How to Improve Therapeutic Adherence

Patients have to want to take their medication or see a treatment regimen through.
Patients have to want to take their medication or see a treatment regimen through.

Not taking medication or following a treatment regimen may not seem like a big deal to your patients. But nonadherence not only costs the health system dearly, it could be the difference between life and death.

For about half of the 3.2 billion prescriptions written each year in the United States, the drugs are not taken as prescribed, according to a report prepared by researchers at Duke University in Durham, N.C., and the National Consumers League (NCL). The total cost for nonadherence is estimated to be up to $300 billion and account for approximately 125,000 deaths each year.

“We view this as a public health problem,” said Rebecca Burkholder, vice president of health policy for the NCL. “It really takes a whole health care team working with the patient to solve this.”

Various strategies are available to help solve the problem: listening to patients, providing comprehensive information, and helping remove barriers to their treatment.

Why patients do not comply

Burkholder's group has been studying nonadherence for its campaign Script Your Future. They are working to educate consumers, their families and providers about the importance of taking prescribed medication.     She said there is no single specific reason people fail to follow their doctor's orders, but a handful of reasons rose to the top of the list.

First, patients are often unconvinced that they need the medication. Second, they don't think it will work, particularly if they do not actually see or feel the results. Others fear adverse effects or experience effects that are unpleasant. Some cannot afford medication, and others simply forget to take it as prescribed.

“There is nothing more important than that five-minute conversation a physician has with a patient to make sure they understand their treatment,” Burkholder said. “Patients know it is important to talk to their physician about it, but it is not always happening.”

Knowledge is power

Leslie Martin, a health psychologist and professor in the department of psychology at La Sierra University in Riverside Calif., said patients have to understand their treatment to follow it.

“It is clear that healthcare providers will say things or use jargon that they fully think the patient gets but they don't,” she said. “And patients aren't on average good at ferreting out information that they don't have.”

What do you need to know as a provider? First, aim low. Do not assume your patient has any knowledge. If you start at a high level, they likely won't request that you dumb things down. If you get a sense their knowledge is greater, you can always adjust your communication.

Second, patients will often nod their heads like they understand directions, even when they do not, she said. To avoid this, ask questions that do not allow them to parrot back your instructions. Try, “What will this look like for you tomorrow?” or “How will you manage doing XYZ?”

Burkholder provides a note card of questions that patients should ask to fully understand their medication. Beat patients to the punch by asking:

  • What is the medicine called and what does it do?
  • How and when should you take it, and for how long?
  • What if you miss a dose?
  • What should you do if you have a side effect?

Physicians should educate patients about whether it is safe to take a certain drug with other medicines or vitamins and mention and whether they can stop taking the drug if they feel better.

What makes them tick

Patients have to want to take medication or see a treatment regimen through. There are ways you can encourage this. The challenge is that people are all motivated by different things. As a physician, you have to find out what it is that moves your patients.

“Take some time, ask questions and allow patients to answer them,” she said. “Patients often get interrupted really early in the dialogue … make sure you let them finish; it indicates you want to listen and you will get better information.”

If you have electronic medical records, Martin recommends keeping good notes about what you know about your patient. And make it a point for the whole staff to do so when they have patient contact.

“Keep track of what motivates them and keep effective notes on what their priorities are, what their struggles are and what can be reiterated and talked about that can be useful,” she said.

A strong motivator for patients is consequences. Burkholder adds that it is important to make sure patients understand not only their condition, but what the consequences are if they don't take their medication – especially for people with chronic diseases.

Breaking barriers

One final thing doctors can do to improve adherence is help patients create strategies to effectively carry out treatment. Factors like cost, unmanageable side effects and lack of transportation can all contribute to nonadherence.

You can help here by knowing the cost of medications and whether or not they come in generics. Be aware of medication cost assistance available for drugs you commonly prescribe. Know the resources available to patients – is there childcare or transportation for someone who needs to get to dialysis?

Martin recommends using your staff as much as possible. Let someone talk to patients before you see them to find out if they are following through on therapies. Have someone who knows local resources to help patients who need assistance.

Your staff can also help with follow-contact with patients, particularly those with chronic conditions. Martin said it is good form to check in with these patients on a regular basis, especially if they are starting a new medication or self-monitoring program.

“Check in to see how it's going and see if there are problems,” she said. “This will build trust and they will give feedback. Over time, it can be minimized, but following up is a good idea and doesn't happen enough.”

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