Report seeks more action on medication noncompliance

Patients commonly fail to take their medications as directed, leading to unnecessary hospital admissions and even death, costing the health care system as much as $177 billion a year. Yet nonadherence has not been given the attention and resources it deserves, says a new report.

Noncompliance has "been overlooked as a serious public health issue and ... received little direct, systematic or sustained intervention," according to the National Council on Patient Information and Education's August white paper. The group, which counts the AMA as a member, is a coalition of business, consumer, government and health professional groups. The new report says improving adherence is simply "not on the radar screen" of many policymakers.

The problem can seem "intractable," said NCPIE Executive Vice President W. Ray Bullman. Studies have shown that patients fail to stick to their regimens for a wide array of reasons, ranging from out-of-pocket costs and side effects to poor understanding of their medicines or illnesses. A fragmented health care system and low health literacy compound the problem. And doctors pressed for time find it hard to tell patients everything they need to know about the medicine being prescribed.

According to Food and Drug Administration surveys, in 1996 only 26% of patients said their physicians told them about their medication's side effects and how and when to take it. In 2004, the figure was unchanged. A similar measure of pharmacist communication actually dropped from 14% in 1996 to 6% in 2004.

"The needles haven't moved much," Bullman said.

One of the NCPIE's 10 recommendations is for a national campaign targeted toward patients and health professionals to raise awareness about the importance of medication adherence. The U.S. Agency for Healthcare Research and Quality is in talks with NCPIE and others about mounting a campaign that could follow the model of its "Questions are the Answer" patient-safety education initiative launched earlier this year, which featured public service announcements and an interactive Web site.

Medication nonadherence "is America's newest drug problem," said AHRQ Director Carolyn M. Clancy, MD.

G. Caleb Alexander, MD, an assistant professor of medicine at the University of Chicago, who has studied noncompliance extensively, said the NCPIE report is laudable but that in a society that respects individual autonomy, there will be always patients who don't stick to the treatment plan.

"Nonadherence can be decreased, but it can't be eliminated," he said.

Doctors need to change their habits, too, Dr. Alexander said. Evidence shows that physicians are poor at guessing which patients are not complying, he said, so doctors regularly should ask patients -- in a nonconfrontational way -- whether they are having any trouble taking their medications.

And some say more needs to be done to teach physicians in training how to detect and handle medication nonadherence.

"I'm seeing that students aren't being taught this," said Virag Y. Shah, MD, program director of the Presbyterian Intercommunity Hospital Family Practice Residency in Whittier, Calif. "You don't really know if the patients are taking their medications unless the doctor goes on offense and asks."

Edward L. Langston, MD, chair of the American Medical Association's Board of Trustees, said, "Patient adherence to the treatment plans prescribed by their physicians is key to achieving and maintaining good health." Physicians ought to educate their patients about the prescriptions they are taking, and patients should not hesitate to ask their doctors or pharmacists if they have any questions, he said.

AMA policy adopted last year states that "patient adherence to any medical treatment program is necessary in order to achieve high-quality and cost-effective health care."