Medication adherence, defined as “as any deviation from the prescribed course of medical treatment,” is a tough issue, and its costs to people and society are well characterized.
I am by no means an expert on medication adherence; the way adherence enters my professional sphere is in the form of technology solutions designed to improve it, typically through the use of electronic reminder systems and other tools, and new ones are cropping up every day.
While I have a lot of enthusiasm for others’ enthusiasm for tools like this, I have felt that the problem of adherence is fairly deep and complicated, and that technological solutions on the patient side may not be the most cost-effective way to start to address it.
Fortunately, this awareness is increasing – A few months ago I was contacted by the National Consumers League, who are working with the Agency for Healthcare Research and Quality to plan a national aherence campaign to improve prescription medication adherence.
What interested me about the work was the fact that the project would include (among other information gathering approaches) focus groups of patient and providers around the issue of medication adherence. I know focus groups aren’t perfect, but I am always drawn to any topic that includes patient perspectives, I can’t help it.
I just received a copy of the focus group report and reviewed it, with permission to blog about it here. Since I don’t see it available for download anywhere else, I’ll just make it available via this link (PDF). National Consumers League performed a literature search as a foundation for this work, and I have combined it with some data from the Deloitte 2009 Survey of Health Care Consumers, which also addressed prescription usage.
If they don’t fill the medication, there’s nothing to adhere to
First, it’s estimated that between 1/4 and 1/3 of people never fill their medications. The 2009 Deloitte Survey of Health Care Consumers provides a nice characterization and some of the causes, a big one of which is cost.
The relationship is key
As I read the focus group findings and some of the quotes below, I couldn’t help getting a visual image of two (or more – think provider and patient + family and community) people working hard to establish a relationship that just ends up with missed connections:
“Do I trust my doctor? You are entering a new relationship that is important as anything and you are wondering if he is the right person for you.”
“Sometimes the doctor explains it but usually at that point I forget and I don’t catch it.” (Short-Term Patient) “
“I agree with him, sometimes when the provider is giving you all of this information you have so many other things going through your mind, like I have to take medication or you know at the end when you get to the pharmacy that you are going to get that pamphlet and you are going to look at the bottom to see what you take once per day.” (Short-Term Patient)
“The doctors do not explain it, I usually ask the pharmacist or I will read the pamphlet.” (Short-Term Patient)
“Some of the medicines I would agree with it {patients are{unaware of why they are taking med}, they might have known when they started it but by the time they are on 10 different meds, maybe 40%, some meds they don’t understand what they are.” (Multi-Specialty)
Providers want to perform for their patients
There are definitely some provider quotes that made me cringe, however, reading carefully, it’s clear that health care providers are aware of the impact of the relationship and do their best to help their patients:
“I agree with her because not a lot of people ask questions, I spend 2 hours with my primary, she had a waiting room full of people and my daughter was a new patient and she spent one hour with her after I saw her.” .” (Chronic Condition Patient)
“If you are asking me personally {specialist}, I do try to explain the medicine because if I take the time doing that I can make the patient much more comfortable accepting my recommendation and the phone calls after the visits are less. The patient remembers 30% of what we tell them once the door is closed and sometimes I think it is less than that so if I spend the time up front explaining to the patient why this medicine is needed, I just find that the patient is much more comfortable accepting my recommendation and the patient has much less phone calls later on.” (Multi- Specialist)
Patients don’t want to be sick
This seems like stating the obvious, however, I think work like this helps to emphasize it. People will take medication when they feel they need it, and when they don’t they won’t.
“Well, maybe (stop taking medication} if I just didn’t think I needed it at that point. I was feeling better.” (Short-Term Patient)
“I agree, I mean the blood pressure medication you just can’t stop, but if it is something for the flu or a bad back or something after a while you feel better you will stop taking it.” (Short-Term Patient)
“I am always trying to minimize the number of medications that I have to take despite the fact that right now that I take 5 or 6, I just don’t like to take chemicals. I try to minimize the number that I take so I am constantly asking my doctor do I have to continue taking this, can I get off it and some don’t have to be forever but there are others that I am trying to get off from. So minimizing the numbers, I don’t like to take meds.” (Chronic Condition Patient)
In addition to the work of National Consumers League, the New England Healthcare Institute also just put out a report that supports broad thinking about the issue of adherence.
This information plus my experience makes me feel that there are actually a broad array of technology approaches to supporting adherence, including reminder systems (whose innovation should be incorporated into a comprehensive strategy to be sure). Those technology approaches may be most cost-effectively applied as close to the provider patient relationship as possible, to include things like:
- An after-visit summary after every encounter (whether on the phone, e-mail, or in person), with an accurate medication list that the patient + family + support can verify and ask questions about
- Education aids in every encounter to promote understanding of medication use to include the “why?” as well as the “what?”
- Accessible two-way communication (phone, e-mail) before, during, and after every encounter. Imagine that adherence could be impacted if a patient, provider, or their family/community could inquire about medication use outside of a formal visit. If that communication is non-existent or cut-off, how will patients and their families fare once they leave the pharmacy?
I want to say again that I do not study adherence for a living, so I welcome others’ thoughts about this in the comments. In the meantime, I am glad to see organizations like Naitional Consumers League and AHRQ engaging on this topic in the first place, and engaging by learning about patients and providers’ experiences. Let us remember that this is what a typical medication regimen can look like for a patient with diabetes and use it to guide our understanding (courtesy of Paulanne Balch, MD, Colorado Permanente Medical Group):
