An Rx for better outcomes, lower costs

The above observation from Dr. Koop seems obvious, but the task of getting our patients to adhere to the medications we prescribe has proven more complex. In fact, nearly 75% of Americans report that they don't always take their medications as directed; one in three never even fill their prescriptions. Needless to say, the lack of medication adherence comes at a huge price and demands our renewed attention.

Consider these facts. Poor medication adherence contributes significantly to medication-related hospital admissions in the U.S. -- an estimated $100 billion annually. Patients who do not adhere to their medication treatment plans have almost twice the total annual health care costs of those who do. Overall, nonadherence costs our health care system nearly $300 billion each year in otherwise avoidable medical spending -- nearly 13% of total health care expenditures.

The cost in human and economic terms is significant under any circumstance but takes on even greater urgency in the current environment, when so much attention is being paid to curbing unnecessary costs. If progress could be made in improving adherence in our patients with chronic conditions, the cost savings could be staggering. It is estimated that approximately 75% of U.S health care spending is devoted to the treatment of chronic disease. Yet only 50% to 65% of these patients adhere to medication regimens that could manage their conditions effectively.

Patients report various reasons for not taking medication as prescribed, including simply forgetting, the presence of other priorities or distractions, a willful decision to skip a dose (often related to side effects), uncertainty or lack of information about instructions, and emotional factors. Predictors of poor medication adherence include psychological problems (especially depression), the presence of asymptomatic disease, adverse reactions, lack of patient understanding or belief in the value of medication, and cost and complexity of treatment.

The drop-off in patient compliance with treatment regimens is not a simple linear function of the number of drugs taken and the dosage intervals. It begins to increase exponentially as patients take more medications at higher frequencies. So physicians sometimes unwittingly contribute to poor adherence by prescribing complex regimens. Additionally, adherence may be compromised when physicians fail to adequately explain the benefits and side effects of a medication, or do not consider lifestyle factors and the cost of medication. It goes without saying that having a poor therapeutic relationship with a patient impedes adherence.

Fortunately, there is help for doctors, and for patients under our care.

The latest comes from the National Consumers League, which is developing a national education campaign aimed at making consumers aware of the importance of taking medications as prescribed (link). The campaign, supported with funds from the Agency for Healthcare Research and Quality and participation by the AMA and many other organizations, will use social media and Web-based portals to educate patients about the importance of medication adherence and to provide further information and tools for prescribers to assist in this process.

This latest campaign is a natural extension of ongoing efforts by the AMA to address this complex issue. Since 1982, the AMA has served on the board of the National Council on Patient Information and Education. NCPIE is a coalition of more than 80 diverse organizations whose mission is to stimulate and improve communication of information on appropriate medicine use to consumers and health care professionals.

NCPIE's 2007 report, "Enhancing Prescription Medicine Adherence: A National Action Plan," garnered considerable attention when it was released a few years ago. The report contains 10 recommendations to improve patient adherence in the U.S. and deserves another look from all of us who prescribe medications (link).

NCPIE offers video, electronic and print materials on various topics related to patient medication information, including the AMA's Medication Counseling Guidelines, which are freely available to all doctors (link).

Broad-based solutions to improving adherence also have been advanced by the New England Healthcare Institute (link). Those solutions include creation of health care teams, better patient engagement and education, payment reform to provide incentives for counseling, and leveraging of health information technologies to provide direct evidence of medication adherence behaviors.

Like medication adherence itself, the task of helping patients stick to medication regimens we prescribe requires vigilance and diligence from many players across the spectrum.

Recently, the Food and Drug Administration has determined that the private sector has not met its obligation to provide useful medication information at the point of dispensing. The FDA is currently re-examining the whole issue of patient medication information in an attempt to move toward providing this information in a format that is comprehensible, concise and balanced. If done correctly, such a document could prove to be a valuable tool in helping physicians fulfill their obligations to educate their patients and move them on the path to medication adherence.

Adherence is a process and behavior (not a person), and physicians, pharmacists, patients, families and caregivers all play a role. The three pillars of improved adherence are simplifying the drug regimen; reducing barriers associated with cost; and improving patient behavior through education, counseling and the institution of a therapeutic alliance.

Patients rely on physicians for guidance and advice. High-quality communication between patients and physicians can promote safe and appropriate medicine use -- and better health outcomes. Better adherence also will help curb unnecessary costs in the current system. Better outcomes. Lower costs. Sounds like the right prescription to me. The good news is -- we don't have to go at it alone.