The Struggle to Get Patients to Take Their Meds

This article originally appeared on HCPLive.com.

Improving drug adherence is one of the most important opportunities in all of medicine to improve public health, according to Duke University cardiologist Christopher Granger, MD. “We have proven approaches, but they are not as systematically applied to our patient populations as they should be,” he said during a presentation at the American Heart Association’s Scientific Sessions 2010.

Michael Ho, MD, PhD, cardiologist at the Denver Veterans Administration Medical Center, pointed to studies that show that nearly one in four patients do not fill their initial prescription. Studies also show that even if a patient fills the original prescription, adherence declines over time. Ho said that low adherence increases risk of coronary revascularizations, cardiovascular mortality, and all-cause mortality.

Causes for non-adherence are complex and include mistrust of providers or drugs, cognitive impairment, increasing co-payments, lack of social support, complex dosing schedules and belief that the drug is not helping. But part of the problem is that non-adherence is under-recognized among providers and therefore undertreated. Ho said that questioning patients as they get their vitals taken on whether they have had trouble taking their medications as prescribed is an important first step in boosting adherence levels.

Citing a study that looked at how frequently providers increased anti-hypertensive medicine in response to elevated blood pressure, Ho said that “about a third of the time patients had their blood pressure medicine increased, but interestingly, this was regardless of whether they were taking their medications.”

Data from meta-analyses have shown that effective interventions incorporate more tailored instruction, communication and counseling via telehealth, simplified dosing with combination pills, efforts to engage patients to help them better understand why they are taking the drugs, and reinforcements and rewards. “If we start to think of non-adherence as a chronic condition maybe that will start the conversation and put it on the radar,” Ho said.

Nancy Artinian, PhD, FAHA, FAAN, associate dean for research at the College of Nursing at Wayne State University in Detroit, said that non-adherence is particularly a problem among older adults. “More than 50% of Medicare beneficiaries do not take their medications as prescribed,” she said. This results in more hospital admissions, emergency department visits, lab tests, and nursing home placements, and costs the US $100 billion a year.

Artinian emphasized the distinction between intentional non-adherence by patients (causes of this include mistrust of drugs or clinicians, denial that they have a chronic condition, etc.) and unintentional non-adherence (causes include physical/cognitive impairments; lack of reminders, etc.). Artinian described the conciliatory patient who is not adherent, but will nod “yes” to avoid embarrassment or confrontation when the provider asks whether he or she takes the medications as prescribed.

Better recognition of all these forms of non-adherence is paramount, Artinian said. She recommends using the ACE-ME model, which emphasizes the collaborative approach to adherence. The acronym represents these steps:

• Assessment of medication management capacity, including cognitive and functional skills.
• Collaboration on a strategy that creates and maintains a person-specific plan that reflects a patient’s daily realities, such as complex dosing schedules. This often may include family members or even religious leaders.
• Education to explain the effects of the medication and articulate why a regimen is important—the risk/benefit of treatment. This should be respectful of literacy level.
• Monitoring to see how well the plan is implemented. Adherence questions should be asked at every visit.
• Evaluation to see when the plan is off-track and time to begin another ACE cycle.

Artinian said that there is no evidence that low adherence can be “cured,” so efforts to improve adherence must be maintained for as long as treatment is needed. “Patients are more likely to adhere with individual medication schedules they perceive as needed, effective and safe,” she said.