Taking our medicine

Apparently even the promise of no co-payments isn’t enough to entice some patients to take their medication.

For those who missed it yesterday, a new study reported that when a group of heart attack survivors was offered prescription medication fully covered by their health plan, fewer than half took the drugs. In fact, the researchers struggled to even get enough people signed up to take part in the study.

Coverage by the Associated Press produced what surely must be the health care quote of the month, from one of the researchers who was involved in the study: “My God, we gave these people the medicines for free and only half took it.”

A quick summary: The study involved 5,855 adults who had recently been hospitalized with a heart attack and who had been prescribed one or more medications afterwards to lower their risk of another cardiac event. About half of them were prescribed preventive medications with no out-of-pocket costs; the rest were given prescriptions with the usual co-pay. At the end of one year, fewer than half of the patients overall were actually filling their prescriptions – and there were only minor differences in the adherence rate between those who had a co-pay and those who didn’t.

So what is up with that? Are patients so unwilling to comply with taking their prescribed medication that they can’t even be motivated by free drugs?

That’s certainly one way to interpret this study. But I suspect there’s more going on here than a straightforward case of collective noncompliance.

Adhering to a medication regimen involves multiple, interrelated steps. For starters, patients have to buy into the notion that they need medication and that it will somehow benefit them. They have to fill the prescription at the pharmacy. They have to remember to take the drugs each day, and take them correctly. They have to remember to get refills. They might have to deal with unwanted side effects. Adherence can go off the rails at any one of these critical points.

Although it’s often assumed that cost is a major influence on whether patients get their prescriptions filled, the NEJM study suggests that it perhaps isn’t as important as other factors – and that if clinicians want to devise effective strategies to encourage adherence, they need to do more than address the money angle.

I’m aware of at least one study that found a surprisingly basic reason for why some patients don’t take their medication: They simply don’t like the idea of taking a lot of pills each day.

It would be interesting to know the extent to which psychology might be contributing to medication non-adherence. The patients in the NEJM study had all recently had a heart attack. On average, they were 53 years old. Among at least some of them, perhaps their vision of themselves was that they were mostly healthy. Perhaps they weren’t emotionally ready yet to accept that their health had changed or that they were going to need medication for the rest of their life.

On top of this, there are strong American cultural attitudes about aging and infirmity. We tend to regard disease as a burden on society and often blame the sick for “not taking better care of themselves.” Should we be surprised when people resist taking prescription medication because, consciously or not, they don’t want to be perceived as one of those sick, costly individuals?

The study in the New England Journal of Medicine did reinforce that when patients stuck with their medication regimen, they were less likely to have a second cardiovascular event. Overall, health care costs for these people also were somewhat lower. The savings weren’t huge but then again, it often can take years to see a measurable payoff from this kind of health intervention, and the study wasn’t designed to track long-term results.

Did the elimination of co-pays help some patients more than others? It’s probably safe to assume that it did, at least among those for whom cost was the main barrier. For other folks, though, it’s clearly going to take more than this to raise the adherence rate. A better understanding of both the practical and emotional issues involved might be a good place to start.

Getting practical with medication adherence

If patients aren’t taking their prescription medications properly, maybe the problem doesn’t rest entirely with their level of health literacy or motivation. Maybe what they really need is more help incorporating their pill regimen in their daily routine.

This is the premise of a newly published article in the Nursing Clinics of North America journal, which examines potential strategies for getting people to take their medication correctly.

Medication adherence is a significant issue. Those who study it have estimated that 30 to 50 percent of Americans take their prescription drugs incorrectly, resulting in billions of dollars each year in additional health care costs to treat the consequences. Although it’s a problem that can occur at any age, it tends to be more prevalent among older adults who are more likely to be taking multiple prescription drugs.

Researchers at the University of Missouri examined a collection of previous studies and concluded that much of the effort to improve medication adherence has focused on things such as the patient’s knowledge, motivation and cognitive abilities – and that this approach hasn’t always worked very well.

What they call for instead is a “personal systems approach” – that is, giving people practical ways that help ensure they take their medication correctly.

This could include strategies such as “putting pills next to the coffee maker as a reminder to take them each morning or using technology like cell phones and computers to set reminders to take medications,” Cynthia Russell, an associate professor of nursing at the University of Missouri, explained in an accompanying news release.

The researchers make several concrete suggestions. One of them is creating a routine that encourages and reinforces adherence. Another is involving a supportive family member or caregiver. Monitoring techniques, such as pill-bottle caps with embedded computer chips that record each time the bottle is opened, might also help people stay on track.

There are many, many reasons, of course, for why people don’t take their medication correctly. Sometimes they don’t think they need medication, or don’t want yet another daily pill. Sometimes they’re reluctant to accept the side effects. And sometimes they just can’t afford to fill the prescription.

If you think of this as a continuum, though, these issues tend to cluster at the front end, when the medication is first prescribed. Once the patient has agreed to try the medication, fills the prescription and brings the pills home, a whole different set of challenges arises – namely, the day-to-day routine of remembering to take the medication and taking it as directed.

I’m not a forgetter. I’m very motivated to take my medication, it’s part of the daily routine and over the past six years, I think I might have forgotten only once. (I’m not quite so adherent with veterinary medications, although the issue here isn’t my memory; it’s the prospect of forcing a pill down the throat of a hissing, protesting, unhappy cat.)

