Battling Nonadherence: What Actually Works?

James F. Sweeney


May 07, 2019

In This Article

The Problem Isn't Always the Patient

Relying on physicians and patients alone to solve nonadherence on a case-by-case basis will never work, said Frederick Kleinsinger, MD, an internist and assistant clinical professor at the University of California, San Francisco, School of Medicine, who has researched the subject.

We ought to have a system where the patients beat down our doors, saying, 'I want to take the medication because I want to live a happy, healthy life.'

"A lot of the problem isn't with the patient; it's a system problem," he said. "We ought to have a system where the patients beat down our doors, saying, 'I want to take the medication because I want to live a happy, healthy life.'"

Such a system must involve professionals other than physicians, such as patient educators, pharmacists, nurses, and mid-level practitioners, as well as electronic health records (EHRs) and other technology, Kleinsinger said. In a 2018 article in the Permanente Journal,[3] he cites an approach used by the Kaiser Permanente Northern California system that boosted hypertension control rates among its patients to 80%, compared to a community control rate of 65% or less.

Kaiser used EHRs to identify patients at risk, then supported them with health education classes, outreach, counseling, generic medications, and other methods delivered by a range of healthcare providers.

It will take a concerted effort on the part of the entire healthcare system to solve nonadherence, Kleinsinger said, adding, "There is no easy solution, and the medical community doesn't take this seriously enough."

Small Steps Could Make the Difference

When he first began treating homeless patients, Jack Tsai, MD, a family physician in Long Beach, California, had a "treat everything now" approach. His patients often suffered from a number of serious and chronic conditions and, because of their lifestyles, he did not know when he might see them again.

Consequently, he said, it wasn't uncommon for him to prescribe first-time patients four to six medications and give them sets of instructions on how to treat their hypertension, diabetes, high blood pressure, and other conditions.

It didn't take him long to realize it didn't work. The homeless were largely nonadherent for a variety of reasons, including lack of access to a pharmacy, poverty, medical illiteracy, mental illness, and more. Trying to solve all his patients' conditions at once resulted in solving none, Tsai said.

"I now take a 'less is more' approach," he said. "I try not to do more than two meds and try to address what they came in for."

Helping a patient with the complaint that is most important to them is crucial, even if it's not the most serious medical condition, he said. Addressing those problems builds trust with patients and makes it more likely that they'll follow future treatment plans, he said.

"Every patient wants to feel well. No one wants to feel bad, but there are complicating factors for a lot of people," he said.


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