Rachael Thorneloe

Adherence to medication in patients with psoriasis: a systematic literature review

Psoriasis is associated with considerable physical and psychological morbidity. Optimal use of psoriasis treatments can limit the physical manifestations of psoriasis and help improve quality of life, but nonadherence is common. Smoking, obesity and excessive alcohol consumption are prevalent in this population. A systematic review of adherence to medication and recommendations for lifestyle change in psoriasis was undertaken, with a critical appraisal of the quality of the selected studies. Electronic searches from inception to March 2012 (PubMed, Web of Science and Embase) were conducted. Twenty‐nine studies were included; however, none examined adherence to advice about lifestyle change. Studies using a dichotomous classification of adherence tended to report suboptimal adherence, with 21·6–66·6% of patients classed as adherent. No consistent pattern of results emerged for sociodemographical, disease and lifestyle factors as determinants of adherence. However, some treatment factors were associated with adherence. While mixed findings were reported for quality of life as a determinant of adherence, psychological factors (psychological distress and patient satisfaction with care and therapy) were associated with adherence. Only tentative conclusions can be made for determinants of adherence because the methodological quality of many of the included studies limits conclusions. There is a need for improved quality of research and reporting in this area, and this review provides a platform from which future research within this area should progress, along with suggested research recommendations.

Adherence to medication in patients with psoriasis: a systematic review

Background  Psoriasis is a life‐long inflammatory condition that can impact on quality of life, psychological and social functioning. Previous literature suggests patient dissatisfaction with psoriasis management; however, little is known about people’s specific experiences of health care consultations.

Nonadherence to psoriasis medication as an outcome of limited coping resources and conflicting goals: findings from a qualitative interview study with people with psoriasis

Medication nonadherence is known to limit the effectiveness of available therapies; however, little is known specifically about medication adherence in people with psoriasis. Medicines self‐management can feel onerous to those with dermatological conditions due to the nature of therapies prescribed and many individuals with psoriasis experience additional challenges such as physical and psychological comorbidities that place significant additional demands on individuals and may undermine adherence. Viewing nonadherence to medication as an outcome of limited personal coping resources and conflicting goals may help to explain medication nonadherence.

'New to me' - changing patient understanding of psoriasis and identifying mechanisms of change: The Pso Well(®) patient materials mixed methods feasibility study

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Motivational interviewing-based training enhances clinicians' skills and knowledge in psoriasis: findings from the Pso Well(®) study

Psoriasis is a common long‐term, immune‐mediated skin condition associated with behavioural factors (e.g. smoking, excess alcohol, obesity), which increase the risk of psoriasis onset, flares and comorbidities. Motivational interviewing (MI) is an evidence‐based approach to health‐related behaviour change that has been used successfully for patients with long‐term conditions. This study assessed change in clinicians’ MI skills and psoriasis knowledge following Psoriasis and Wellbeing (Pso Well®) training.

The challenges of assessing patients' medication beliefs: a qualitative study

BackgroundAn estimated 50% of patients do not take their medication as prescribed, with medication adherence associated with adverse outcomes and higher costs of care. The Necessity-Concerns Framework identified individual’s beliefs about their medication as playing a key role in adherence, and UK Clinical Adherence Guidelines recommend eliciting and incorporating individual’s perceptions of their medication within the consultation. The Beliefs about Medicines Questionnaire (BMQ) is widely used to assess medication beliefs, however, given the condition-specific nature of some self-management regimens, it is unknown whether this tool is able to fully capture beliefs about more complex medication regimens.MethodsWe examined the challenges of assessing medication beliefs using the BMQ in 20 people with a complex relapsing-remitting condition recruited from community sources. Data were collected from people with psoriasis; a patient group characterised by complex medication regimens, which include therapies that are applied topically, phototherapy/photochemotherapy, and therapies that are administered orally or via subcutaneous or intravenous injections. Semi-structured cognitive interviews were undertaken, with responses coded using established schedules and analysed using Content analysis.ResultsIndividual’s beliefs about their condition specific therapies were not accurately captured by the BMQ. Medication beliefs as expressed during ‘real-time’ completion of the BMQ were underestimated, or failed to be captured, by the corresponding scores given by participants.There was mismatch between the terminology used in the scale and individuals perceptions of their condition and the complexity of its management and treatment outcomes. Currently the BMQ cannot represent beliefs about medicines underuse, even though some individuals with psoriasis viewed access to therapies as overly restrictive. Some the BMQ items were misinterpreted in part due to ambiguous item wording or due to misreading by participants.ConclusionsThis is the first study to identify general and condition-specific difficulties experienced by individuals completing the BMQ in ‘real time’. The main implication of this research is the need to develop condition-specific versions of the BMQ in order that this important instrument can capture the full range of medication beliefs in individuals living with a complex relapsing-remitting condition. Access to condition-specific versions could significantly increase our understanding of beliefs which facilitate or reduce medication adherence.

