Abordaje de la adherencia en diabetes mellitus tipo 2: situación actual y propuesta de posibles soluciones ☆

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Resumen

Objetivos

Definir el impacto y las causas de la falta de adherencia terapéutica en los pacientes con diabetes mellitus tipo 2 (DM2), las posibles intervenciones para mejorarla y el papel de las distintas partes implicadas.

Diseño

Valoración de cuestionario estructurado mediante método Delphi aplicado en 2 rondas.

Emplazamiento

Estudio realizado en el ámbito de atención primaria.

Participantes

Panel formado por profesionales médicos de reconocido prestigio y con amplia experiencia en diabetes.

Mediciones principales

Valoración a través de una escala Likert de 9 puntos del grado de acuerdo o desacuerdo de 131 ítems agrupados en 4 bloques: impacto; causas de incumplimiento; diagnóstico de la falta de adherencia y de sus posibles causas, y mejores intervenciones y papel de los distintos roles implicados en la mejora de la adherencia.

Resultados

Con una tasa de participación del 76,31%, los profesionales sanitarios de atención primaria consensuaron 110 de las 131 aseveraciones propuestas (84%), mostrando acuerdo en 102 ítems (77,9%) y desacuerdo en 8 (6,1%). No se logró consenso en 21 ítems.

Conclusiones

La falta de adherencia en los pacientes con DM2 dificulta lograr el control terapéutico. La formación específica y disponer de los recursos necesarios en la consulta son esenciales para minimizar el impacto de la falta de adherencia terapéutica.

Translated abstract

Objectives

Define the impact and causes of non-adherent type-2 diabetes mellitus (DM2) patients, possible solutions and the role of the different health care professionals involved in the treatment.

Design

Structured questionnaire rating by a two-round Delphi method.

Location

The study was conducted in the Primary Care settings.

Participants

The expert panel consisted of renowned medical professionals with extensive experience in diabetes.

Main measurements

Assessment through a 9-point Likert scale, of the degree of agreement or disagreement on 131 items grouped into 4 blocks: impact; causes of nonadherence; diagnosis of non-adherence, and possible causes, solutions and role of the different professionals involved in adherence.

Results

The participation rate was 76.31%. The primary care health professionals agreed on 110 of the 131 proposals statements (84%), showing agreement on 102 items (77.9%) and disagreement in 8 (6.1%). Consensus was not reached on 21 items.

Conclusions

The lack of adherence of DM2 patients makes the achievement of therapeutic control difficult. The medical practice needs to have specific training and enough resources to reduce the impact of the lack of therapeutic compliance.

Related collections

Most cited references 29

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Prevalence of diabetes mellitus and impaired glucose regulation in Spain: the Di@bet.es Study

F. Soriguer, A Goday, A. Bosch-Comas … (2011)

Aims/hypothesis The Di@bet.es Study is the first national study in Spain to examine the prevalence of diabetes and impaired glucose regulation. Methods A population-based, cross-sectional, cluster sampling study was carried out, with target population being the entire Spanish population. Five thousand and seventy-two participants in 100 clusters (health centres or the equivalent in each region) were randomly selected with a probability proportional to population size. Participation rate was 55.8%. Study variables were a clinical and demographic structured survey, lifestyle survey, physical examination (weight, height, BMI, waist and hip circumference, blood pressure) and OGTT (75 g). Results Almost 30% of the study population had some carbohydrate disturbance. The overall prevalence of diabetes mellitus adjusted for age and sex was 13.8% (95% CI 12.8, 14.7%), of which about half had unknown diabetes: 6.0% (95% CI 5.4, 6.7%). The age- and sex-adjusted prevalence rates of isolated impaired fasting glucose (IFG), isolated impaired glucose tolerance (IGT) and combined IFG–IGT were 3.4% (95% CI 2.9, 4.0%), 9.2% (95% CI 8.2, 10.2%) and 2.2% (95% CI 1.7, 2.7%), respectively. The prevalence of diabetes and impaired glucose regulation increased significantly with age (p < 0.0001), and was higher in men than in women (p < 0.001). Conclusions/interpretation The Di@bet.es Study shows, for the first time, the prevalence rates of diabetes and impaired glucose regulation in a representative sample of the Spanish population.

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Interventions to enhance medication adherence in chronic medical conditions: a systematic review.

