Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider

Abstract

ObjectiveTo analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).MethodsAn overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.ResultsAfter reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.ConclusionsThe results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

2020 EULAR points to consider for the prevention, screening, assessment and management of non-adherence to treatment in people with rheumatic and musculoskeletal diseases for use in clinical practice

“…18 An international expert task force was established by a steering committee (LC, VR, AdT and TAS), and included people with RMDs (n=2), EMEUNET members (n=3 (AM, RGD and VR)), and representatives from relevant HCP groups: nurses (n=3), occupational therapists (n=2), psychologists (n=3), physiotherapists (n=1), pharmacists (n=2) and rheumatologists (n=6), all of whom had various levels of expertise in the field of non-adherence and came from a broad geographical distribution across Europe. A systematic review (SR) of reviews and meta-analysis on existing strategies to prevent or mitigate nonadherence, supervised by the methodologist and the convenors, was presented at a first task force meeting (the SR is subject of a separate publication 19 ). In this meeting, the scope, users, structure of the document and overarching principles were established by nominal group technique, as well as additional clinical questions to be addressed by SR.…”

“…In RMDs, non-adherence has been associated with worse disease severity, increased pain and fatigue, higher rates of depression, lower function and a decrease in quality of life and physical activity. 19 Overarching principle B: shared decision making is key, since adherence is a behaviour following an agreed prescription Ideally, patients and their HCPs should agree on the recommended treatment, including duration, dosage and frequency of medication intake, or exercises or device use over a period of time. To make an informed decision, patients need to understand their choices (ie, shared decision making, or SDM).…”

“…Effective interventions to reduce non-adherence in RMDs were reviewed by our group, and we confirmed that HCP, both physicians-namely, rheumatologists, GP and orthopaedic surgeonsand HPRs-such as nurses, physiotherapists, occupational therapists, psychologists, exercise physiologists, patient educators and pharmacists-were involved in the delivery of these interventions. 19 Nieuwlaat et al underscore in their Cochrane review that nurses, pharmacists and therapists are increasingly becoming part of delivering interventions that target nonadherent behaviour in people with RMDs. 24 This PtC gives responsibility to the full care team.…”

“…Barriers to adherence are considered complex and multi-faceted and non-adherence should never be perceived as patients' fault only (eg, the hospital pharmacy was not open the only day a patient could take off from work that month, or the patient's skills for self-injection are very limited). Based on the overview SR, 19 we have produced a checklist of factors related to non-adherence, which could help HCPs to identify barriers to adherence at the individual level (see online supplemental table S1).…”

“…Most interventions with proven effectiveness in non-adherence include components of patient education, 19 namely provision of knowledge or information, self-management programmes, cognitive behavioural interventions, mindfulness, stress management, individual consultations, sharing experiences among patients, motivational discussions, exercise counselling, lifestyle change interventions and self-help courses. With this PtC, the task force wants to emphasise that 'all people with RMDs should have access to and be offered patient education throughout the course of their disease including as a minimum; at diagnosis, at pharmacological treatment change and when required by the patient's physical or psychological condition'.…”