Five Ms of adherence

The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate (Hippocrates1) Adherence to recommended regimens is difficult to ensure in the treatment of diabetic people for hyperglycemia, dyslipidemia, and hypertension,2 although adherence correlates well with metabolic control3 and outcome.4 Diabetes treatment typically requires one to two drugs, blood pressure lowering two to three drugs, and lipid lowering at least one drug. Patients with multiple cardiovascular (CV) risk factors require antiplatelet agents as well, so that a minimum of six separate agents, often given in divided doses, becomes necessary. Self-monitoring of blood glucose is often recommended, requiring additional prescribed materials, and we typically endeavor to pursue lifestyle goals of dietary change aiming for a 5%–10% weight loss and of regular moderate exercise for 30 min daily. Thus, the regimen of people with Type 2 diabetes becomes highly complex and expensive, with the need to maintain a variety of scheduled self-treatment tasks. Clearly, a diabetic person’s attitude to the disease is crucial to successful treatment and, equally, it is well-recognized that there is considerable variability in attitudes, from highly positive to negative and detrimental, which may interfere with adherence.5 Approximately two-thirds of people follow their diabetic regimen.6 When blood pressure- and lipid-lowering agents are added, adherence is further reduced.7 Numerous approaches have been recommended and should be incorporated into the management of diabetes by healthcare professionals and patients alike, perhaps even with peer support of patients with diabetes interacting with one another to better understand and follow their treatment approach.8 To simplify this task, and to better remember the steps required, we propose that people with diabetes be helped in the five “Ms” of messaging, motivation, monitoring, money, and mobility. Messaging refers to a core concept, namely the crucial need for novel approaches to improve patients’ health literacy, enhance effective communication by patients during clinical encounters, and to induce a sustained interest in patients’ desire to achieve optimal outcomes. This novel approach is necessarily patient centered. Motivation refers not to the exhortation of the diabetic patient to follow the proposed regimen but, more subtly and much more effectively, to teaching healthcare providers motivational listening skills, empowering diabetic patients by understanding their concerns, and ultimately allowing them to be self-motivating participants in their own clinical management.9,10 If a diabetic man believes that antihypertensive medications are the cause of his erectile dysfunction, no amount of shouting will overcome his reluctance to take them; but, listening in such a fashion as to learn his concerns and respond appropriately may lead to treatment adjustment that will improve his blood pressure and also his overall functioning. Monitoring refers not only to glucose self-monitoring, but being aware of the medication schedule and observing whether it can be readily followed, and to monitoring exercise and diet. Helping diabetic patients to formulate self-monitoring plans impacts this behavior.11 Money refers to the response of the patient with diabetes to costs and rewards. There is evidence that patient cost sharing adversely influences adherence,12 whereas financial incentives improve medication adherence,13,14 although such approaches alone may not be sufficient to improve outcome.15 Finally, mobility refers to ensuring that medications can be taken and that diet, exercise, and self-monitoring can be performed by patients with busy, mobile lifestyles not conducive to traditional fixed regimens. We suggest that the use of “smartphone apps” will be the next breakthrough in developing appropriate and easy ways to achieve these goals. A single app can include messaging to the patient with reminders of times to take medications and of diet, as well as between the patient and healthcare provider, planning advice to enhance the motivational interview of the patient’s healthcare visit. The app can be used to monitor and record administration of medications, food intake, macronutrient composition, and extent of physical activity. The apps may even be adaptable for automated recording of blood glucose, weight changes, blood pressure, laboratory tests, and examination findings from the healthcare provider, leading to reports from the patient to the provider and from the provider to the patient. Such an enhanced interaction, messaging and communication between patient and physician could create a level of engagement that augurs well for positive clinical outcomes.16,17 The app could incorporate tracking features linked to financial incentives. Efforts to begin such approaches have been developed with text messaging reminders,18 with pedometers linked to an online social support network,19 with insulin pen delivery devices having memory features,20,21 and with personal digital assistant devices.22 One advantage of using cellular phones is the much greater likelihood that the diabetic person will carry and use the device through the day. A number of early prototypes of cell phone-based diabetes apps are already being developed. Part of this is simply the old-fashioned art of medicine, but we envisage repackaging the art to which Hippocrates referred so that we and our patients will be less likely to find “experience perilous, and decision difficult”.1 Let us harness technology to help this future to come into being.