Intentional and unintentional medication non-adherence in psoriasis: the role of patients’ medication beliefs and habit strength

Medication non-adherence is a missed opportunity for therapeutic benefit. We assessed “real-world” levels of self-reported non-adherence to conventional and biologic systemic therapies used for psoriasis and evaluated psychological and biomedical factors associated with non-adherence using multivariable analyses. Latent profile analysis was used to investigate whether patients can be categorized into groups with similar medication beliefs. Latent profile analysis categorizes individuals with similar profiles on a set of continuous variables into discrete groups represented by a categorical latent variable. Eight hundred and eleven patients enrolled in the British Association of Dermatologists Biologic Interventions Register were included. Six hundred and seventeen patients were using a self-administered systemic therapy; 22.4% were classified as “non-adherent” (12% intentionally and 10.9% unintentionally). Patients using an oral conventional systemic agent were more likely to be non-adherent compared to those using etanercept or adalimumab (29.2% vs. 16.4%; P ≤ 0.001). Latent profile analysis supported a three-group model; all groups held strong beliefs about their need for systemic therapy but differed in levels of medication concerns. Group 1 (26.4% of the sample) reported the strongest concerns, followed by Group 2 (61%), with Group 3 (12.6%) reporting the weakest concerns. Group 1 membership was associated with intentional non-adherence (odds ratio = 2.27, 95% confidence interval = 1.16−4.47) and weaker medication-taking routine or habit strength was associated with unintentional non-adherence (odds ratio = 0.92, 95% confidence interval = 0.89−0.96). Medication beliefs and habit strength are modifiable targets for strategies to improve adherence in psoriasis.

Medication non-adherence: the hidden problem in clinical practice

Medication non-adherence was recognized over 2000 years ago when Hippocrates observed that patients did not always take the medicines recommended to them. Today, medication nonadherence remains a considerable and often hidden problem in clinical practice, with people typically taking only half of their prescribed medication. In this issue of the JEADV, Zschocke et al. explored adherence to psoriasis treatment. This is an important area of research with high relevance to clinical practice. We know that adherence can be problematic in people living with inflammatory skin conditions, and this is a missed opportunity for optimizing the effectiveness of available treatments. It can be difficult for patients to be honest about their medication usage, through fear of being labelled ‘a bad patient’. It is important that we take a non-judgemental approach and recognize non-adherence as the norm for at least some of the time. We all know how difficult it is to adhere to health behaviour recommendations, such as diet, alcohol and exercise; medication adherence is no different. Taking a ‘no-blame’ approach encourages honest and open discussions about medication use and is fundamental in helping to identify non-adherence and its causes. Just as we cannot ascertain a patient’s medical diagnosis without performing diagnostic procedures or tests, we cannot discern which patients are (or are not) using their medication as prescribed. Adherence to medication involves complex combinations of decision-making and behaviours. This is particularly true in the context of dermatological conditions such as psoriasis. Even supposing the patient concurs with their clinician’s choice of a therapy, they are then expected to make additional judgements such as ‘how much’ or ‘how often’ to use a topical treatment, or whether a recent infection is severe enough to justify omitting their next methotrexate dose. While adherence is sometimes labelled as intentional (patients decide to use less or more of their treatment than prescribed or stop treatment for a while) or unintentional (patients forget or lack capacity to use their medication), the reality is often more complicated. We need to know what level of adherence is ‘good enough’ for a particular therapy to advise patients about their degree of latitude. Finally, we need to develop accurate systems to determine the extent and types of non-adherent behaviours so that we can intervene as necessary. Improving medication adherence requires more than simply ‘giving advice’ especially in the Internet age of readily accessible but potentially conflicting recommendations. So where should clinicians and researchers go from here? First, it is well established in other diseases such as asthma, cardiovascular disease and diabetes that patients’ beliefs about their illness and medication are key modifiable drivers of nonadherence. Patients’ experiences of medication can shape their expectations and vice versa. Patients who have concerns about the potential for adverse effects and perceive poor control of symptoms may underuse their psoriasis treatment to manage these concerns. Eliciting and addressing their perceived need for treatment and any concerns they may have about its usage could help support adherence Second, psychological distress can be very high in dermatology patients. This may reduce motivation and ability to manage their condition. Concerns about the nature or impact of dermatological treatments may be additional sources of distress; however, these issues are often missed or the distress is undertreated. Third, patients must also manage other real-life demands on their time and energy, such as relationships, work and additional comorbidities. It is important to encourage patients to discuss how medication use fits into their daily life and identify practical barriers they may face. Such discussions help identify potential solutions and develop good medication-taking routines. Longitudinal studies of treatment outcome in the ‘real world’ are increasingly common in dermatology. These provide the ideal platform to identify biomedical and psychological predictors of intentional and unintentional non-adherence. However, this is where the need for well-designed dermatology-specific measures is highlighted. The evidence supporting self-management interventions in dermatology is currently very limited. Understanding modifiable factors that influence non-adherence would pave the way to the development of tailored and targeted adherence interventions ultimately allowing patients to optimize the benefits from prescribed medicines.

