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9990 · 3.2.3

Improving adherence — practice questions

Practice and worked examples for 9990 Improving adherence. Short previews only — attempt the full question in MarkScheme against the official scheme.

Worked example 1

A hospital wants to improve post-discharge adherence among heart failure patients who frequently miss diuretic medication.

(a) Design a multi-component adherence intervention for these patients. [4 marks] (b) Evaluate one psychological technique and one practical technique in your intervention. [6 marks]

Show solution outline

(a) Multi-component intervention:

  1. Patient education session before discharge — explain why diuretics prevent fluid retention and hospital readmission (target HBM perceived benefits).
  2. Simplified regimen — once-daily dosing timed with breakfast.
  3. SMS reminders — daily text at 8am: "Time for your heart medication."
  4. Pill organiser (dosette box) pre-filled by pharmacy.
  5. Motivational interviewing call at 1 week — explore fears about side effects.
  6. Family involvement — teach spouse to support without nagging.

(b) Evaluation:

Motivational interviewing (psychological):

  • Strengths: Respects patient autonomy — avoids Milgram-style authority dynamic where doctor orders and patient passively complies. Elicits intrinsic motivation — patient articulates own reasons for taking medication.
  • Limitations: Requires trained staff — time-consuming; not cost-effective for all patients. Less effective for cognitive impairment where MI dialogue is difficult.

SMS reminders (practical):

  • Strengths: Randomised trials show 15–20% adherence improvement; targets unintentional forgetting; low cost, scalable via NHS apps.
  • Limitations: Digital divide — elderly patients may lack smartphones. Does not address intentional non-adherence (e.g. stopping due to side effects). Message fatigue over time.

Judgement: Best outcomes when psychological (MI, education) and practical (reminders, simplification) components are combined — addresses both belief and behaviour barriers identified in 3.2.1.

Worked example 2

A health clinic is trying to improve adherence to hypertension medication for its 500 registered patients. Baseline adherence, measured by prescription refill rates, is 55%. The clinic implements a multi-component intervention for 6 months, costing £10 per patient. After the intervention, adherence increases to 75%. The average cost of an emergency hospital admission for a hypertensive crisis is £2,200. It is estimated that for every 20 patients who become adherent, one hospital admission is prevented during this period.

Calculate the net financial impact of this intervention for the clinic over the 6-month period. Show your working.

Show solution outline

Step 1: Calculate the increase in the number of adherent patients.

  • Initial number of adherent patients = 500 patients * 55% = 275 patients
  • Number of adherent patients after intervention = 500 patients * 75% = 375 patients
  • Increase in adherent patients = 375 - 275 = 100 patients

Step 2: Calculate the total cost of the intervention.

  • Cost per patient = £10
  • Total number of patients = 500
  • Total intervention cost = 500 patients * £10/patient = £5,000

Step 3: Calculate the cost savings from prevented hospital admissions.

  • Number of patients needed to become adherent to prevent one admission = 20
  • Total number of new adherent patients = 100
  • Number of hospital admissions prevented = 100 / 20 = 5 admissions
  • Cost per admission = £2,200
  • Total cost savings = 5 admissions * £2,200/admission = £11,000

Step 4: Calculate the net financial impact.

  • Net Impact = Total Cost Savings - Total Intervention Cost
  • Net Impact = £11,000 - £5,000 = £6,000

Final Answer: The intervention resulted in a net financial saving of £6,000 for the clinic over the 6-month period, demonstrating its cost-effectiveness.

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