Battling Nonadherence: What Actually Works?

James F. Sweeney

Disclosures

May 07, 2019

In This Article

The True Cost of Nonadherence

Hippocrates warned about nonadherence. "Keep watch also on the fault of patients which makes them lie about taking of things prescribed," he is alleged to have said.

Much has changed in the 2500 years since Hippocrates laid the foundation of modern medicine, but his caution about nonadherence still holds true.

A review in the Annals of Internal Medicine[1] estimated that medication nonadherence causes 125,000 deaths in this country, placing it between stroke and Alzheimer disease as the sixth most common cause of mortality. It's also responsible for 10% of hospitalizations and costs the healthcare system as much as $289 billion a year. About one quarter of new prescriptions are never filled, and patients do not take their medication about half the time.

With the greater emphasis on value-based care and population health, more attention than ever is being paid to the problem of nonadherence, but there is no single proven way to correct it. And it's clear that current efforts are falling short.

Communication Is the Key

Some say technology holds the greatest promise for correcting nonadherence, but others aren't convinced.

"All sorts of technology has been tried, but nonadherence doesn't improve very much," says Wayne Weston, MD, a former director of the Institute for Healthcare Communication, a nonprofit organization that seeks to improve healthcare by bettering communication among those in the system. "I think the point is that we're not communicating with the patients in a way that promotes engagement."

There are so many possible causes of nonadherence, from the practical (eg, finances, access, health illiteracy) to the psychological (eg, lack of trust, depression), that a physician needs to learn the underlying reasons in order to address the problem, Weston says.

He advocates a "confidence/conviction" interviewing method, which uses open-ended questions, reflective listening, and empathy to assess the patient's belief that an action, such as taking medication, will improve their lives. It also measures the patient's confidence in their ability to take the action.

Originally described in a Journal of Clinical Outcomes Management article,[2] the method allows physicians to place patients in one of four quadrants based on their levels of confidence and conviction and then, in collaboration with the patient, provide the support to address any shortcomings.

The desired outcome, Weston said, is a patient invested in following a prescribed treatment plan which they had a say in developing.

"We're all much more likely to follow the advice we come up with on our own," he said.

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