As part of SERMO’s partnership with Joslin Diabetes Center, Dr. Sethu Reddy, MD, MBA, MACE shared this post with our community. If you’re an MD or DO in the US or UK, please join us!
Across the country, this scenario gets repeated daily. A new drug is discovered and proves to be very helpful for controlling the blood sugars. Many millions of dollars were spent studying the medication with real patients for six months or longer. Then the drug gets approval from the FDA and is soon available in the neighborhood pharmacy. The doctor is excited about the potential of the new drug and writes a prescription.
It has been said that up to one-third of these prescriptions don’t actually reach the pharmacist. Mr. Smith with diabetes has not been told too much about the new medication. (The doctor was running late in the office that day.) The medication just had to be taken twice a day.
When Mr. Smith went to the pharmacy to pick up the medication, the pharmacy technician asked Mr. Smith if he needed advice on the medication from the pharmacist. Since there were quite a few people near the Pick-Up Counter, Mr. Smith was nervous about discussing medical details with strangers nearby.
He wasn’t sure whether to take the medication before meals or after meals. He tried calling the doctor’s office but got one of those talking computers. He got frustrated and hung up. His only daughter lived thousands of miles away in California – “no need to bother her”.
There really wasn’t anyone else to ask. Ever since his wife passed away, he didn’t get out of the house much. Friends became more like acquaintances with only occasional interactions. He turned the TV on and forgot about the medication. “He’ll think about it tomorrow.’
This drama plays over again and again in our country in thousands of homes. All too common! The doctor and the pharmacist assumed that they did their job, and now it was up to the patient.
So what has happened?
A lot of time and energy was spent on a presumed course of action.
There was poor communication all around.
Money was spent on a medication. It had been approved by the FDA because of the success of the medication in clinical trials.
The medication was not taken the way it was supposed to be.
The patient, Mr. Smith’s health did not improve as expected.
The wrong assumptions are made and thus lead to not only to wasted resources but lead to hospital admissions or procedures that could have been avoided. Over the course of a year, this may result in spending several hundred billion dollars that could have been avoided.
The World Health Organization defines ADHERENCE as ‘the extent to which a person’s behaviour – taking medication, following a diet and/or executing lifestyle changes – corresponds with agreed recommendations from a healthcare provider’.
NON-ADHERENCE could be:
- Failing to get a first prescription filled,
- Discontinuing a medication prematurely (i.e. without completing the regimen),
- Taking the wrong amount of medication (more or less than prescribed), OR
- Taking a dose at the wrong time (this is particularly important for diabetes medications.)
It is thought that 1/3 to half of all prescribed medications are not taken correctly. Almost 1/3 of all hospital admissions in the US for those over age 65 may be due to NON-ADHERENCE. Overall, may cost close to $300 billion. This is money that could be either saved or spent on public health measures.
NON-adherence is more common for long-term conditions, like diabetes, high blood pressure or arthritis. What are some responses to this? For one, the health care system may have to develop programs to manage non-adherence, through medical clinics, pharmacies, community centers and other facilities. The doctor may prescribe another medication thinking the first medication is not working. A medication that someone buys but does not take is like that unused Christmas gift of a shirt that your brother bought you. It truly is a WASTE of money.
NON-adherence could be intentional. i.e. the patient for a variety of reasons does not want to take the prescription: perhaps the drug is too expensive; perhaps the patient does not fully understand the importance of taking the medication.
NON-adherence could be unintentional. i.e. the patient wants to take the medication but a variety of life scenarios prevent her from taking the medication consistently. It could be her work or family schedule. It could be the complexity of the medication regimen. It could be unwanted side effects of the medication. It could the lack of a reminder system. Its possible health care issues of her friends or relatives are affecting her motivation. Sometimes the adherence can vary over time; one month, it may be very good and the next month, not so good.
One could learn more about the medication or simplify the regimen. One could also make it easier with a reminder system (like a weekly pill-box). However, these measures alone are not enough. And with respect to diabetes, the impact of not taking medications may show up to a degree with elevated glucose levels which may or may not be manifest to the patient depending on how much self-monitoring is being done. The ultimate impact, however, may not be seen for years.
As a clinician, how should you approach the issue of adherence? Some thoughts would include:
- Make sure you explain to all patients what the new medication does.
- Patients should know what the new medication will do for them. What to look for in seeing its effect. How fast will those effects be seen?
- What side effects should the patient look out for? Address the issues out there in the lay press and internet – what is a real concern and what may be an issue that is blow out of proportion or misunderstood from inaccuracies in reports and lay-discussions.
Proactively address other options and issues
- Will it be OK to take the medication with other medications? Including non-prescription items such as vitamins and herbal remedies?
- If a dose is missed, what should the patient do?
- How will use of this medication fit into the patient’s lifestyle, schedule, and health beliefs?
No patient should leave the doctor’s office without a discussion as to whether he or she understands the recommendations for medication use, and if they agree with them and think that they can use the medication successfully. Do they really agree with the recommendation for that particular medication?
General Overview of NON-adherence:
A lot of focus is spent on intervening on patient-related factors, but one should remember that there are other reasons for people to be NON-adherent. Factors contributing to NON-adherence are related to the condition/disease itself, the therapy, social/economic issues, and health system or healthcare team can all play a role in adherence. Often, less attention is paid to the health care provider and health system-related factors.
Adherence to medications, optimal diet and to optimal exercise habits is DIFFICULT for everyone. We must forgive occasional lapses and continue to look after our health. When I go skiing, the first thing I do is fall or trip so that I don’t have to be nervous about never falling for the rest of the day. We all slip but we must get up and continue our efforts towards better health.
People can’t do it alone. It does take “a village” to stay on track. We all need help not just from the doctor, but from other health care professionals including pharmacists and from friends, relatives and colleagues.
So what adherence issues have you encountered? What issues have been particularly challenging to you? Perhaps you have some advice on how to address them.
Have you incorporated MI (motivational interviewing) to increase patient engagement in your office?
We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O. in the US or UK, please join us.