Research published in the Annals of Internal Medicine showed that 2 or 3 in 10 prescriptions are never filled, and half of all patients don’t follow their drug instructions, even if doing so is necessary to keep them alive.
There’s a proper way to take medicine, whether it’s a prescription or over-the-counter remedy; all meds come with directions about when, how and how much to take. Doctors have a term for whether people follow those directions: “compliance” or “adherence.”
A recent story in the Washington Post recounted just how difficult it can be for doctors, and pharmacists to get patients to follow medication instructions. Some patients resist because of cost, some because instructions are unclear or taking the meds properly is inconvenient. Some aren’t convinced the meds are helping, and some just can’t stand the side effects. Compliance can be challenging especially for elderly people, many of whom take multiple pills or other treatments a day, and get confused over the drill for each.
Still, as Meera Viswanathan told The Post, “the amount of nonadherence is staggering.” She’s director of the RTI-UNC Evidence-based Practice Center, a public-private institute that analyzes health care and health policy.
Decades ago a study pegged the number of annual deaths due to noncompliance at 125,000, which is about how many people die every year from strokes.
In addition to failing to address the underlying medical problem or, worse, harming the patient, noncompliance is expensive: According to The Post, as much as $289 billion is spent every year on needless hospitalizations, emergency room visits and other consequences of people not following their drug regimens.
So lots of things have been tried to solve the noncompliance problem. Even offering medicine for free, The Post said, hasn’t shown impressive results. But new funding as part of the Affordable Care Act (ACA) is subsidizing experiments that seem to offer hope in the intractable problem.
The experiments are part of the “health care innovation awards” granted by the ACA, and other efforts, by both public and private interests also are seeking solutions to the problem.
One project is about “behavioral economics.” About 1,000 people who were discharged from the hospital after having a heart attack were given “electronic pill bottles.” If they forgot to take their medicine, the cap on the bottle would illuminate and beep. If they remained noncompliant for a few more days, a person they had designated, as well as their doctor, would be notified, in the hope those folks would remind them to take the medicine.
If they did, they became eligible to win small cash prizes.
“I know $5 may not seem a lot to you, but it is thrilling to win a lottery,” one study subject, Melody Givison, told The Post. She had left the hospital with four medications she was supposed to take every day, at different times, in addition to the thyroid med she was already taking. She credited the program with keeping her on her medications for a year, and won two $50 prizes and a dozen $5 awards.
David Asch, director of the center that conducted the research, reported that the preliminary data suggest a big improvement in adherence when compared with other efforts involving similar patient populations.
“We designed it with the foibles of human nature in mind, not with the rational person in mind,” he told the newspaper. “Because the rational person would have been taking their meds in the first place.”
That’s a bit harsh — you don’t have to be irrational to forget to take your meds, or believe that because you’re feeling well you don’t need them — but reminders and incentives clearly have value in this application.
Other compliance-promoting projects include the “Pharm2Pharm” experiment, which seeks to connect doctors and pharmacists who dispense medication to patients being discharged from hospitals with community pharmacists who provide a continuum in dispensing them as those people resume their lives.
Community pharmacists, the story said, often don’t know which medications their patients are taking, especially when they leave the hospital with new ones, so they run the risk of missing a dangerous drug interaction, especially with patients who take tons of different meds, vitamins and supplements.
Another program involved pharmacists who took a training course, and 100,000 mostly poor or elderly people who appeared to be failing to refill their prescriptions or taking incorrect drugs based on data provided by insurers. After working with the patients, the pharmacists relayed their findings to prescribers, which included cost concerns and an inability to recognize the importance of taking the medicine.
But the trick is to keep patients following the drill once the outside programs or incentives have ended making smart use of medications a habit, just like brushing your teeth or exercising regularly.
To become a better, more “adherent” consumer of medicine, read Patrick’s newsletter, “Becoming a Smarter Buyer of Prescription Drugs.”