Practical Solutions to Adherence
To quote C. Everett Koop, M.D., the former U.S. Surgeon General, Drugs dont work in patients who dont take them.
The high level of non-adherence in the U.S. today poses a major obstacle to achieving optimal health outcomes for patients and a major challenge for the pharmaceutical industry. While it is clear that the pharmaceutical industry does care about non-adherence and is spending money to address it, the sad fact is that this investment may be at best ineffective and might even be counterproductive.
The scope of the problem is well documented.
33% of prescriptions are never filled
50% of patients with chronic conditions are non-adherent
$1.5 billion is lost in earnings; $50 billion is lost in productivity
36% losses in sales for the average drug due to non-adherence
$30 billion shortfall in sales for the pharmaceutical industry as a whole
The Human Cost
The National Council on Patient Information and Education (NCPIE) report (the source for the figures cited above), "Enhancing Prescription Medicine Adherence: A National Action Plan," pegs the costs for poor medical adherence at approximately $177 billion annually. Included in the report:
"In the United States non-adherence affects Americans of all ages, both genders, and is just as likely to involve higher-income, well-educated people as those at lower socioeconomic levels. Furthermore, since lack of medication adherence leads to unnecessary disease progression, disease complications, reduced functional abilities, a lower quality of life, and even premature death, poor adherence has been estimated to cost approximately $177 billion annually in total direct and indirect health care costs.
Of the $177B cited, hospital admissions represented $121.5 billion (69%) per year, and long-term care admissions represented $32.8 billion (18%). Physician visits accounted for another $13.8 billion (8%), and emergency department visits and additional treatment cost more than $5.8 billion (3%) and $3.5 billion (2%), respectively. (1)
Patient-Physician Communications
The quality of the relationship between the physician and the patient plays a key role in patient medication adherence. This relationship starts with the effectiveness of communication and the resulting degree of comprehension concerning the prescribed treatment regimen and is underpinned by the level of trust that the patient has in the physician. In todays busy world the time that physicians get to spend directly with each patient has often been shown to be continually diminishing. Authority plays a key role as well. Older patients tend to accept unconditionally what the physician says and are often more inclined to take their medication if the physician tells them it is important. Younger patients, on the other hand, who rely on the vast information resources (both accurate and suspect) that the Internet provides, may uncover opinions that compromise the physicians advice.
Trust issues aside, treatment communication between physician and patient are not always ideal. According to an Archives of Internal Medicine study in 2006, patients who are given more information and who discuss their medication regimen with their physician are more likely to be adherent.(11) Five different variables were measured: name of the medication, purpose, duration, dosage (amount/frequency), and adverse events. The study concluded that thirty-eight percent of essential elements were not communicated. This is an overwhelming hurdle at the initiation of the patient journey that only serves to exacerbate the patient-specific challenges that each new medication regimen brings.
In comments to the FDA, the AMA (American Medical Association) advocated ways in which the pharmaceutical industry could improve the communication of risk and side effects information, from prescriber to patient.
"Pharmaceutical companies should be obliged to train and send their sales forces to physicians to educate them on important new risk information about company products. The company should provide incentives to sales representatives to do this because the highest priority of any company should be to prevent harm to patients who use their products. The effectiveness of the 80,000 pharmaceutical sales representatives in the United States in promoting the benefits of their companies' products is well documented, and they could have similar success in educating physicians about important product risks."
Proactive Education for Patients Sets the Stage for Adherence
Pharmaceutical companies struggle with effective ways to communicate a balance of information about a medications benefits and risks. When helpful and complete information is clearly outlined to patients up front, they are able to anticipate, identify, and react appropriately. Armed with this information, they are able to understand changes in symptoms and anticipate side effects, either dismissing the symptoms (because they understand they will subside) or calling their physician when needed. As was shown in a recent program that educated patients proactively on a common side effect (flushing) when using a particular cholesterol medication, this approach reduces patient anxiety and increases adherence. Getting information that is balanced also increases patient trust in their medication, something the industry desperately needs to restore.
The Consumer Health Information Corporation feels strongly that information provided in patient inserts, DTC ads, and collateral must be written in a style that makes sense to patients. If symptoms are described in ways that are not meaningful from a patients experience, then the warnings are not helpful. For example, instead of simply listing liver dysfunction as a potential side effect, The Corporation suggests being quite specific to the patient about what warning signs to look for and recommends that the educational materials provided help patients understand when and how they should manage side effects themselves or when it is advisable to call the prescribing physician. (9)
Feedback to the Physician
In addition to educating patients, for any program to be successful it is imperative to keep the physician informed and in the loop. Very few adherence programs today fully address this critical need, dealing exclusively with the patient despite the physicians demonstrable influence on patient behavior. Physicians for the most part are appreciative of the receipt of net new information about their patients and are usually happy to incorporate interim reports into each patients medical record. The content of the reports which are fed back can radically accelerate physician understanding of the product and thereby increase confidence in subsequent prescribing and support.
Conclusion
Everyone in the health care system has a significant role to play in improving prescription medicine adherence. Thus, an agenda that removes the barriers and advances education and information sharing is a critical step to improving the health status of all Americans. Clearly, the time for action is now.(11)
References
(1) Ernst, F.R., Grizzle, A.J. Drug-Related Morbidity and Mortality: Updating the Cost-of- Illness Model. Journal of the American Pharmaceutical Association. March/April 2001.
(9) Education and debate: Perspectives from the pharmaceutical industry. Bonaccorso, Silivia, and Sturchio, Jeffrey. BMJ; 2003;327:863-864 (11 October)
(11) Consumer Health Information Corporation, Volume 4, no. 6
The preceding is excerpted (with permission) from Practical Solutions to Adherence, by Stanley Wulf, MD, Vice-President and Chief Medical Officer, InfoMedics, Inc., with input from Ray Bullman, M.A.M., a senior staff member from the National Council on Patient Information and Education (NCPIE).