We’ve Got An Adherence Problem: What Are We Doing About It?

By Dr. Tal Rapke, founder, ScalaMed.

According to a 2003 report by the World Health Organization (WHO) into medication adherence, about 50 percent of patients with chronic illness don’t take their medications as prescribed. This poor adherence to medication leads to wastage, disease progression, increased morbidity and death, increased burden on medical resources, and is estimated to cost approximately $100 billion per year.

A 2012 study published in the Annals of Internal Medicine recorded a lack of adherence to taking medication as the cause of almost 125,000 deaths in the US per year. The research found that 10 percent of admittances to hospital were as a consequence of non-adherence to prescribed medication, resulting in an estimated annual cost to the healthcare system of between $100 billion an $289 billion.

Of course, it can be easy to write this issue off as the patient’s responsibility, and naturally they have a huge role to play in solving this issue. There are, however, myriad factors that contribute to non-adherence of the 4.45 billion prescriptions written in the US each year.

The medication-taking experience is a complex interaction that involves patient, physician and the broader healthcare system, and all of these protagonists need to be functioning together correctly if we are to reach a state where avoidable medical treatment is minimized.

Given that increased adherence would not only greatly improve patient outcomes, but also save the healthcare sector billions of dollars, addressing this pervasive issue should be a priority for the industry. But what really causes it, and how can we improve our approach?

The patient
From the patient’s perspective, there are a number of factors that can contribute to the non-adherence of prescribed medication. One overarching theme for patients is patient activation and empowerment. The healthcare system isn’t constructed to ensure patients take on the role in self-management expected of them. Our paternalistic healthcare system can often make patients feel disempowered, and excluded from care decisions.

A poor understanding of both their condition and the medication that has been prescribed can lead to a lack of ownership of and accountability for the management of their condition. In numerous reports, patients are overly concerned about side effects, lack understanding on how to take the medicine safely, and may not understand why it is so important to continue to remain in therapy (especially in asymptomatic non-communicable diseases). Increasing the patient’s understanding of their condition, and the management thereof, can play a significant role in increasing adherence.

Sometimes, of course, non-adherence isn’t a deliberate decision by the patient, but an unintentional side effect due to capacity and resource limitations. For example, problems physically accessing prescriptions, a prohibitive cost, or competing demands on a patient’s time can all result in non-adherence.

Literacy is also a large contributing factor – in the US alone, close to 90 million adults have inadequate health literacy. The consequential lack of understanding puts them at greater risk of hospitalization and poorer clinical outcomes. Their beliefs about and attitudes toward health and treatment effectiveness, together with previous experiences with pharmacological treatments, also affect their level of adherence.

The physician
Within 10 and 80 minutes of being provided with information about their condition and medication by their physician, between 40 and 60 percent of patients struggle to correctly relay what their physician expected of them.

And while it again may be easy to lay the responsibility for that with the patient, many physicians are contributing to non-adherence by prescribing complex drug regimen not spending adequate time with patients, sand failing to fully explain the benefits and effects of the specific medication to the patient.

Physicians can also fail to appropriately consider or consult with the patient in terms of the financial burden that comes with the medication – particularly in chronic cases where the medication will be a long-term cost – and the intricate detail of why the medication is required.

From the perspective of the physician and medical system at large, increasing medication adherence leads to better health outcomes and eases the burden on the healthcare system. In a future where outcome based payments are likely to play a more significant role in our healthcare system, incentives for helping to empower and educate patients will likely ensure physicians are appropriately compensated for the time it really takes to ensure patients are adequately activated to continue self-management with their prescribed medicines.

The healthcare system
Healthcare systems across the world are severely fragmented, with knowledge and information held at multiple points. This fragmentation has resulted in numerous sources of information about every individual, rather than a single source of truth, and this lack of clarity has significant time and cost implications for physicians and the healthcare system.

A single source of information about each individual patient, detailing medical history and prescriptions, physician’s notes and pharmaceutical information, could be hugely beneficial. However limited healthcare technology interoperability, and limited will to agree on standards and sharing protocols, prevents physicians, pharmacists – and patients themselves – accessing information from different locations.

This can affect many things, including timely medication refills and patient–physician communication, as well as consistency of care and treatment.

A solution
There are a number of ways we can begin attempting to solve the widespread issue of non-adherence to prescribed medication, and they all revolve around the patient. If we can develop a patient-centric method of managing medication, the knock-on effects and benefits could be significant. The only person in common at the specialist, the general practitioner, the pharmacist, the hospital and the home — is the patient.

The first step to finding the solution is to empower the patient to feel engaged and motivated to manage their disease and medications themselves. To start, physicians should encourage a “blame-free environment” so patients can speak openly about their medication-taking behavior rather than feeling judged. Physicians also need to fully assess health literacy to ensure that patients genuinely understand the key information about their medication and condition.

Involving the patient in their own treatment decisions is also critical; for example, a patient may be more likely to adhere to a medication regime if they have chosen the time of day they need to take their medicine, or the form that medicine is in.

The opportunity to utilize new technologies to combat non-adherence cannot be overstated, and presents an opportunity to close the information gaps that a fragmented and mainly paper-based system creates. That opportunity is the implementation of a secure, mobile, patient-centered, integrated source of truth.
The healthcare sector, however, particularly prescription management, has been slow to embrace technology, especially when compared to other sectors that deal with sensitive information. And as a result, it’s near impossible for physicians to be up-to-date with their patient’s medical history, particularly when patients often have more than one physician they see semi-regularly.

Security of information is often identified as a major hurdle in the implementation of technology in prescription management, however, as an example, blockchain technology now enables us to keep this data definitively secure.

Technology can also help empower the patient by giving them full control over, and 24/7 access to, their healthcare data.

A technology solution that allows patients to “automagically” receive and carry their prescriptions with them on their smartphone at all times, that delivers automatic reminders to tell patients when to take their medication, along with information about when their prescriptions are due to run out, could significantly affect the adherence problem.

But, of course, physicians can also play a fundamental role that will still complement the technology, by providing traditional medication adherence tools such as pill boxes, calendars or schedules that specify the time to take medications, and helping to increase and develop patient understanding of their condition and medication – and the implications of non-adherence.

Addressing this epidemic of medication non-adherence requires a concerted effort by healthcare professionals across all patient touchpoints. Collectively, we need to focus on educating and empowering the patient, communicating effectively, and harnessing the power of prescription management technology to drive behavioral change.

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