For many people, though, forgetfulness and inconsistent routines are significant reasons for falling off the medication wagon. In a study published earlier this year, researchers queried more than 8,000 people who had been prescribed medication for high blood pressure but weren’t complying. The chief findings: “forgetfulness” and “being too busy” topped the list of reasons for non-adherence.

The researchers make a telling observation:

Our findings indicate that events interfering with daily routine had a significant impact on adherence. Medication adherence appears to be a patterned behavior established through the creation of a routine and a reminder system for taking the medication. Providers should assess patients’ daily schedules and medication-taking competency to develop and promote a medication routine.

All of the clinician’s careful work to explain why a medication is needed and how it should be taken can be completely undone if the patient goes home and then forgets, or can’t stick to a routine. When it comes to medication adherence, the practical things really do seem to matter.

Photo: Wikimedia Commons

When patients don’t follow orders

Getting patients to adhere to the doctor’s advice has always been one of the struggles in medicine. Sometimes patients don’t truly understand what’s expected of them or why they would benefit from, say, taking a prescription drug or receiving physical therapy. Sometimes there’s just honest disagreement between doctor and patient about the best course of action.

It can be easy to write off these nonadherent patients as stubborn, misguided or self-destructive. A rather intriguing new study suggests, however, that patients’ own beliefs about their ability to manage their health play an important role in adherence – and that health outcomes tend to be better when the doctor and patient have compatible beliefs. The study appeared in the May issue of the Journal of General Internal Medicine.

Eighteen primary care physicians and 246 patients at the VA Iowa City Medical Center and affiliated clinics were involved in the study, which queried both the doctors and the patients about their beliefs in personal control over health outcomes. Doctors and patients then were assessed for how closely their beliefs matched and how well this match corresponded with the likelihood that the patients filled their prescriptions and had well-controlled blood pressure and blood sugar measurements.

According to the findings, health outcomes were best when physicians and patients shared similar beliefs. This seemed to hold true not only for patients and physicians who both had a strong belief in personal control over their health but also for those who shared a weaker belief in this control. Patients fared less well, though, when there was a gap between their beliefs and the physician’s beliefs.

It should be noted that this study only involved VA patients who had both high blood pressure and diabetes, so the findings can’t necessarily be generalized to the rest of the population. It raises some interesting issues, though, about doctor-patient dynamics, especially when it comes to advising the patient what to do.

Does it matter whether the patient’s values are considered? Maybe it does, the study’s lead author, Alan G. Christensen, explained in an article this week in American Medical News. For instance, patients who place a high importance on control might react negatively – perhaps by not filling a prescription – if they perceive the doctor doesn’t take their values into account. On the other hand, patients who don’t have a strong sense of personal control over their health might feel pressured or overwhelmed if they’re dealing with a doctor who believes in greater empowerment. 

“The nonadherence itself can be a way for the patient to restore some sense of control,” said Christensen, chair of the University of Iowa Dept. of Psychology and senior scientist at the Center for Research in the Implementation of Innovative Strategies in Practice.

Patients don’t all have the same views of how they want to manage their health, he said. “One patient’s empowerment is another patient’s burden.”

Indeed, patients’ values and beliefs influence their actions to a greater extent than many health care professionals realize. Stephen Wilkins, a specialist in health care communication, explored this issue awhile back on his blog, Mind the Gap:

One of the basic tenets of the patient-centered care model is getting to know the “person behind the patient label,” i.e. their health motivations, attitudes, beliefs and so on. Why? It is because people that show up in the doctor’s office each have their own pre-existing set of experiences, knowledge and beliefs about their health and the health care system.

A patient’s motivations, attitudes and beliefs are shaped by a variety of experiences. Maybe they had a family member or friend with the same health condition. Maybe they saw or heard a TV or radio commercial. Or maybe they had a previous bad experience with another provider. Regardless of where this thinking comes from, or whether it is “right or wrong,” patient thinking plays an important yet often overlooked role in patient adherence.

A commenter on Wilkins’s blog brought up another point: Perhaps health care professionals unintentionally encourage nonadherence by what they convey, verbally or nonverbally, to the patient. The commenter writes: “Lack of empathy, focus on the numbers of lab results, threats of complications, judgment, etc., during an office visit (or over the phone) often sets a patient up to feel he/she has already failed (so why bother?), and has an enormous impact on how a patient may or may not manage a chronic disease.”

Whether busy physicians are willing or able to take the time to uncover their patients’ beliefs is a separate question. The authors of the Iowa City VA study suggest a good first step would be to develop a quick assessment tool that could be used to help better understand the patient’s values and motivation, and presumably help tailor the doctor’s recommendations more effectively.

Nonadherence is a tough problem to solve. And it’s not just about the physician; at some point patients have to take responsibility too. Knowing what makes a particular patient tick, however, and gaining insight into why the patient might not be adhering to the doctor’s orders can be a critical step toward addressing it constructively.

Update, May 20: Here’s another look at patient nonadherence, specifically nonadherence to prescription drugs, that appeared today in the New York Times.

Photo: Wikimedia Commons