A nation of noncompliance
Every year, Americans spend billions of dollars and millions of hours in their health care provider’s office seeking advice. Why then, do we refuse to take it?
Several recent studies point to an alarming trend; one that is more destructive than obesity, diabetes, hypercholesteremia and hypertension combined: medication nonadherence. This is more than ignoring general medical advice to stop smoking, limit salt and saturated fat intake, and to exercise regularly. This isn’t forgetfulness, this is deliberately and knowingly refusing to fill or refill prescriptions for serious medical conditions, and it’s killing us. Every year millions of Americans experience serious complications from untreated medical conditions such as heart attacks, strokes, heart failure, kidney failure, ischemic limbs (gangrene) and other complications of untreated hypertension, diabetes, asthma, hypercholesteremia and heart disease.
This isn’t just hurting our health, it is costing us billions. In a 2010 study on community-based pharmacies, researchers noted that 25% of all Americans don’t adhere to their prescribed medication regimens. The New England Healthcare Institute estimated the annual cost of medication nonadherence at 290 billion dollars.
Primary versus secondary nonadherence
When patients fail to fill the initial prescription, it is called primary nonadherence. Failure to continue to refill long-term medications is termed “secondary nonadherence.”
What medications we are avoiding
In an article published last August, Shin et. al reviewed over half a million prescriptions written over a three-month period for almost 400,000 patients in an attempt to identify trends in medication noncompliance. In this study, all medications were provided as part of a health care plan that included a low-cost prescription co-pay. While these researchers found that the overall rate of primary noncompliance was 9.8%, the rates for specific types of medications were much higher. In fact, 1 in 5 participants did not fill their prescriptions for cholesterol, osteoporosis or pain medications.
Who isn’t taking their medications
In a distressing study by Joshua Shulman-Marcus, which was published in the Journal of the American College of Cardiology, people aren’t taking their medications even after serious, and life-threatening events. In this study, Shulman-Marcus interviewed 510 people who had recently had heart attacks. The interviewers asked people about their adherence to the post-heart attack aspirin regimen. This study, along with several previous studies showed that African Americans, particularly African-American females were more likely not to take their medications as instructed. In addition, the study by Shin et. al showed that people with diabetes, high blood pressure, paraplegia or peripheral vascular disease were at higher risk of not filling their prescriptions. Several studies including one by Sirey et al (2013) examining the psychosocial reasons for nonadherence showed noncompliance to be up to 50% in certain groups including elderly people with chronic medical conditions.
Why people don’t fill their prescriptions
Despite daily headlines regarding the cost of medical treatment and medications, the reasons behind nonadherence to prescription medications often have nothing to do with finances. In a study published this April, entitled, “Primary nonadherence to statin therapy: Patients’ perceptions,” Harrison et. al explored the rationale behind patient’s decisions not to fill prescriptions for statin medications. In this study, researchers telephoned 98 people who had been prescribed statin medications but failed to fill these prescriptions. Researchers were able to track the prescriptions thru the Kaiser Permanente health system and its pharmacies. Once these people had been identified, researchers called the people to ask why they were not taking their cholesterol medication.
Medication not necessary
Nearly 40% of the people polled stated that they did not feel the medication was necessary, and 35% did not consider their condition life-threatening. This finding replicates those of Sirey’s in his recent study, “Medication beliefs and self-reported adherence among community-dwelling older adults.”
Not enough information
In Harrison’s cohort, 63% stated that they had general concerns regarding the medication, with over 53% fearing the side effects. One-third of respondents felt they hadn’t been given enough information. Only 12% cited cost concerns.
In the post-acute coronary syndrome aspirin use study, participants echoed concerns about the safety and long-term effects of this medication. In the meantime, these patients have been putting themselves at greater risk of another cardiac event by omitting this life-saving medication. In a review of several large studies, lack of education or understanding regarding both the need for, and the function of prescribed medications was cited as the number one reason for nonadherence.
Not just an American problem
Just like the global diabetes pandemic, medication nonadherence isn’t only an American problem. Articles in medical journals from around the world discuss different ways for providers to address this growing problem. However the reasons for noncompliance vary by region, and may include inability to afford medications, or lack of access to prescription medications in more poverty-stricken areas.
What the health care industry is doing about it
Several recent initiatives have been aimed at providing additional education. In 2012, Taitel et al, published the results of a large scale program implemented in 76 pharmacies in the Midwest, which was specifically aimed at increasing compliance in people taking statin medications. The study, which was sponsored by Walgreens demonstrated increased medication adherence with face-to-face educational counseling sessions with the local pharmacist.
Doctors, nurse practitioners, physician assistants, and hospitals have also attempted to bridge this gap through communication. As part of Medicare core measures requirements, all hospitalized patients with specific diagnoses receive educational materials regarding their medications prior to discharge. Other specialists such as diabetic educators, cardiac nurse educators and even dieticians have been enlisted to provide additional information and opportunities for people to ask questions and receive information about their medications.
Ultimately, the most effective strategies probably won’t be as benign. Just as third-party payers such as Medicare, and large insurance companies are refusing to pay doctors and hospitals for avoidable complications and unnecessary admissions, patients may begin to pay the price for nonadherence. People are already paying for their lifestyle choices and co-morbid conditions such as smoking or diabetes in the form of increased premiums, but now people may have to pay for each missed pill. Alternatively, many companies offer ‘health and wellness’ discounts based on healthy lifestyle choices such as participating in a formal exercise program, maintaining a healthy weight or smoking cessation. Adhering to medications is the logical next step.
What you can do about it as a consumer
If you have questions or concerns over a recently prescribed medication; don’t just tuck the script in your pocket, or throw it away. Ask questions; and ask the right people. Ask the provider who prescribed the medication and ask your pharmacist. Ask the right questions:
– Why is the medication prescribed? (What are we treating?)
– What is the duration of therapy? (How long do I have to take it?) Don’t be surprised if the answer is ‘forever’ if the medication is used to treat a chronic condition like high blood pressure.
– How often do I have to take it? (If the answer is more than twice a day, you may want to request an alternative).
– What are the most common side effects? What are the most serious ones?
– What is the likelihood of having side effects with this medication? If I do have side effects, will they go away with time?
– What happens if I miss a dose, or several doses?
– What does it cost? (Are there cheaper alternatives, if I cannot afford this medication?)
– Are there any alternatives to medications that I can try first? (Be aware that just because an over-the counter supplement is natural, it may not be safe. Also, many pharmaceuticals are derived from natural ingredients that have been placed into a standardized dosing formulation.)
Healthcare providers spent a lot of time and effort to prescribe the correct medications for our patients, aimed at treating specific conditions while limiting side effects, drug interactions and overall medication burden. Providers also attempt to do this in the most cost-efficient manner possible. Providers also use information gathered over time to titrate medications and fine tune treatment, so if you aren’t taking the medications for high blood pressure, and your blood pressure remains elevated (as it will), your provider will want to treat that: by prescribing another medication.
Pharmacists are excellent sources of knowledge, particularly regarding cost-effective alternatives as well as drug interactions, and side effects of medications.
Lastly, if you do fill that prescription, be sure to take it regularly as directed. Abrupt discontinuation of several types of medications can cause serious medical problems, as the original medical problem resurfaces, in spades.