Habit-Based Interventions Increase Treatment Adherence in Gout

Niteesh Choudhry, MD, PhD

Credit: C4HDS

A predictable, structured routine designed to incorporate medication-taking behaviors was shown to promote consistent treatment adherence among a cohort of patients with gout, according to a study published in ACR Open Rheumatology^.1 Other useful tools included setting reminders and identifying context cues to promote the incorporation of medication-taking into daily routines.

Previous intervention studies have used financial incentives, reminders, pharmacist-led behavioral interviewing, and clinical-led educational counseling strategies. However, the long-term success of these interventions has not been proven.²

“When people engage in a habit, they consistently perform an action in the presence of relevant context cues,” wrote a team of investigators led by Niteesh Choudhry, MD, PhD, professor of medicine at Harvard Medical School. “Creating urate-lowering therapy (ULT) associations between context cues in a patient's daily routine and taking long-term medications such as ULTs could overcome barriers to adherence (eg, forgetfulness) and increase the regularity with which patients take their medications.

The study evaluated medication-taking routines as well as the feasibility of harnessing habit formation to improve treatment adherence. Eligible patients were recruited from the Brigham and Women’s Hospital and affiliated rheumatology clinics. Patients were aged ≥ 18 years, had a confirmed gout diagnosis, and were prescribed a ULT for ≥ 4 months.

Investigators conducted semi-structured qualitative interviews among subjects with gout who resided in an urban health care system to better understand typical medication-taking behavior, past experiences using electronic pill bottles, identify any barriers to adherence, existing context cues, and potential cues and rewards for habit-forming behavior. Patterns of treatment adherence were recorded for 6 weeks using electronic pill bottles prior to the interviews. Themes were generated using team-developed codes and interview transcriptions.

A total of 15 patients participated in the interview process, of which the mean age was 60.6 years, 60% (n = 9) were White, and 20% (n = 3) were women. Among patients, adherence to ULT was high (mean .91) and 1 patient reported an active gout flare.

Five key themes identified included (1) reasons for nonadherence, (2) internal and external motivating factors for adherence, (3) structured routines around taking medications, (4) rewards for good adherence, and (5) the role of pill cap technology in taking medication.

Patients who were nonadherent noted a variation in their typical routine or lack of standard routine. Patients also mentioned avoidance of pain as a significant factor for medication adherence, with overall wellbeing as a meaningful motivator. Patients who were more adherent were more likely interested in spending time with their loved ones with no restrictions.

Investigators noted limitations of the study including recruiting patients from a single institution, which may not be generalizable. Additionally, high adherence rates may have led to an establishment of a higher cutoff for nonadherence.

However, investigators noted strengths included using discussions that were directly informed by joint review of adherence patterns and photographs from the participants. Therefore, relevant adherence data were obtained from the pill bottles during the observation phase and were able to obtain more specific information regarding instances of nonadherence.

“This study provides in-depth insight into how context cues and routines can be used to establish habits around medication-taking behavior,” investigators concluded. “The new knowledge gained from this work demonstrates the feasibility of measuring adherence to ULT through electronic pill bottles and directly informs a habit-based intervention that uses context cues to improve medication adherence in patients with chronic conditions such as gout.”

References

1. ^{Crum KL, Choudhry NK, Fontanet C, et al. Leveraging Habits to Improve Adherence to Gout Medications: A Qualitative Study. ACR Open Rheumatol. Published online July 15, 2024. doi:10.1002/acr2.11706}
2. ^{Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014; 2014(11):CD000011.}