Optimizing Medical Adherence in Your Practice

A health professional can be the best provider, he or she can have the best technology and interventions, and if the patient doesn’t follow his or her advice, it all comes to a screeching halt, according to Geralyn Datz, PhD, during her PAINWeek 2010 presentation, "Optimizing Medical Adherence in Your Practice."

"I know you have encountered this in your practice," Datz said. "I hope that’s why you're coming today. All of us have shaken our fist at the sky. 'Why does this person not want to follow my advice? Why are they resisting? Why are they not accepting their diagnosis?'" Datz said. "This is a great source of frustration for all of us."

During her presentation, Datz discussed the scope of non-adherence, identified the psychological, behavioral, and system factors that contribute to the problem, and reviewed recommendations for communication strategies to improve prescription adherence.

Non-adherence is described as failing to fill prescriptions as directed, omitting doses, taking more medication than prescribed, prematurely discontinuing mediation, or taking doses at the wrong time. "Medication adherence has to do with patient behavior and provider behavior," she said. Although most may be familiar with the problem of overuse in the country, underuse is also a big issue, Datz said.

She highlighted a Harvard study revealing that 20 percent of prescriptions for chronic disease patients were not filled. Among the three types of non-adherent patients are the active decliner, who actively chooses not to fill/refill prescriptions; the refill procrastinator; and the sporadic forgetter, who intends to adhere but periodically forgets to refill prescriptions.

Perceptions of disease and medications can greatly help predict who will adhere to medication regimens, she said. These predictors include unwanted side effects, patient beliefs about medications in general, high costs, patient's lack of understanding regarding the benefit of the medication therapy, and a poor-patient-provider relationship. The quality of physician-patient communication, interaction, and sense of collaboration, then, can have a significant positive impact on compliance.

Social and economic factors can also impact compliance, as can low literacy levels. Datz highlighted specific research showing that 26 percent of patients with low literacy levels fail to return for follow-up visits, often claiming they didn’t even know they had appointments. More than 40 percent of these patients were unaware of the medication instructions, such as how often to take a medication or whether to take it after a meal or on an empty stomach. With these patients, Datz recommends that physicians create shame-free environments, use plain language, give simple verbal instructions, provide fifth grade-level written instructions, or use methods like the "Teach Back" technique. This method requires the physician to have the patient explain the directions given back to him or her.

Faulty beliefs by both physicians and patients can lead to poor medication adherence. Physicians may feel it is the patient's responsibility to make sure he or she understand the directions, Datz said. Patients may believe taking breaks from medicine may be a good idea to "help the body heal," or that since he or she still feels pain, the medications are ineffective and not worth taking. Datz said both physicians and patients may have different expectations. Physicians may tend to think in terms of improvement when it comes to chronic pain, while the patient is seeking a cure.

There are a number of strategies that can be used to improve adherence, she said, including simplifying regimens and praising patients when they do adhere to regimens. Referring patients to mental health professionals for psychological diseases in certain cases can help as well. Treatment agreements with patients are another strategy; they allow for adherence to be assessed and measured. They lay out the ground rules and help set boundaries, she said. It can help improve the physician-patient relationship, minimize misunderstandings, and also help reduce substance abuse, she said.

Assessing patient attitudes prior to beginning medication therapy will provide further insight to the situation, she said. Physicians can ask patients "What results do you expect to receive from this medication?" or "Tell me some ways you plan to remember to take your medications?" Datz also outlined what not to do, including invalidating the patient's pain, treating them as just a case, ignoring their emotional state, or assuming they understand you. It's important to remember that a patient may not always call if they have a question or if a problem arises during the course of their therapy.

Datz said that physicians can use tools such as the shared decision-making model, or the principles of elicit-provide-effect. Other strategies include emphasizing the value of the regimen, involving the pharmacy, simplifying dosing, and involving family and caregivers.