Adherence Assessment

Guidelines published by the American Diabetic Association suggest glycemic goals as the achievement of hemoglobin A1c levels at less than 7%, fasting glucose levels of 70-130 milligrams per deciliter, and an after meal glucose level of less than 180 milligrams per deciliter.

Clinical and Other Flags: •Persistent high levels of A1c •Erratic fluctuations of blood glucose and diabetic crisis episodes •Signs of medication ineffectiveness •Dietary non-adherence and weight gain •Inadequate self-monitoring of blood glucose •Missed appointments

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Many diabetic educators have abandoned the word “compliance” as one that is used as a diagnosis and may be used to judge a patient’s character or personal values--rather than a description of the obstacles they face. The purpose of the assessment is not simply to determine whether a patient is not adhering to recommended therapies, but to determine the barriers to adherence so that they can be addressed.

Non-adherence should not only be identified early, but carefully assessed in order for the patient, caregivers, and providers to determine the most suitable course of action to improve adherence and outcomes.

Clinical signs can trigger an assessment. Laboratory values that are at odds with what should be seen in therapy-adherent patients suggest the need to investigate both adherence and the appropriateness of medications and dosing levels. Persistent hemoglobin A1c, erratic changes in blood sugar levels, and episodes of diabetic crisis resulting from lack of blood glucose control should be evaluated for possible non-adherence issues.

Other co-existing conditions that are medication-controlled, such as hypertension and hyperlipidemia, can be evaluated for effectiveness. If hypertension and hyperlipidemia are persistent despite prescribed medications and other therapies, an assessment for overall adherence to therapy recommendations should be completed.

If patients experience weight gain or continued elevated hemoglobin A1c levels despite dietary recommendations that should control those issues, then non-adherence should be explored. If the patient does not have adequate records of self-monitoring of blood glucose, routinely misses appointments, and fails to follow through on recommended clinical testing, a well-rounded assessment may identify barriers to adherence.

 

Identifying non-adherence but not seeking to alter the underlying cause is like diagnosing a disease and making to attempt to cure it.

Assessments can be designed to allow the patient to self-report barriers to adherence. Quick surveys can help to identify the need for more in-depth exploration of these barriers during the office visit, and can help to prioritize those issues that can be initially emphasized.

Further assessments may include psychological evaluation, such as a depression index or signs of problematic family and support network dynamics. A self-reported questionnaire on dietary intake and activity levels can help to identify non-adherence to dietary and exercise recommendations.

Costs for therapies is a common barrier to adherence and both costs of medications and type of insurance coverage may make a difference in this aspect of treatment. In addition, a discussion on the patient’s perceptions about the complexity and burden of treatment will assist in identifying the need to intervene in these areas.

 

It is important to remember that surveys and assessments are only accurate in a non-judgmental environment. A patient who feels they can not trust their healthcare team to not condemn them for having barriers, will not reveal those barriers, and treatment is unlikely to progress effectively.