence. -DM


The Advantage of Nurse Case Management

Follow-up by advanced practice nurses yielded shorter hospital stays.

Patients who have had a long stay in an ICU and have required mechanical ventilation experience high rates of readmission. Barbara J. Daly, PhD, RN, FAAN, of the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio, was principal investigator of a study, "Disease Management of the Chronically Critically Ill," where a team of advance practice nurses (APNs) coordinated patient care for two months after discharge to try to reduce the readmission rate.


All patients in this study had been on mechanical ventilation at least four days; the average time on the ventilator was 12 days. The average length of stay in the ICU was 17 days. Although most of these patients had been living at home before hospitalization, less than one-third of them were discharged home; most went to another care facility, such as a nursing home. In the two months after discharge, the APNs made an average of 34 contacts with the 231 patients assigned to the disease-management group. The 103 patients in the control group, who received standard follow-up care, had an average of only four contacts in the same period (and those were made for data collection purposes).


The rates of readmission during the two months after the initial hospitalization were similarly high in the two groups. In that time, 40.4% of the disease-management patients and 41.9% of control patients were readmitted. Multiple readmissions were common; 29% of the disease- management group and 35.9% of the control group were readmitted more than once in the two months. But the lengths of stay were quite different in the two groups. The average stay upon readmission was 11 days among the patients who were followed by the APNs, compared with 16 days among patients receiving standard follow-up.


By reducing the length of readmission, the disease-management program saved $481,000. The main cost of the program was the salary of the APNs.


Daly concluded that "this study suggests that the frequent rate of readmission cannot be altered in this chronically critically ill population. But costs can be reduced significantly because of the shorter length of stay on readmission."-LL