Patient adherence to drugs is low and what doctors can do

Frequently in preventive health we ask patients to take medications that will reduce the risk of a certain bad medical outcome years down the road: cholesterol-lowering agents that lower the risk of a heart attack, blood pressure-lowering agents that reduce the risk of kidney disease, glucose-lowering medications that reduce the risk of diabetes-related complications.

Sometimes these medications make patients feel better — for example, insulin in patients with symptomatic diabetes or a beta-blocker in someone with exertional angina — but more commonly patients get no tangible benefit from these medications on a day-to-day basis.

As doctors, we prescribe medications as a matter of course. If we deliberate, it is primarily in choosing which pill to prescribe. If the patient has hypertension, should we prescribe hydrochlorothiazide (HCTZ), an ACE-inhibitor, a calcium channel blocker, or a beta blocker? If a beta blocker, do we go with metoprolol or carvedilol or perhaps the newest beta blocker nebivolol? And what about the dose? There are sometimes good medical reasons to select one drug over another. There are dozens of clinical studies that test the use of different drugs in different patient populations and then there are evidence-based guidelines to help doctor make point-of-care decisions.

It turns out though that in practice despite the million dollar drug studies, the expert guidelines, and the deliberating, the most important thing we can do in prescribing a drug is to get our patients to actually take it. Adherence is a measure of how well a patient follows a treatment plan. Though the exact numbers vary by disease and treatment, adherence is on average 50 percent. That is, patients take their medications as prescribed about half the time.

As one might expect the harmful effects of low adherence are enormous. According to a recent report in JAMA, poor adherence accounts for an estimated 33 to 69 percent of medication-related hospital admissions with an estimated cost of $100 billion. More importantly, poor adherence is also a major contributor to preventable deaths and reduced quality of life. Adherence is also a huge public health opportunity. In one recent study, simply improving adherence to statins from 50 to 75 percent in patients at high risk for coronary heart disease averted twice as many cardiovascular deaths than would an equivalent increase in prescribing statins for those at lower risk. I would love to hear of any new drug or device that could match that kind of impact.

So why is adherence so low? And more importantly, what can we do about it?

Part of the problem is reimbursement. It’s easier for me to get a cardiac stress test covered for a patient than it is a pill box to help him or her organize and remember to take their blood pressure and cholesterol medications.

Part of the problem is human nature. We tend to place greater value on today than tomorrow. This practice of “discounting” actually makes economic sense and is the basis for a large segment of the financial industry. However, in general we tend to discount the future more than we should – a phenomenon called “hyperbolic discounting.” Because we place undue emphasis on today compared to tomorrow, we are even less likely to take a medication that does little for us today for the sake of future benefit.

Part of the problem is the health care system. Chronic diseases are not treated in doctor’s offices or even the hospital. They are treated at home; they are treated every day in the decisions people make over what to eat and what not to eat and in the little blue pill they choose to swallow every morning or not. But the health care system has little reach on the home; it is not designed around where chronic disease management and prevention actually happens.

Reimbursement is a Washington issue (though as citizens we can certainly make an impact). Human nature, while largely unchangeable, can be tricked into working for us. This largely has to do with patient education. By helping people “see” the daily benefits of the medications they are taking today, we can improve their health tomorrow.

For example, for hypertension, by encouraging people to track the change in their blood pressure daily or weekly, we can help them better relate the act of taking their medication each day to its long-term beneficial effects. Finally, we have the health care system. At my institution, I’m part of a study trying to link up a key part of a person’s daily life — his or her cell phone — to the health care system. Through automated text messages, we are helping patients with diabetes better remember to take their medications during the 8758 hours of the year they are not with us in clinic.

But there is certainly more all of us can do. For example, doctors do not regularly assess adherence. Imagine a clinic setting where adherence was the fifth vital sign right next to temperature, heart rate, blood pressure, and respiratory rate.

As doctors, we spend a lot of time hemming and hawing about which pill to give our patients. As researchers, we study new drugs in hopes that they will be a few percentage points better than the ones we have currently. One pill may be 5 percent better than next, but if the patient only takes it 50 percent of the time, does it really matter?

In our excitement over choosing between the red pill and the blue pill, we ought to spend more time just making sure our patients are actually taking the pills we give them.

Shantanu Nundy is an internal medicine physician and author of Stay Healthy At Every Age: What Your Doctor Wants You to Know.

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  • anon

    I like what Sapira writes on the issue of “compliance” in the introduction to Art and Science of Bedside Diagnosis: “… It is quite likely that the problem was with me, not with the patient. I had failed to spend enough time to persuade the patient of the presumed wisdom of my advice; or perhaps I had not got to know the patient well enough to understand why the advice would not be attractive.” Its application to the present article is that one of the element lacking in the state of the current health care system is time.

    Finances, certain side effects (read sexual side effects, among others), and dosing (as well as a host of other factors) all affect patient’s differently, and without sufficient time invested into the interview, it can’t be expected that we would fully understand an individual patient’s lack of adherence.

    Unfortunately, the lack of time is one of the major issues facing Medicine today and is often the underlying issue of the majority of the articles on this blog.

