Understanding medication nonadherence: 10 essentials
As co-founder and chief medical officer of a company in the medication adherence space, I have spent the past four years thinking about the problem of medication nonadherence. The following are 10 concepts that I consider essential to understanding the problem better.
1. Look beyond cost and forgetfulness as causes. Various forms of reminders and cost reductions can certainly be helpful for patients already motivated to fill and refill their prescription. However, many patients lack that sufficient motivation and, for those patients, human psychology is largely the culprit. A well-publicized trial of free medications for patients leaving the hospital after a heart attack, published in the New England Journal of Medicine, achieved a relatively small uptick in adherence (an increase of 4–6 percentage points over the control group, which demonstrated rates between 36–49%). Increasingly, adherence experts understand that “present bias,” or the preference for short-term rewards, is a key driver of the problem. The central challenge is this: medications for chronic disease offer no short-term benefits, and are often accompanied by immediate annoyances.
2. The problem spares no demographic. Many studies have shown that nonadherence is more significant at the lower end of the socioeconomic spectrum, but it exists across the population. Cost and literacy barriers are obviously greater in selected groups. Apart from those barriers, however, human psychology is human psychology.
3. It is a problem across all medical conditions. Nonadherence tends to be worse in certain primary care conditions, like hyperlipidemia, but it’s also a challenge in more “serious” conditions, like in women being treated with adjuvant therapy for breast cancer. Speak to cancer clinicians. They’ll tell you about patients who quit refilling simply because they want to go back to feeling “normal” again. The pills, a daily reminder of their diagnosis and status as a “cancer patient,” work against that. There’s a strong negative psychology at play, even for drugs that work to prevent cancer recurrence.
4. Interventions need to enhance the value proposition. Given that nonadherence is often more of a value problem than a cost problem, modern approaches should strive to wrap more value around the pill in the eyes of the patient, and preferably immediate value. How? Add incentives. Add the fun factor (honestly!). Add high quality and engaging education. And, look beyond healthcare for inspiration—healthcare has not traditionally done a stellar job in the motivation department. Think entertainment industry, social media, consumer goods. Shake things up a bit.
5. Interventions need to reach beyond the doctor’s office. Doctors care deeply about adherence given its central role in improving health outcomes, but they often don’t have enough time or even the skillset to effect adherence behaviors significantly. Plus, how many hours per year does the average patient spend with their physician? Read this fantastic “automated hovering” piece from the New England Journal of Medicine. We need to focus on the 5,000 hours that patients are not with their healthcare provider. Luckily, mobile and other digital solutions provide that opportunity.
6. Be aware of the “healthy adherer effect.” In assessing studies of health outcomes in relation to medication adherence, it is important to understand the difficulties in disentangling the effect of adherence to the medication vs. adherence to other healthy behaviors—they often go hand-in-hand. A patient who is careful to refill on time and take their medication daily is also more likely to be a patient who pays attention to diet and exercise. See this interesting paper on the relation between statin adherence and car accidents—a further extension of this effect! This doesn’t lessen the importance of medication adherence, but simply means that it can be difficult to accurately assess the precise degree of its effect. Even careful randomized controlled trials that control for demographic factors and comorbidities may not be able to control for confounding behaviors.
7. Improving persistence is paramount. The most significant threat to health outcomes are patients who quit taking their medications for chronic conditions altogether, or who never even fill in the first place. Patients who are good about refilling long term but forget an occasional dose here or there do not tend to pose a great threat. Paradoxically, many adherence solutions focus on the latter category of patient.
8. Adherence, cost, and outcomes: not always perfectly in sync. It is generally understood that greater adherence is associated with better outcomes, and there is little debate on the topic. However, there is a less-than-perfect correlation in the published literature to date between better adherence and lower healthcare costs. See the results of a literature review here. In some conditions, such as with asthma, poor adherence does clearly correlate with increased costs across studies, even in the short term, due to emergency room visits and hospitalizations for exacerbations. In other conditions, however, the cost equation is unclear or more equivocal. Despite the intense and justified focus on cost these days, as a physician I would argue that promoting better health outcomes should still remain priority number one.
9. Diverse research methods make meta-analyses difficult. It is always a good idea to avoid hanging your hat on the results of a single study. Even carefully controlled trials, when repeated, can demonstrate different results (see here). Add to that the potential biases (sometimes intentional but often not) that can creep into a research effort, and it makes sense to look across as many studies as possible. However, in looking across adherence studies, it is important to be aware of the diversity of methodologies used to measure adherence. Consider the following questions. Were drug switches within the same drug class accounted for? What about pharmacy or health plan switches (if not, nonadherence may have been overestimated)? Was primary nonadherence (failing to fill the initial prescription) taken into consideration? Were patients who filled only once excluded from analysis? What was measured: MPR, PDC, or persistence? And so on. The diversity of approaches poses a challenge.
10. If patients stick with their medications, everybody wins. Luckily, improving medication adherence is a win-win for all healthcare constituencies, including patients, providers, insurers, and pharmaceutical companies. No single constituency “owns” the problem and no one entity can solve it.
About the author:
Katrina Firlik is chief medical officer and co-founder of HealthPrize Technologies. She is also a neurosurgeon and author of Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside.
Closing thought: How can medication nonadherence interventions target the patients who will benefit the most?