The Official Medtipster Blog

www.Medtipster.com Source: The Wall Street Journal, 3.28.2011 -by Katherine Hobson

Too many people don’t take the drugs they’re supposed to. Tackling that problem could save a lot of money and a lot of lives.

Medication can do great things for people—but only if they take it. And a lot of people aren’t taking it.

Half of patients in the developed world don’t properly take their drugs for chronic conditions, according to the World Health Organization. The additional costs for treating diseases that progress unchecked run into the hundreds of billions of dollars a year. One study estimates nearly 90,000 people die prematurely in the U.S. each year because of poor adherence to high-blood-pressure treatment alone.

So how do you get people to take their medicine? There isn’t one answer, because there isn’t one reason people aren’t sticking to their regimens. Cost, forgetfulness, side effects and doubts about effectiveness can all be factors, among others. And for many people the health-care system isn’t designed to monitor or encourage adherence to drug prescriptions.

But there are plenty of health-care professionals and researchers tackling this issue, and they have some ideas about what can be done and what should be done. Here are some of those ideas.

More Refill Information

Doctors and other health-care providers need “some way of tracking to know if patients are refilling their medications, so we can step in and help people” if they aren’t, says Robert Reid, a physician and researcher at Group Health Cooperative, a Seattle-based nonprofit health-care system that coordinates care and coverage.

Providers like Group Health and Kaiser Permanente, a large managed-care consortium based in Oakland, Calif., can track refills because they manage all aspects of their patients’ care, so all information for each of their patients is collected in one easy-to-access electronic record. Alec Does, a family-medicine physician at Kaiser Permanente Anaheim Hills, says that when he shows patients records indicating they haven’t been consistently filling their prescriptions, “90% of the time, they’ll open up” and start talking about any issues they’re having.

But most people don’t get their care from such comprehensive providers, so their doctors rarely have access to their pharmacy records.

The technology to fix that problem exists, says Valerie Fleishman, executive director of NEHI, a national health-policy research institute based in Cambridge, Mass. “Physicians are sending prescriptions to the pharmacy, so we have the capability to close that feedback loop,” she says. The problem, she says, is that most doctors are paid for specific services, like office visits and medical procedures—not for managing their patients’ health outcomes. So there is no financial incentive for them to take on the cost of tracking prescription refills.

There is no quick fix for this problem, Ms. Fleishman says, but the recently passed health-care overhaul bill includes funding for new models for care and payment that might do a better job of rewarding providers for doing whatever it takes to keep patients healthy.

Get Pharmacists Involved

“Retail pharmacists appear to be able to play a really substantial role in encouraging patients to use their medications better,” says William Shrank, an assistant professor of medicine in the division of pharmacoepidemiology at Brigham and Women’s Hospital in Boston. “They are an underutilized resource.”

At Stamford, Conn.-based customer-communications company Pitney Bowes Inc., on-site pharmacist Antonio Tierno says he talks with patients about their conditions and medications. If a patient is picking up a refill behind schedule, he’ll ask what’s up. “If a person is late, you need to find out why,” he says.

Mr. Tierno says he always asks patients if they know why they’re taking a drug. That conversation can help ensure that patients will take their medication, he says, by making the drug’s benefits clearer to them and by making them feel more involved in their care.

A study by researchers at the Walter Reed Army Medical Center in Washington, D.C., published in the Journal of the American Medical Association, found that a pharmacy-care program for 200 people age 65 and older who were taking at least four medications for chronic conditions boosted adherence to 97% from 61% after six months. Patients were educated about their medications, including usage instructions; medications were dispensed in blister packs that made it easier to keep track of whether they had taken their pills for the day; and pharmacists followed up with patients every two months.

After 12 months, those who continued to get the pharmacy care kept their adherence at about 96%, while adherence among those for whom the program was discontinued dropped to 69%.

Another review of efforts to improve adherence—sponsored by CVS Caremark Corp. and carried out by Dr. Shrank and other researchers from Brigham and Women’s Hospital, Harvard University and CVS—found that nurses talking with patients as they were discharged from the hospital were right behind pharmacists in terms of how often they successfully encouraged patients to take their medications as directed.

Treat Patients as Individuals

Every patient’s story is different—so every solution has to be tailored to the individual.

The first step is to engage the patient with a simple, open-ended question, says Elizabeth Oyekan, area pharmacy director at Kaiser Permanente South Bay Medical Center: What’s getting in the way of picking up your medications?

“That will give you some concrete information, and then you target the solution to the individual patient,” she says. Kaiser has created a set of online tutorials to help doctors and others engage more effectively with patients who are skipping their medications.

If a patient is worried about side effects, a health-care provider might offer a substitute for the medication, or a lower dose. For the forgetful, it could be as easy as using a simple pillbox, or maybe something more technologically advanced, such as text-message reminders or souped-up pillboxes with audio or visual alerts.

If money is the problem, the solution may be generic substitutes, a mail-order program (which not only provides drugs at a lower cost but also helps those who have trouble getting to a pharmacy), or a drug company’s assistance program.

In many cases, though, problems can be addressed only by looking at medication adherence as a behavioral issue with often complex roots, says Alan Christensen, chairman of the psychology department at the University of Iowa. As with diet and exercise, getting people to change their behavior can be difficult.

“There’s more and more interest in how to better motivate and engage patients beyond just simply reminding them or reducing financial barriers or simplifying therapy,” says Dr. Shrank. Multifaceted programs that entail various combinations of those elements and education delivered by health-care professionals have shown promise in studies, but “we don’t have a good sense of what precisely is the right mix,” Dr. Shrank says. And, he says, if that ideal mix turns out to involve a lot of expensive face time, someone will have to figure out how to implement those efforts in a cost-effective way.