Evaluation of the IMPACT study practitioner training intervention: using motivational interviewing to optimize self-management in psoriasis

PS01 Evaluation of the IMPACT study practitioner training intervention: using motivational interviewing to optimize self-management in psoriasis A. Chisholm, P.A. Nelson, A.J. Littlewood, K. Kane, C. Pearce, A.L. Henry, R. Thorneloe, M. Hamilton, J. Lavallee, M. Lunt, C.E.M. Griffiths, L. Cordingley and C. Bundy Manchester Centre for Dermatology Research; Manchester Centre for Health Economics; School of Nursing, Midwifery and Social Work and Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K. Psoriasis is a common long-term, immune-mediated skin condition that is exacerbated by unhealthy lifestyle factors including smoking, excess alcohol and obesity. These behavioural factors are also linked to cardiovascular disease and depression, and both are associated with psoriasis. Psoriasis management should therefore address these factors, but previous research shows this is rarely done in practice. Motivational interviewing is an evidence-based approach to supporting patients with behaviour change in a range of long-term conditions, but has not been applied to psoriasis management in the clinical setting. We explored the efficacy, feasibility and acceptability of a motivational interviewing-informed training intervention (‘Pso Well ’: Psoriasis and Well-being) for healthcare professionals who manage psoriasis. This training intervention addresses current recommendations for psoriasis care to integrate physical, psychological and behavioural aspects, thereby supporting patients to make behavioural changes leading to improved health and quality of life. This study investigated (i) whether participating in the Pso Well training intervention improves healthcare professionals’ behaviour change skills and knowledge of the behavioural factors related to psoriasis; (ii) whether intervention delivery of this kind is feasible to run within U.K. health settings; and (iii) whether the training content was acceptable to clinicians. Clinicians’ behaviour change skills were assessed before and after training using the Behaviour Change Counselling Index (BECCI) to score audio-recorded practitioner–patient actor consultations. A 22-item questionnaire assessed clinician knowledge of behavioural factors related to psoriasis before and after training. Feasibility and acceptability data were explored via semistructured interviews with practitioners following training and were analysed using an inductive thematic analysis approach. Sixty-one practitioners completed the training (35 dermatology nurses, 23 dermatologists and three general practitioners). Practitioners’ BECCI scores increased significantly post-training [t(54) = 8 37, P < 0 001; g = 0 56], as did their knowledge scores [t(60) = 4 30, P < 0 001]. Practitioners valued the training because it allowed them to examine and reflect upon their own consultation approach, and because it provided them with the skills and confidence to tackle challenging discussions with patients about lifestyle behaviours. Clinicians also highlighted that the training offers a significant shift in the usual consultation approach, and that they would like further training to consolidate these skills. The Pso Well training improved healthcare practitioners’ behaviour change skills in relation to providing holistic psoriasis management. Clinicians judged the training content to be relevant and useful, although further opportunity for skills consolidation may be needed. Investigation of the impact of the intervention on patient outcomes is now required.