“Drugs don’t work in patients who don’t take them” – C. Everett Coop, MD, former US Surgeon General.
Medication adherence, or the degree to which a patient’s medication-taking behaviors comply with a prescribed regimen, represents a serious and insidious barrier to optimal patient care. Many factors may affect adherence to a regimen, including perceived acuity of the disease being treated, regimen complexity, sequelae of the patient’s underlying illness, and provider-patient relationships. Regardless of the reasons for nonadherence, it is clear that patients may not receive the full benefit of a medication regimen as a consequence of not taking the medication. In the United States, an estimated 33–69% of medication-related hospitalizations result from poor medication adherence.
While many studies report percentages of “adherence” and “nonadherence” as dichotomous and mutually exclusive variables, the true nature of medication adherence more likely resembles a continuum. Recognizing medication non-adherence and acting to improve patient self-efficacy present opportunities to improve both patient care and provider-patient relationships.
et al.. Adherence to medications: insights arising from studies on the unreliable link between prescribed and actual drug dosing histories. Annu Rev Pharmacol Toxicol. 2012; 52:275–301.
T. Drug therapy: adherence to medication. N Engl J Med. 2005; 53:487–497.
Because it is difficult to predict patient adherence behavior, it is critical to identify barriers to adherence that may be controlled or modified. Many techniques may be used to assess compliance, including directly observed therapy, pill counts, review of prescription refill records, and patient interviews. Directly questioning the patient, while efficient and easy to do in an office visit, may create a bias towards perceived compliance that is not actually true. Morisky and colleagues developed a validated four-question assessment to gauge patient adherence behaviors. Patients are asked these questions:
Do you ever forget to take your medications?
Are you careless at times about taking your medications?
When you are feeling better, do you sometimes stop taking your medications?
Sometimes if you feel worse, do you stop taking your medications?
Techniques from motivational interviewing may be useful in eliciting useful responses. In particular, empathizing with the patient about their medication regimen may be helpful. For example, a physician might ask about medication adherence while providing support, as in the following example: “I know it is difficult to take all of your medications—how often do you miss taking them?” This approach makes a patient comfortable and allows the physician to gain useful and truthful information.
If nonadherence to a medication regimen is identified, consider assisting the patient by helping them to create a medication list or calendar, provide refill reminders, use a pill organizer, develop a medication reminder chart, or consider electronic devices and compliance services. Additionally, consider referring the patient to their pharmacist for support.
et al.. Current and predictive validity of a self-reported measure of medication adherence. Med Care. 1986; 241:67–74.
Clear communication with patients when prescribing new medications is imperative. Improved medication adherence has been associated with patients who receive better general communication, more medication information, and better explanations about how to take medications. Despite the importance of conveying this information, prescribers often fall short. Tarn and colleagues (2006a, b) studied physician communication for new medications and found that physicians failed to describe the medication’s name 26% of the time, potential side effects 65% of the time, and cost 88% of the time.
The measurement tool used by Tarn and colleagues, known as the medication communication index (MCI), was developed from national guidelines for communication about new medications. This simple five-category index can be used as a guide for the five points to discuss with patients each time a new medication is started: (1) name of the medication, (2) purpose or justification for use, (3) duration of intake, (4) directions for use, and (5) potential adverse effects.
et al.. Development and evaluation of a medication counseling workshop for physicians: can we improve on ‘take two pills and call me in the morning?’ Med Educ Online. 2011; 16:7133.
et al.. Physician communication about the cost and acquisition of newly prescribed medications. Am J Managed Care. 2006; 12:657–664.
In 2011, spending on prescription drugs in the United States amounted to $263 billion, or 9.7% of national health expenditures. These costs continue to rise from year to year; between 2001 and 2011, prescription drug spending increased by almost 90%. For patients who have trouble affording their prescriptions, there are several ways to combat the high costs of drug therapy.
If the patient has prescription insurance coverage, prescribing within the payer’s formulary will aid in reducing out of pocket costs. Many third-party payers now post their formularies online where patients and providers may easily reference them. Prescribing of generic or lowest-tier drugs is encouraged whenever possible. Some retail pharmacy chains provide generic drug pricing plans that can decrease patients’ medication costs even further. Overall medication burden may also cause financial strain for patients. In this case, a thorough medication regimen review may identify drugs that can be discontinued, if medically appropriate.
For patients who do not have insurance, a few options can be pursued to help them obtain medications at a reduced cost:
A patient aged ≥65 years can apply for drug coverage through Medicare Part D. To determine which plans the patient is eligible for, and associated costs, visit www.medicare.gov.
Determine whether your patient qualifies for any federal, state, or military-operated program. Income restrictions apply.
Have contact information available for state Medicaid programs.
Consider applying for medication assistance programs sponsored by pharmaceutical manufacturers. Pharmaceutical manufacturers supplied free or low-cost medications to >5 million people in the United States. Several Internet sites are available to aid in obtaining information on how to use these programs, including www.needymeds.com, www.rxhope.com, and www.themedicineprogram.com.
et al.. What is the evidence for pharmaceutical patient assistance programs? A systematic review. J Health Care Poor Underserved 2011; 22:24–49.