107 Clinician-led Intervention to Improve Medication Adherence among Patients with SLE

Background Medication nonadherence is common and is associated with increased disease activity, morbidity, and mortality in SLE. Medication nonadherence is more common among patients from racial and ethnic minority groups, which likely contributes to racial disparities in SLE outcomes. Effective patient-clinician communication can improve adherence through honest exchange of information and by strengthening trust and therapeutic alliance. However, patient-clinician discussions about nonadherence occur sporadically and at times may be potentially confrontational. Further, Black patients tend to experience poorer communication quality with clinicians and have less active participation in decision- making in clinic visits. Existing adherence interventions in SLE have not addressed patient-clinician communication nor focused on reducing racial disparities in SLE medication nonadherence. Our group developed an intervention that involves clinicians reviewing real-time pharmacy refill data during the visit and using effective communication techniques with patients to collaboratively overcome adherence barriers (figure 1). Prior pilot testing demonstrated intervention feasibility, acceptability, and preliminary effect on adherence. However, we found that the intervention did not work as well for patients who were Black, single, of younger age, and lower income. To enhance the intervention effects for patients with these characteristics, we conducted a follow up study to examine how the intervention is performed in practice and identify areas for improvement to inform future implementation. Methods Clinicians at a tertiary lupus clinic implemented the intervention during routine visits. We audio-recorded 4–5 encounters per clinician of nonadherent patients (90-day proportion of days covered (PDC) <80% for SLE medications). Recordings were coded and scored for intervention components performed, communication quality, and time spent discussing adherence. Clinician communication quality was rated using a 5-point Likert scale (with 5 being the best) on the following domains: level of engagement (attentiveness), how well clinicians addressed and anticipated patient concerns, flow of the conversation, and how much respect and warmth the clinician showed. We assessed active patient participatory behavior such as asking questions and making assertive statements. Following the intervention encounter, we also conducted audio-recorded semi-structured interviews with patients and clinicians about their experiences with the intervention and analyzed the data using applied thematic analysis. Lastly, we assessed change in 90-day PDC after the intervention visit and considered a 20% increase as major improvement. Results We recorded and analyzed 25 patient encounters (median age 39, 100% female, 72% Black) among 6 clinicians. Clinicians performed most intervention components in most encounters, with the exception of asking open-ended questions which occurred in about half of visits (table 1). Global communication scores and rates of active patient participation were high, suggesting excellent communication. Adherence discussions took on average 3.8 minutes. Following the intervention visit, 44% of patients had a major improvement (>20% increase) in PDC. Nineteen patients and 5 clinicians completed in-depth interviews. Nearly all participants felt the time spent discussing adherence was just right and necessary. Many patients felt heard and valued and described being more honest about nonadherence and more motivated to take SLE medications. To improve the intervention for Black patients, patients emphasized patient-clinician communication and financial and logistical assistance. Some clinicians wanted additional resources and training to improve adherence conversations (table 2). Conclusion Our findings suggest that this intervention encouraged high quality communication and can be performed within an encounter. Both patients and clinicians described positive experiences with the intervention. Future work will focus on optimizing clinician training, exploring ways to increase the intervention's efficiency and effectiveness, and testing the intervention in a larger controlled setting.