COMMENTARY

Why Patients Won't Fill Your Prescriptions

Charles P. Vega, MD

Disclosures

September 02, 2014

In This Article

Discussion

Patient care requires diligence and conscientiousness. All practitioners work hard on behalf of their patients. So the results of the current study[1] are disheartening. For every 3 new prescriptions we write to improve symptoms, treat acute illness, or prevent severe complications of chronic illness, approximately 1 prescription will be ignored.

Moreover, the current research suggests that patients may be selecting entirely the wrong types of prescriptions to fill. The lowest rates of nonadherence were identified for anti-infective therapy, which makes sense in terms of such conditions as urinary tract infection. But there is clear evidence that many prescriptions for antibiotics are inappropriate.[5] So following doctors' orders for these prescriptions may be doing nothing but contributing to the rise in antibiotic resistance while also subjecting patients to the known adverse events of anti-infective therapy.

At the same time, care for chronic illness is clearly deficient on the basis of current data, and previous research corroborates that the greatest rates of nonadherence are for chronic therapy for dyslipidemia.[3] It is understandable that patients may not intrinsically value preventive treatment as much as acute therapy for symptoms, but this does not explain the high rates of nonadherence to thyroid medication, which should both improve symptoms and prevent chronic illness in terms of the clinical consequences of untreated disease.

Let's Get Smarter Regarding Prescription Therapy

It is easy to feel exasperated, throw up one's hands, and try to forget the problem of prescription nonadherence. But healthcare professionals cannot afford to do this. Our patients see us for comfort, if not cure, and we are obliged to understand nonadherence from the patient's perspective and work constructively to minimize it.

The good news is that relatively simple interventions have been demonstrated to improve adherence to short-term treatment. These interventions include verbal and written patient education, provision of medications in more convenient forms (eg, tablets vs liquid), and reducing the cost of antibiotic therapy.[6] However, it is interesting to note that a trial of pharmacy follow-up with a phone call to ensure completion of antibiotics failed to improve self-reported adherence to therapy.[7]

Although results of research focused on improving adherence to chronic medical therapy are generally bleak, a pharmacy-based program to monitor and optimize lipid-lowering treatment halved the risk for treatment discontinuation.[8] Moreover, Markov economic models suggested that this program resulted in a substantial improvement in quality life-years, plus a relative cost savings through the prevention of cardiovascular events.

However, this study swims against the tide of results from interventional studies to improve chronic medication adherence. In a systematic review,[6] only 44% of included interventional studies designed to improve medication adherence accomplished this objective. Improved adherence resulted in some positive change in clinical outcomes in only 31.2% of studies. Moreover, these outcomes were generally intermediate outcomes, such as lipid levels or blood pressure, as opposed to patient-oriented outcomes, such as myocardial infarction or cardiovascular death.

In general, the interventions that were effective in improving adherence to chronic treatment were complex, involving patient education, reminders, supportive care, and even psychotherapy. One interesting recurrent theme in the collected research was that reducing the number of daily doses of chronic medications improved treatment adherence but not clinical outcomes.[6]

Medical treatment may be only a part of the solution to the management of chronic illness. Heart failure is notoriously difficult to manage and usually requires at least several prescriptions. However, an in-depth review of community-based, multidisciplinary care for heart failure demonstrated that coordinated efforts could reduce the risk for all-cause mortality by 29%.[9] Analyses of pooled data revealed that multidisciplinary care could also reduce the risks for heart failure-specific mortality and hospitalization due to heart failure, although these results missed statistical significance.

The individual practitioner cannot achieve truly outstanding results alone. Medical home models which emphasize coordination of care represent the future of chronic disease management. These systems should not only improve health outcomes for patients, but improve the efficiency of care as well. Therefore, they could actually reduce the overall number of prescription medications given to patients, while also improving adherence to the treatments that patients truly need. It will take this conscientious and resource-savvy approach to improve the challenge of patient nonadherence.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....