The Medication Adherence Challenge: Insights and Strategies From The Field

Medication AdherenceThis past fall I found myself doing back-to-back research projects investigating how to drive greater medication adherence to two separate and quite different medications.  While the conditions, patient populations and medical treatments were all completely different, the medications in question were both extremely effective, and yet, in both cases, many patients just weren’t willing to stick with their course of treatment.

While Western Medicine has made great advances in developing treatments for countless types of medical conditions, adherence to these treatments is shockingly low.  Many medical prescriptions are not filled at all, and for numerous medications, the average drop-off rate is about 50%.   Low adherence has inevitable costs – to patient outcomes, and to the healthcare system itself.  Consequently, adherence is a significant concern to the medical world, as evidenced by studies by the World Health Organization and anxious presentations by the Centre for Disease Control.

There are multiple reasons why patients do not continue taking medications that are critical to their conditions.  A big one is – let’s face it – side effects, or the fear of them.  But as I talked to dozens of patients to understand their therapeutic journeys and the reasons they had for stopping, or continuing with their medications, it became clear that a major factor in encouraging medication adherence was how well they were handled by their doctors.

I heard from a patient who was sent home with a self-injection kit after being rushed through his appointment and told to read the instructions on the pack.  His first injection took place in a supply cupboard at work, where he sat, sweating with anxiety, reading and re-reading the instructions and feeling completely unprepared to deal with the situation he was in.  As he recounted the story to me, a number of years later, it was clear that the experience had been extremely traumatic and I marvelled that he had managed to stick with the medication.  As it turned out, he had persevered despite the odds, and the medication had worked wonders for him.  But I heard many similar stories where the patients got off to a shaky start due to poor support from their health care practitioners.  In many cases, if any other challenges arose, they did not persevere, and did not get the full benefits of their prescribed medication.

Sticking with your medication is driven by a number of factors.  Obviously, the primary one is whether the medication works on the condition.  But, getting to the point where it is clear that the medication is working can require quite a bit of resilience from patients.  They have to manage their anxiety about side affects, be confident and proactive about managing their dosage, weather any side effects that emerge as they begin the course of treatment, and in some cases, deal with feelings of shame or stigma about their condition and the treatment they are taking.

Having the right support from your health care provider is critical to building that resilience.   In the interviews I did with patients who did tend to stick with their medications, in many cases, they were willing to do so because of the reinforcement they received from the doctors and nurses who worked with them.  Health Care Practitioners who took the time to listen to patient concerns, who put their anxieties in context, who laid out options and gave clear directions, gave patients far greater confidence in the treatments they were to embark upon and this confidence helped patients stick with the treatment.  On the other hand, patients who received high-handed treatment and insufficient training tended to start their treatments with a bad feeling about the whole thing, which meant that they were far less committed.

Being Mortal Atul GawandeAs I was conducting this research, I could not help but be struck by the parallels with a recently published book by Atul Gawande, “Being Mortal: Medicine and What Happens in the End.” Although ostensibly a book about the way the American medical system handles patients at the end of life, it is also about the more general issue about the Doctor-Patient relationship, and how the way Doctors treat patients has as big an impact on their outcomes as what they treat them with.

Most doctors’ current approach, argues Gawande, is too detached, and does not take into account their individual circumstances and priorities.   Even doctors who provide patients with different options tend to offer information without clear and empathetic guidance.  As he comments in an interview with Canadian publication MacLean’s:

“The god-like approach—doctor knows best—is mostly gone. Still common, though, is the retail doctor who says, “You got the red pill, you got the blue pill. I’ll tell you the pros and the cons and then you tell me what you want and I’ll execute.” What patients commonly say to me is, “What would you do?” and the medical school answer is, “You shouldn’t tell them. It’s their choice.” But the real answer has to be, “Okay, I will tell you, but I need to know a lot more about you. Tell me what your fears are, your goals, what outcomes are acceptable and not acceptable.” It’s a counsellor role, and that we don’t teach in the medical schools, though we’re starting to.”

In the interviews I conducted I heard over and over that a counsellor was precisely what patients were looking for (which may be precisely why so many of them were turning to “natural healing” practitioners who took more time to understand patients’ broader circumstances).

Interestingly, in the same research, we learned that most doctors did not believe their patients had issues with medication adherence, despite the numbers indicating otherwise.   They believed that they had prescribed their patients the appropriate medication, sent them home and all was as it should be.  They were not heartless.  They were just behaving as current medical practice directs.

For pharmaceutical manufacturers, obviously, this dynamic presents a significant challenge.  Widespread patient medication drop-off is obviously not good for the bottom line.  So, what can pharma companies do to encourage doctors to provide the kind of experience that helps patients get off to the best possible start on their meds?

Clearly, education is key.  If health care practitioners have a greater understanding of the challenges of adherence, of the impact their patient interactions have on clinical outcomes, and a detailed approach to the optimal way of helping patients embark on new medications, they will hopefully be much more likely to give their patients the right kind of support.  And, if more patients get the right kind of support, maybe more of them will stay on their medications long enough to receive fuller benefits from them.

If Pharma companies provide this training and education to health care practitioners, the benefits will be manifold.  If it leads to increased medication adherence, that would certainly be good for business.  But if they can help doctors and patients to build more positive relationships, that improve both patient experiences and clinical outcomes, than that change is good for healthcare in general.

s