February 15, 2015
A recent study published by Hutchins et al. in the journal Circulation: Cardiovascular Quality and Outcomes is causing a buzz on news sites and blogs. Paraphrasing some of the headlines we have seen: “Many prefer an early death to pill taking” and “Some patients willing to pay almost $1500 to avoid taking daily medication”. These headlines may grab attention, but it’s important to understand the research behind them, the reasons adherence is such a big issue, and what is at stake.
Depending on who you talk to, the issue of medication non-adherence is a $100-300 Billion hit to our total spending for health care in America. With all the attention on new payment models for health care delivery, which focus on paying for quality outcomes rather than the quantity of services performed, we are not going to make any progress on improving outcomes or bending the cost curve if patients do not take their medications and take them appropriately.
From our glass half-full prespective, we see a cohort of patients answering Hutchins et al.’s hypothetical questionnaire on the value of taking preventative (not treatment) medications which would prolong their lifespan. Headlines notwithstanding, ~70% of patients were NOT willing to trade any amount of their lifetime to avoid taking daily preventive medications, and only ~40% say they would be unwilling to pay ANY amount of money as well (respondants were willing to pay $1445 on average to avoid daily preventive medication use).
This of course does not lessen the fact that 30% of patients had a strong aversion to adherence to a daily preventive medication regimen, and that patients would be willing to spend some real money to simplify their medication use and improve the quality of their daily living.
The lead author himself states “Most physicians I know are very well aware of that, however, so it reiterates that we should be having discussions with patients about what their priorities are…”
So let’s take a step back and approach adherence from the perspective of understanding root causes and context. Adherence is a complex issue with many facets and many dimensions, much bigger than just considering a hypothetical pill a day to get an extra year of life. It should include assessing medication use for treatment of conditions that are causing poor quality of life right NOW. Ask an asthma or COPD patient if they will trade their medications for more life time to struggle with their conditions. . Certainly as this study shows, patient beliefs and preferences about medication use and value are important to understand. But root causes for non-adherence may go beyond patient beliefs and preferences to the complexity of medication regimens, poly-pharmacy and unnecessary medications (including OTCs); and utilization (cost) control policies that foster multiple times a day dosing rather than single daily dosing or restrict more costly combination products in favor of less costly multiple individual medications. Adherence may be impacted by access to a pharmacy or affordability of medications, or perceived or real side effects. (Remember the folks in the study were willing to put down some real money to improve their “medication quality of life”).
To get to those root causes we need to talk to our patients. Analytics show us refill frequencies, and help us to predict the “non-adherent” patient type. We can send a text to a mobile device or implement any number of reminder or administration solutions, but in the end we must talk to the patient to understand what is working, and what isn’t. Tools and analytics help point us to a potential problem, but a full regimen analysis provides all-important context. Any adherence intervention that does not involve hands-on patient interview to address root causes is a glass half-empty approach, and ultimately likely to be unsuccessful. In the ActualMeds solution for medication reconciliation and risk assessment, integration of patient-self reported information and a structured interview process helps uncover these root causes and enable more specific assessment of risk – critical to understanding the context of a patient’s regimen, and assuring that any adherence interventions applied are likely to succeed.
Joseph Gruber, RPh, CGP, FASCP: Chief Clinical Officer, ActualMeds Corporation. Past President, American Society of Consultant Pharmacists. @jgactualmeds