    I don’t propose a solution here nor do I condemn those that are suffering from “hypochronia”, simply an observation that taking the time to understand why each individual patient stops taking their medicine, and the forces acting on the patient that contribute to it, may be the most important element in improving adherence in the future… impractical as it might be in today’s system.

  • http://nostrums.blogspot.com Doc D

    When I was a hospital commander in the Air Force, as a part of our Child Safety program we would send teams door-to-door to ask for leftover medicines: The goal was to limit opportunities for children to accidentally overdose.

    We were astonished at what was collected. Prescriptions for hypertension that were filled years previously, half-filled bottles of pen-VK, etc. It confirmed other studies on compliance, and led us to work harder with patients on “why” to take an antibiotic for 10 days, and “what it means” to stop a medicine they need to take regularly.

    Finally, asking patients to bring their medicines to the clinic with them (which some of them thought an unnecessary hassle) sometimes gave us a clue as to whether they were following the prescribed regimen or not.

  • http://www.silvercensus.com/ Steffan Lozinak

    As true as it is to help with the problems that occur, I think another major reason people don’t adhere is that coming up with a pill is not the best way to handle these problems. Many people more than likely believe that they shouldn’t need any pill or help and in general tehy are right that they shouldn’t (even though they might.

    I feel a pill may be a good way to reverse symptoms that have already occurred (such as a pill to counter the growth stunting effects of Ritalin, or to help clean arteries) however for most things, we should focus moreso on trying to prevent the problem from occurring in the first place. Like for high cholesterol, we need to work on our diets and the foods we eat, produce, and sell.

  • Anonymous

    How does compliance with recommendations to clean up one’s diet and increase exercise compare with compliance with taking prescribed drugs?

  • http://www.blausen.com/iphone bruce blausen

    Agree with your reasons for non-adherence, but would expand the “Human Nature” one beyond “hyperbolic discounting.” I think a lot of this disregard comes from many patients not fully understanding their condition or treatment plan. They know their diagnosis and treatment relate to some ephemeral condition they’ve heard of and been verbally told about, but they don’t fully comprehend. That’s why point of care patient education will become increasingly important in the future, and with it the rapidly evolving mobile devices can help the clinicians deliver it. At Blausen we believe that showing patients high quality animations with explanatory narration via an iPhone or the new iPad will enhance their understanding and buy-in to their role in their treatment. Of course, it will save the doctors’ time as well. This entire area of point of care education delivered by mobile communications devices (already underway with the iPhone and other smartphone apps) is only going to grow. Now, with the richness, clarity and larger screen size of devices like the iPad, get ready to see more and more of it. The Blausen Human Atlas iPhone app is already available (http://www.youtube.com/watch?v=XpxFmlTn120 ) and we are optimizing it for release very soon on the iPad. Hopefully, things like these will help increase patient adherence and overcome some of the negatives of “Human Nature”.

    Bruce Blausen CEO Blausen Medical
    http://www.Blausen.com

  • LynnB

    What a terrific article about adherence. I am so delighted that someone can write about this without yelling at the patients who are doing what seems best to them. When I am in clinic it makes me nuts. Whn I am in the hospital it makes me nuts. Perhaps I am just nuts .

    One of the problems I see is that the insurance companies “grade” us on prescribing all the right meds. In the clinic , I prescribe them, try to “sell ” the med to the patient (who may think to himself–I know that my nephew lost weight and got off insulin, I will just wait and see if I really need it) and put them on the list. I get in trouble with insurance because if the patient says they won’t take it, I remove it from the list. They send me tons of educational materials with stunning new information like , did you know that ACE inhibitors and ARB’s are preferred meds in diabetes , or Statins reduce cholesterol. Really?

    Thus when I am in hospital I see long lists of meds that I assume the patient with nephrotic syndrome or a CVA is actually taking. The frightened patient says “I take lisinopril” or ” I take simvastatin” because they know they should be taking it . Armed with that information I change call the nephrologist about a biopsy, or change to a more potent more expensive med , send the dietitian over and maybe set up the outpatient lipid clinic.
    I think if we got a “ping” back to the EMR whenever the patient picked up the med , as opposed to whenever I wrote the prescription, it would help at the next visit or admission. If the insurance company paying for the script spent their energy educating patients rather than me , and pharmacies focused counseling towards BENEFITS as well as risks it would help a bit. I would also, like to be able to hold responsible any person (forgiving “counselors” who have low health literacy) who convinced another patient that their blood pressure cholesterol, diabetes , thyroid or HIV meds were dangerous. I truly wish that behavior would become socially unacceptable. I really can barely stomach the non-resident family members who flock to the bedside if the elderly person who is taking cinnamon for cholesterol, changed to stevia for diabetes, and is swallowing enough dandelion to cause renal failure based on the advice of this person (who often sells the stuff) who knows a lot because he/she was a home health aide or read a book. Enough of that

    What a great article, and so much to the point . I just ordered 3 copies of the book for my exam rooms on Amazon. I only have 2 rooms , I am HOPING patients will ask to borrow it.

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