Making adherence stick: It's not easy to get patients to follow directions

Lisa M. Vinci, MD, a general internist in Chicago, is well aware of the challenge involved in motivating patients to follow treatment regimens and has developed approaches to urge them in the right direction.

For instance, she often repeats herself to make it more likely that her patients will take the medication she prescribes and follow her directions about making lifestyle changes. She collaborates with them to break larger goals into smaller, more achievable ones. She sends them to nurse practitioners if more intensive counseling appears necessary. And she even relies on family members to support the effort.

"I reinforce, reinforce, reinforce and go over and over again dietary recommendations and the importance of taking medication on a regular basis," said Dr. Vinci, also a clinical associate at the University of Chicago. "And I really negotiate with them and say, 'What can you do and what are you willing to do?' Then I work from that."

She is not alone.

Physicians often find themselves going to great lengths to make it more likely that patients will carry out a treatment plan. Patient nonadherence is a documented threat to health, blamed for costing thousands of lives and billions in health care dollars. It's bedeviled physicians for so long that Hippocrates even complained about it. And the American Medical Association adopted policy at its Annual Meeting in June stating that patient adherence is a necessary factor in achieving high-quality, cost-effective care.

"In the near future, I believe that a greater number of lives will be saved by learning how to motivate our patients to follow recommendations from current medical knowledge than from new technology development," said David D. Luehr, MD, a family physician at the Raiter Clinic in Cloquet, Minn., and immediate past president of the Minnesota Medical Assn. He proposed the AMA's policy resolution.

The problem has been studied and its impact quantified, but it is a long way from being solved. An analysis published last year in the Cochrane Database of Systematic Reviews found that methods for improving medication adherence for chronic health problems were labor intensive and not very effective.

"Figuring out how to treat people is obviously the easy thing," said Thomas C. Rosenthal, MD, chair of the Dept. of Family Medicine at the State University of New York at Buffalo. "The really, really tricky thing is getting people to buy into it."

One of the biggest trials physicians face is diagnosing the extent to which patients are complying with their recommendations. Several studies have suggested that physicians tend to be overly optimistic.

"My signature on the prescription pad does not mean it happens," said George Kikano, MD, professor and chair of family medicine at Case Western Reserve University in Cleveland. "One-third of patients will take the medicine all the time. One-third will take it some of the time. And one-third will never take it."

In response to this reality, experts say more specific investigation during office visits might be required.

Searching for solutions

Lars Osterberg, MD, MPH, chief of general internal medicine at the VA Palo Alto Health Care System in Palo Alto, Calif., has had patients lie to him about whether they were taking the recommended drugs. Sometimes their motivation has been to prove him wrong and demonstrate that they don't really need medication. He also has found that some patients have closely held, unusual rituals they use to decide whether to take their pills on a given day.

"The way you phrase the question to patients is very important. It's so quick and easy just to say, 'You're on this, this and this,' and just assume they're taking it," Dr. Osterberg said. "You have to take a step back and ask nonconfrontationally how they're taking the medication."

But even after nonadherence is detected, a means to reverse it is not usually obvious.

"Adherence is a tough nut to crack," said Sunil Kripalani, MD, assistant professor at Emory University School of Medicine in Atlanta, one of the authors of the Cochrane paper. "There are so many reasons why patients may have barriers to taking their medication correctly."

No one expects a single solution to suit all people and all situations. But researchers have examined certain techniques that could help doctors reach some of the people at least some of the time.

Several studies suggest that continuity of care and a strong patient-physician relationship might improve the situation. One study in the September/October Journal of the American Board of Family Medicine found that nonadherence was more common among patients who lacked confidence in their doctor's ability to help them or who were not satisfied with the physician's concern.

"If the patient trusts the physician and has confidence in them and believes that they know what they're doing, then [the patient is] more likely to follow through with the medication course," said Tom Wroth, MD, MPH, lead author and assistant professor of family medicine at the University of North Carolina.

Others are focusing on various forms of patient education and counseling. Experts say a complete, culturally and educationally appropriate explanation about the medication's purpose can go a long way to improve patient adherence.

"Patients need to understand why taking the medicine is important and what exactly the medicine is doing," said Sandra Fryhofer, MD, a general internist from Atlanta and former president of the American College of Physicians. "I think it's easier for patients to do what we ask if they understand why they're supposed to do it."

This discourse also can be an opportunity to address any reasons for hesitation -- ranging from fears about adverse events to complaints about the pill being literally too large to swallow. Patients having problems juggling multiple medications can be advised about which ones are higher priority than others.

"For a given patient, the benefit of each of the medicines they may be on is not equal," said Patrick J. O'Connor, MD, MPH, senior clinical investigator at HealthPartners Research Foundation in Minneapolis. "An important part of adherence is for the docs to coach the patients in terms of, 'If you can't take everything, these are the ones that are the most important. If you're going to stop something, fine, but don't stop these.' "

Sharing the load

But researchers note that the burden for this education is not completely on the shoulders of the physician. Other health care professionals can play important roles, too.

Dr. Vinci helped run a study examining the impact of group visits lead by nurse practitioners on how diabetes patients followed the American Diabetes Assn. guidelines for screening and preventive services. These visits were in addition to usual care, and the group leader called participants between sessions. Results are expected to be published next year.

"It translated to better care in that a higher proportion of the patients started taking aspirin on a regular basis, a higher proportion of the patients got a pneumonia vaccine, a higher proportion of patients met their blood pressure goals," Dr. Vinci said.

The visits did not, however, completely solve the problem at hand. Those who attended these sessions had better outcomes, but getting patients to show up was no easy task, despite numerous reminder calls.

Spreading the responsibility for adherence beyond the patient to family members can help, especially for older and younger patients who might have less control over their surroundings, experts say. This concept is true particularly if the recommended treatment requires a lifestyle change, which is regarded as far more challenging than getting someone to take pills regularly.

"Enlisting family members to help with compliance for medication or for diet and exercise is really central," said Paul James, MD, head of the Dept. of Family Medicine at the University of Iowa, Iowa City.

Researchers are exploring this issue further. A study expected to start in June 2007 at the VA Medical Center in Durham, N.C., will investigate whether enlisting a spouse will help a patient adhere to medication, diet and exercise recommendations and translate into a cost-effective reduction in cholesterol.

High-tech solutions also are in the mix. The Baltimore-based disease-management company XLHealth is investigating the use of an electronic pill box that reminds patients when to take their pills and records when they open the compartments. It also asks the patient to input information about side effects and cost issues that may be interfering with adherence.

"We will know for these patients exactly whether they're taking their medications as directed," said Harry Leider, MD, the XLHealth's chief medical officer. "It can be really confusing if you're on six or seven or eight medications. This is really exciting technology."

Other projects seek to link reminders more closely to a patient's environment. Joseph C. Kvedar, MD, director of Partners HealthCare's telemedicine division in Boston, is researching the use of an electronic pill bottle linked to a softball-sized globe that changes colors if a patient has opened the bottle and, hopefully, taken the drug.

"It's a very simple way of giving someone information that is glanceable, and we think there's a lot of opportunity for your environment, your furniture, your bathroom mirror to be part of your health care," Dr. Kvedar said.

But experts point out that there are limits to how much doctors can motivate a response. They can do a lot to make it more likely that recommendations will be followed, but the final decision of what to do is still made by the patient.

"The reality is the health care is in their hands," Dr. Osterberg said. "They're the ones who are going to get better or not. I'm here to guide them."