Sunil Kripalani, Xiaomei Yao, R. Brian Haynes (2007)

Approximately 20% to 50% of patients are not adherent to medical therapy. This review was performed to summarize, categorize, and estimate the effect size (ES) of interventions to improve medication adherence in chronic medical conditions. Randomized controlled trials published from January 1967 to September 2004 were eligible if they described 1 or more unconfounded interventions intended to enhance adherence with self-administered medications in the treatment of chronic medical conditions. Trials that reported at least 1 measure of medication adherence and 1 clinical outcome, with at least 80% follow-up during 6 months, were included. Study characteristics and results for adherence and clinical outcomes were extracted. In addition, ES was calculated for each outcome. Among 37 eligible trials (including 12 informational, 10 behavioral, and 15 combined informational, behavioral, and/or social investigations), 20 studies reported a significant improvement in at least 1 adherence measure. Adherence increased most consistently with behavioral interventions that reduced dosing demands (3 of 3 studies, large ES [0.89-1.20]) and those involving monitoring and feedback (3 of 4 studies, small to large ES [0.27-0.81]). Adherence also improved in 6 multisession informational trials (small to large ES [0.35-1.13]) and 8 combined interventions (small to large ES [absolute value, 0.43-1.20]). Eleven studies (4 informational, 3 behavioral, and 4 combined) demonstrated improvement in at least 1 clinical outcome, but effects were variable (very small to large ES [0.17-3.41]) and not consistently related to changes in adherence. Several types of interventions are effective in improving medication adherence in chronic medical conditions, but few significantly affected clinical outcomes.

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GPs' perspectives of type 2 diabetes patients' adherence to treatment: A qualitative analysis of barriers and solutions

Johan Wens, Etienne Vermeire, Paul Van Royen … (2005)

Background The problem of poor compliance/adherence to prescribed treatments is very complex. Health professionals are rarely being asked how they handle the patient's (poor) therapy compliance/adherence. In this study, we examine explicitly the physicians' expectations of their diabetes patients' compliance/adherence. The objectives of our study were: (1) to elicit problems physicians encounter with type 2 diabetes patients' adherence to treatment recommendations; (2) to search for solutions and (3) to discover escape mechanisms in case of frustration. Methods In a descriptive qualitative study, we explored the thoughts and feelings of general practitioners (GPs) on patients' compliance/adherence. Forty interested GPs could be recruited for focus group participation. Five open ended questions were derived on the one hand from a similar qualitative study on compliance/adherence in patients living with type 2 diabetes and on the other hand from the results of a comprehensive review of recent literature on compliance/adherence. A well-trained diabetes nurse guided the GPs through the focus group sessions while an observer was attentive for non-verbal communication and interactions between participants. All focus groups were audio taped and transcribed for content analysis. Two researchers independently performed the initial coding. A first draft with results was sent to all participants for agreement on content and comprehensiveness. Results General practitioners experience problems with the patient's deficient knowledge and the fact they minimize the consequences of having and living with diabetes. It appears that great confidence in modern medical science does not stimulate many changes in life style. Doctors tend to be frustrated because their patients do not achieve the common Evidence Based Medicine (EBM) objectives, i.e. on health behavior and metabolic control. Relevant solutions, derived from qualitative studies, for better compliance/adherence seem to be communication, tailored and shared care. GPs felt that a structured consultation and follow-up in a multidisciplinary team might help to increase compliance/adherence. It was recognized that the GP's efforts do not always meet the patients' health expectations. This initiates GPs' frustration and leads to a paternalistic attitude, which may induce anxiety in the patient. GPs often assume that the best methods to increase compliance/adherence are shocking the patients, putting pressure on them and threatening to refer them to hospital. Conclusion GPs identified a number of problems with compliance/adherence and suggested solutions to improve it. GPs need communication skills to cope with patients' expectations and evidence based goals in a tailored approach to diabetes care.

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All references

Author and article information

Contributors

Domingo Orozco-Beltrán

Journal

Journal ID (nlm-ta): Aten Primaria

Journal ID (iso-abbrev): Aten Primaria

Title: Atencion Primaria

Publisher: Elsevier

ISSN (Print): 0212-6567

ISSN (Electronic): 1578-1275

Publication date PMC-release: 13 January 2016

Publication date (Print): Jun-Jul 2016

Publication date (Electronic): 13 January 2016

Volume: 48

Issue: 6

Pages: 406-420

Affiliations

[a ]Cátedra de Medicina de Familia, Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, España

[b ]Grupo de Trabajo de Atención Primaria y Diabetes de la Sociedad Española de Diabetes (SED) y de la RedGDPS, Centro de Atención Primaria La Mina, Sant Adrià del Besós, Barcelona, España

[c ]Miembro de la comisión RedGDPS, Centro de Salud Hereza, Leganés, Madrid, España

[d ]Secretario General de la Federación Europea de Medicina Interna (EFIM), Hospital General Universitario Gregorio Marañón, Madrid, España

[e ]Coordinador del Grupo Diabetes Mellitus de SEMERGEN, Centro de Salud Burgos Rural, Burgos, España

[f ]Coordinador Nacional del Grupo Diabetes SEMG, Centro de Salud Buenavista, Toledo, España

Author notes

[* ]Autor para correspondencia. dorozcobeltran@ 123456gmail.com

Article

Publisher ID: S0212-6567(15)00270-X

DOI: 10.1016/j.aprim.2015.09.001

PMC ID: 6877892

PubMed ID: 26775266

SO-VID: 2d6bd0e3-6103-4911-8d3a-a98e7a65d263

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).