American College of Physicians: Internal Medicine — Doctors for Adults ®

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Mistrust, costs, side effects keep patients from taking pills

From the February ACP Internist, copyright 2009 by the American College of Physicians

By Jessica Berthold

NEW ORLEANS—No patient walks through the door with a sign proclaiming that she isn't adhering to her medication. But non-adherence is a big problem—much bigger than most physicians realize, according to several speakers at a session on the topic during November's American Heart Association Scientific Sessions conference.

Several studies on heart disease patients have found that adherence drops sharply, by about 15%-18%, in the first month after initiation of treatment and/or hospital discharge, and continues to decline steadily over the next few months and years, said Michael Ho, MD, PhD, of the Denver VA Medical Center.

Not surprisingly, other studies show non-adherence is associated with worse blood pressure control regardless of therapy intensification, and higher mortality after acute myocardial infarction, among other things, Dr. Ho said.

“In the words of [former Surgeon General] C. Everett Koop, ‘Drugs don't work in patients who don't take them’,” Dr. Ho said.

Why patients don't adhere

The first step in getting patients to adhere is understanding the reasons they don't, said Carole Decker, RN, director of cardiovascular outcomes at the Mid-America Heart Institute in Kansas City, Mo. Ms. Decker and her colleagues recently completed two qualitative studies examining patients who'd had a myocardial infarction and were prescribed clopidogrel or cholesterol-lowering therapy. The patients self-reported their medication-taking behavior, and were interviewed about it by the researchers.

“I had one 55-year-old woman who was adamant that her doctor had told her to stop taking her medication after a month. Yet looking at her chart, there was no reason to stop at 30 days,” Ms. Decker said. “Others said they had been told two different things by their cardiologist and the primary care provider, or they indicated the cost of the medication was prohibitive.”

Other research has shown that patients usually don't set out to be noncompliant with their treatment. A June 14, 2005 Annals of Pharmacotherapy study, for example, found that patient nonadherence to hypertension medication was unintentional in 77% of cases.

“Nonadherent patients may have difficulties establishing a pattern of behavior,” Ms. Decker said. “They may have trouble remembering things or creating a routine.”

Those who deliberately skip their medications often do so because of side effects, she added, while others prefer alternative therapies or distrust the healthcare system, she said.

In Ms. Decker's clopidogrel study, the patients' top reason for not taking medication was lack of awareness about the need to take it. Physicians, on the other hand, assumed the patients' top reason was cost.

“A patient's perspective is very enlightening, and it doesn't need to take a long time for the patient to describe to you his or her adherence behavior,” Ms. Decker said. “Your interventions need to be geared toward the specific reason your patient has stopped taking the medication, or is likely to stop.”

How can doctors tell?

Studies suggest that both house staff and family physicians are bad at guessing which patients will adhere. House staff predictions of noncompliance were wrong about 75% of the time, and family physicians' predictions were no better than chance, said Ian Kronish, MD, an internist at Mount Sinai School of Medicine in New York City.

“It's important to find out if your patient isn't adhering, because sometimes if a patient doesn't reach a goal, like lowering the blood pressure or A1C, we just intensify the treatment regimen,” Dr. Kronish said. “That isn't going to help if they aren't adhering in the first place.”

Several factors predispose a patient to nonadherence, he said. These include having:

  • an asymptomatic disease,
  • a complex medical regimen with side effects,
  • a psychological problem like depression,
  • a lack of belief that treatment will help,
  • a poor social support network,
  • poor access to care, and
  • financial difficulties such that co-pays and drug costs are a burden.

Of course, asking a patient directly is a good way to find out about adherence, although the patient may not always be truthful for fear of disappointing the physician. As such, it's important to ask in a way that is non-threatening, Dr. Kronish said.

“Use non-judgmental questions, ask about the side effects, ask if they know why they are taking the medications, and ask about their beliefs about the medications,” Dr. Kronish said.

The Morisky Medication Adherence Questionnaire uses many of these tactics, he added. It is a validated, self-report scale with eight items that has shown to be 93% sensitive in identifying poor hypertension control, according to a May 2008 article in the The Journal of Clinical Hypertension.

Merely asking patients about their medications can help them adhere if they are not, because it can uncover the issues that are hampering them, Dr. Kronish said.

“Communication from health care providers really can have an impact, and the more people talk about it, the better,” Dr. Kronish said.

There will always be patients who choose not to adhere, and a physician should really talk through the reasons to figure out the best way to help those people.

“Someone seeking care has already chosen to say ‘I need to know more about what is causing my chest pain,’ or whatever the issue is. So if you assess what their barrier is, you can help. If a person wants to do all alternative medicine, you have an opportunity to thoroughly provide a plan, and say that maybe if this doesn't work, the patient could consider a chemical compound,” Ms. Decker said.

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Strategies that work: simplify, explain, involve

Several evidence-based tactics exist for helping patients improve adherence, though the evidence itself is somewhat mixed, said Robert Carney, PhD, a professor of psychiatry at the Washington University School of Medicine in St. Louis, Mo.

Reminder packaging helps patients put medications in compartments, reminds them to take their pills, and then shows them at the end of the day whether they have taken everything. Some packages are quite sophisticated, and include a calendar, a clock and an alarm that goes off when one is supposed to take a pill, which is especially good for patients with complicated medical regimens. “You should be familiar with at least some of the kinds (of packaging) on the market, so you can recommend one that might be best for your patient,” Dr. Carney said.

Simplify a patient's medication regimen by reducing the number of drugs taken per day, either by changing the dosing—going from two pills a day to one, for example—or combining pills. One study found nine trials on fixed-dose combinations associated with a 10% improvement in adherence, Dr. Carney said. “Studies show that if you can switch from two pills a day to one, you'll see a 6%-12% improvement. Going from three to one a day, you'll see a 10%-15% improvement, and from four to one a day, you'll see a 20%-25% improvement,” Dr. Carney said.

One potential drawback: when a patient skips a day, he skips all of his pills for that day. Using extended release pills, or pills with a longer half-life, can help alleviate that problem. Some drugs also simply can't be combined.

Explain the need for the medication regimen, as well as your expectations of the patient. “Try to understand their routines and whether they are likely to have problems taking the medications,” Dr. Carney said. “Then customize a regimen that will work for that person.”

Involve family and community resources, especially if money is an issue. Also involve patients in decisions about medication. If there are a number to choose from, sit down and discuss the options with the patient, Dr. Carney said. Talk about what to expect in terms of the course of the disease and the side effects, and encourage a pill-taking system.

Ask about barriers to taking the medication. “Patients may be embarrassed to talk about a certain side effect like increased appetite or sexual dysfunction, so you need to raise those kinds of questions,” Dr. Carney said.

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