The effectiveness of corticosteroids in calming irritable bowel disorder (IBD) flares is a double-edged sword. Patients who experience relief may believe they are free from flares and eschew longer-term therapy, raising their risk of hospitalization, ED visits and surgeries, says Sara Horst, M.D., a gastroenterologist at Vanderbilt University Medical Center.
Horst is working to identify strategies to improve patient adherence to prescribed therapies and optimize outcomes. Her recent research identifies the risks and other factors most associated with nonadherence. Horst is also testing how health coaching may help patients and providers partner in chronic disease management.
“The biggest thing I have learned in health coaching is how to more readily earn the patient’s trust, to better help them understand I have their best long-term interest at heart,” Horst said. “I have to establish a strong enough trust relationship in 20 minutes for the patient to change their routine and commit to long-term medication, often an injection or infusion. That is a challenge that can’t be met if I walk in, diagnose them, ask if they have questions, and hand them a script on the way out.”
“I have to establish a strong enough trust relationship in 20 minutes for the patient to change their routine and commit to a long-term medication.”
Barriers to Adherence
The good news for IBD patients is that long-term therapies are coming online at a rapid pace, including vedolizumab, a monoclonal anti-integrin antibody; ustekinumab, an anti-interleukin 12/23 agent; and the first small molecule, tofacitinib, a JAK inhibitor. “Data show a decline in the surgical rates in patients with both Crohn’s and ulcerative colitis, which may be in part due to newer medication and care strategies,” Horst said.
However, “all these options can be confusing for our patients,” Horst added, “and this confusion sometimes plays into less-than-ideal medication adherence.” When Horst and her colleagues studied 393 patients with Crohn’s disease and 67 with ulcerative colitis, only 69 percent overall were adherent to self-injectable biologic medication.
Nonadherence can have serious consequences. The risk of disease flare is significantly enhanced when the patient’s medication possession ratio (MPR, the rate at which the medication is refilled) is below 0.86. Hospitalization rates and corticosteroid use can increase dramatically.
Horst found that among patients who are nonadherent (MPR <0.86), the strongest distinguishing factors were current smoking, noncommercial insurance status, psychiatric history and current narcotic use. Multiple risk factors further increased the odds of nonadherence. Seventy-two percent of patients who had zero or one risk factor were adherent versus only 42 percent of those with all four risk factors.
Building a Partnership
After enrolling in a six-month health coaching course developed by Ruth Wolever, Ph.D., director of Vanderbilt Health Coaching, Horst began integrating health coaching into her own practice. She believes it can be a powerful tool for encouraging IBD patients to adhere to therapy and adopt healthy lifestyle changes.
Studies have shown that health coaches can help patients lower risk for cardiovascular disease, diabetes, and stroke, allow for improved weight loss, and help in medication adherence. “This is a new and innovative way to help patients make longstanding life changes,” Horst said.
She is currently running a randomized 24-month trial where study participants have up to ten half-hour sessions with a health coach every other week. Patients’ adherence will be measured by two pharmacy fulfillment parameters that predict the use of injectables.
Horst has experienced the impact of health coaching already in her interactions with current IBD patients. She is more deliberate today in how she connects personally and validates each patient’s experience with IBD. “They need to know I empathize with their disease experience,” she said. She is also integrating more discussion with patients about therapy options, including the available medications and their likelihood of adherence.
“We have to address their fears and reluctance and find what works for them,” Horst said. “Our shared goal is to get them healthy, but they may be focused on an immediate goal of not having to go to the bathroom ten times a day. My goal is also to take care of the person they will be in ten or fifteen years.”
“We have to address their fears and reluctance and find what works for them.”