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WHY FOLLOWING DOCTOR'S ORDERS CAN BE A TALL ORDER
Low health literacy // Lack of trust // Expensive medications // The medical world is working to find a smarter spoonful of sugar

Medication: Timely Reminders

By Cathryn Delude // Winter 2013
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REINHARD HUNGER

It’s a sad fact of modern medicine that many diseases—cancer, Alzheimer’s, Parkinson’s—remain difficult to treat. But for many of the most prevalent disorders, chronic diseases that affect large swaths of the population, there’s little mystery about what it takes to get better. Nutrition and lifestyle improvements can go a long way in keeping such diseases at bay. Still, those changes are hard, and a tough sell for doctors to make to patients. But we also have simpler and still highly effective ways to treat these diseases—shelves full of medications to reduce high blood pressure, lower cholesterol and decrease high blood sugar levels.

Yet there’s one big problem with that solution. C. Everett Koop, the former U.S. surgeon general, once noted that “drugs don’t work in patients who don’t take them,” and remarkably often, that’s exactly what happens. Over half of all prescriptions in the United States are not taken as directed, and 20% of new prescriptions are not filled. Many people don’t take any of their pills, while others omit doses, cut pills in half or take them less often than prescribed to save money. Or they take doses at the wrong time of day, with food instead of on an empty stomach, or with other medications that may undercut their effectiveness. Patients may discontinue therapies too early or fail to refill prescriptions.

In other words, they are nonadherent—and that’s exacting an underappreciated toll on patient care and the medical system. Adherence to a medication regimen means taking the prescribed dose on the right schedule and for the right length of time. “Incomplete adherence is the most common reason for the failure of medicine to achieve its intended goal,” says David Bangsberg, director of the Center for Global Health at Massachusetts General Hospital.

The nonadherence malady afflicts all demographic groups, although it is worse among the poor, the less educated, minorities, and those without health insurance or ongoing relationships with providers. Chronic diseases pose the biggest challenge. Patients who have an acute disease are likely to take their medicine. They can feel their symptoms subside, and they get to stop taking their antibiotics or other pills after a short course of treatment. Those with chronic diseases, in contrast, often don’t feel sick, and prescribed therapies may have side effects that make them feel worse. There’s also no end to their drug regimens, and elderly patients in particular may need to take several kinds of pills, for different conditions, with a complicated choreography of what to take when.

Patients are not the only ones at fault. Many doctors, pressed for time, scribble prescriptions with no explanation and then fail to follow up to see whether a patient is tolerating the drug. Improving both sides of the ledger—with physicians helping patients become more adherent—will require a range of remedies. The system will need to revamp the way doctors are compensated so that they’re rewarded for keeping patients with chronic diseases healthy, experts say. Pharmacists, nurses and office staff will need to get involved, and patients can be helped by various technological approaches. The payoff could be very large. “Improving adherence is easy pickings to improve health outcomes, rather than having to discover new ways to treat a disease—or reduce the cost of medicine,” says Janet Wright, a cardiologist and executive director of the national public-private Million Hearts initiative.

Concerns about nonadherence have been rising as many chronic diseases become more common. Almost half of the U.S. adult population now has at least one chronic condition, and treating those diseases accounts for three-fourths of all health expenditures. Seven out of 10 deaths result from chronic diseases, a reality that exacts a huge toll in disability and in loss of productivity and earning power.

Yet even looming death doesn’t seem to scare patients into adherence. Heart attack survivors, for example, may leave the hospital with instructions to take aspirin, a statin and a beta-blocker. A week later, almost a quarter of patients won’t have filled the prescriptions, and within a month, one-third will have stopped taking at least one medication, according to a 2009 study published in the journal Circulation. Only 40% will have remained on statins after two years. This nonadherence leads to more severe complications and more frequent emergency room visits, hospital admissions and readmissions. Nonadherence is thought to cause 125,000 deaths each year and a quarter of all nursing home admissions.

It also comes with a high price tag. Diabetes, hypertension and high cholesterol nonadherence cost the United States $106 billion a year, according to a 2012 analysis. In contrast, a 2011 study by national insurer CVS Caremark found that when patients take their medicine as prescribed, annual medical spending is reduced by almost $9,000 per patient with congestive heart failure, more than $4,000 per patient with hypertension or diabetes, and about $2,000 per patient with high cholesterol.

In many cases, patients may intend to take their medicine but forget or get confused, says Pascal Imperato, dean of the School of Health at SUNY Downstate in Brooklyn. Unintentional slipups are especially likely for elderly patients, those with cognitive decline or psychiatric disorders, and those who have to deal with multiple chronic conditions and may be taking several medications prescribed by different doctors. Affordability is another major hurdle. Study after study finds that the high cost of drugs and steep insurance co-payments prevent many patients from filling prescriptions and taking full dosages.

In some cases, though, patients just don‘t want to take what has been prescribed for them. They may not believe they are sick or that they need a drug, or they simply don’t care about their health. When asked about their adherence, they often lie. In a recent case study at Columbia University Medical Center in New York City, for example, one elderly patient who’d had a heart attack was discharged with several medications. A month later, he reported taking them every day. But an electronic pillbox and pharmacy records revealed he’d taken three of the drugs only a few times and never filled the fourth prescription.

Often, a lack of health literacy holds patients back, particularly when they’ve been prescribed pills for a condition without obvious symptoms. “You need to believe in a disease that’s silent,” says Edward Boyer, a physician affiliated with Boston Children’s Hospital and University of Massachusetts Medical School.

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1. “Adherence to Medication,” by Lars Osterberg and Terrence Blaschke, The New England Journal of Medicine, Aug. 4, 2005. This oft-cited review article discusses the measures of medication adherence and the impact of nonadherence, as well as the barriers to adherence, behaviors that contribute to it and interventions to improve it.

2. “The Adherence Estimator: A Brief, Proximal Screener for Patient Propensity to Adhere to Prescription Medications for Chronic Disease,” by Colleen A. McHorney, Current Medical Research and Opinion, January 2009. In nonadherence as with disease, an ounce of prevention is precious, but physicians rarely diagnose it. The three-item Adherence Estimator boils down the complex issues to a fast screening so that physicians can address the problem and help patients comply.

3. “A Multimodal Blood Pressure Control Intervention in 3 Healthcare Systems,” by David J. Magid et al., The American Journal of Managed Care, April 2011. In three health care systems, hypertension patients improved their blood pressure control during a six-month period when they received education, home blood pressure monitors and access to an interactive voice response system for reporting measures in tandem with monitoring by clinical pharmacists.

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