50% of patients do not take their medicines as prescribed. What can we do about it?
Jennifer K. Bussell, MD, FACP, is an expert who speaks nationally to the Institute for Healthcare Improvement on improving medication adherence and is involved in developing the medication adherence module for the AMA's STEPS Forward Program.
Q: How do you describe medication adherence and nonadherence?
A: If a patient takes 80% of their medication in a given time frame, that's medication adherence. For example, if a provider were to prescribe one pill per day of metformin to a patient with diabetes, and the patient took one pill daily for at least 24 days out of a 30-day period, then they would be adherent because they would be taking at least 80% of that medication.
Anyone taking less than 80% of prescribed medicines would be considered nonadherent. Sometimes a patient will be adherent to several medications and not adherent to one or two of them. It's not an "all-or-none" issue.
Q: What is realistic for providers to expect from a patient in terms of medication adherence?
A: We should not expect perfection. Providers need to recognize that medication adherence is a tough thing to discover. Some patients are stating that they're honest about their medication-taking behavior; however, providers need to recognize that there's a "white-coat adherence." Patients may be adherent a week or a month before they come to your office, so they can honestly say, "Yes, I'm taking my medication as prescribed."
Q: What are some clues to look for to identify medication nonadherence?
A: It's very tough. It takes your interest being piqued to recognize the subtle clues. For example, some clues include patients who have suboptimal critical outcomes, such as uncontrolled A1C, blood pressure and lipid profiles. Other clues are patients who are "frequent flyers" when it comes to hospital admissions or readmissions, or patients who miss their appointments and follow-ups. Also, patients who have psychological stressors, anxiety disorders, a history of depression and even low health literacy can be clues to investigate further.
Q: What are some tips for improving medication-taking behavior in patients?
A: Once you have clues that a patient may be nonadherent, then you have to start the dialogue and ask your patient some questions. Patients don't want to be reprimanded. They don't want to be scolded. How you ask and who does the asking makes a really big difference to discover a patient's true medication-taking behavior. Look your patient in the eyes and ask about it in an encouraging way. Don't type away on your computer as you're discussing this.
Q: How do you start the conversation and create a blame-free environment?
A: I always start by wording questions in a way that gives patients the permission to say, "I'm not taking the medicine." Instead of asking, "Are you taking these medicines?" consider a different approach such as, "I know taking medicine every day is difficult; how often do you miss them?" This way, you give the patient an opportunity to say, "Yes, I do miss them sometimes."
Q: Why is the conversation about medication adherence important both for the provider and the patient?
A: I've had colleagues tell me, "My patients do as I tell or advise them." I say, "Well, then you're not looking, because 50% of patients do not take their medicines as prescribed, and 25% of patients never fill the prescriptions written for them." Providers have to look. If they don't ask, they'll never know what their patients are actually doing.
The impact of medication adherence on the patient is enormous but not exclusively the responsibility of the patient. Patient and provider have to work together to improve health outcomes.
Thank you Dr. Bussell for sharing your expertise on medication adherence with us. To learn more tips for improving medication adherence, check out Dr. Bussell's article, and stay tuned for a future post on strategies to boost patient medication adherence.
Tell us some tips on how you have improved patients' medication adherence.
About Jennifer K. Bussell, MD, FACP
Jennifer K. Bussell, MD, FACP, is an instructor of Clinical Medicine at the Northwestern University Feinberg School of Medicine. She previously served as Clinical System Professor in the Department of Medicine at the University of Chicago and Associate Program Director of Internal Medicine and Transitional Year Residency at MacNeal Hospital. Dr. Bussell is a member of the Patient Quality Committee at Northwestern Medicine and serves as Chair of the Patient Safety and Quality Committee and as an Executive Board Member for the Illinois Chapter of the American College of Physicians.