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Doctor-Driven Patient Adherence:
Adherence is a question that is much on the mind of Adherence has often been examined from the perspective of the patient, but less research has been devoted to the perspectives of prescribing physicians, though there is wide variance in patient adherence among prescribers. A case study produced by SDI (formerly Verispan),1 reported the following patient adherence levels among high-prescribers of cholesterol medications:
To better understand physician-to-patient messaging variables that impact patient adherence, SDI conducted a HealthTrak patient survey. De-identified claims data for participating patients was used to measure refill purchases, and increases associated with patient-reported incidences of specific exam room dialogue between the patient and their physician were correlated. The results clearly portray the powerful impact that specific exam room dialogue, and positive doctor-patient relationships have on patient adherence.
On average, about 80% of patients purchase the first fill of their prescription, but 2nd fill purchases plummet to 60%, and decline each month thereafter, so that only 50% of patients continue medication therapy for chronic medical conditions after 6 months.2 Numerous adherence studies have looked at patient-related variables within individual disease states, most commonly hypertension, hyperlipidemia, diabetes, depression, asthma and AIDS. But “Just What the Doctor Ordered,” a CME program produced by the Interstate Postgraduate Medical Association of North America (IMPA) included a series of physician interviews and surveys to assess attitudes about adherence, and measure physicians’ perceived competencies and barriers to reducing non-adherence. 3 Their research revealed that physicians do not consider adherence to be their primary responsibility; seriously underestimate the incidence of non-adherence; and perceive many barriers to their ability to address the issue. Highlights include: Physicians believe that the patients are by far the most responsible for their own adherence…a significant number believe that nurses and pharmacists bear minimal or no responsibility for patient adherence. When prescribing new or different medication regimens, physicians spend the most time explaining the purpose, side effects, and how to take the medication. Little time is spent on consequences of non-compliance, potential interactions, and refills. Most of the respondents indicated at least 20% of the patients seen in a typical week are not adequately adhering to their prescribed treatment regimen. Most physicians see at least 11 patients a week for whom adherence is a significant problem. Physicians rated diabetes as the top condition in which non-adherence creates a serious patient management problem; hypertension, depression, asthma and hyperlipidemia were also rated highly on this measure. Physicians reported that they gauge adherence during follow-up appointments by asking the patient whether they are taking the medication, typically phrased as “Are you still taking [medication]?” Physicians ranked factors limiting their ability to mitigate non-adherence:
Physicians rated their current adherence-related competency levels:
Physicians rated their need for increased competency as greatest in the areas of:
Unidentified Non-Adherence Many patients fail to report non-adherence to their physicians.4 They miss out on the benefits the prescribed medication could have provided -- it is a sad fact that many patients suffer unnecessary discomfort, disability, hospitalizations, and even death as a direct result of non-adherence. In follow-up visits, physicians who assume that a patient who has not achieved expected results is adhering to the medication regimen as prescribed may inappropriately alter the diagnosis and/or treatment. In addition to the serious medical consequences that such a change in course might entail, unidentified non-adherence can also increase patients’ out-of-pocket costs for office visits, testing and if their medication is switched, additional co-pays for newly prescribed medications.5 A reason for non-adherence may be utilization of alternative therapies. An increasing number of people are taking a dual approach to curing their ills by testing the waters of alternative medicine while simultaneously collaborating with their MDs, according to Shelley Adler, PhD, a UCSF professor of medical anthropology, whose study offers insight into why many women with breast cancer choose to keep their forays into alternative therapies, such as traditional Chinese medicine and nutritional supplements, to themselves. Impressions of physician disinterest, anticipation of a negative response, and the belief that their physician had inadequate training in or a bias against alternative medicine deterred women from discussing their use of alternative medicine.6 Pitfalls that Produce Patient Non-Adherence Physicians Lack Written Instructions With the plethora of medications prescribed, few physicians have the ability to provide up-to-date written instructions to their patients for the medications they prescribe, but as highlighted by the IPMA survey, most physicians consider themselves very competent in their provision of ‘simple, clear instructions on the regimen.’ But patients forget, on average, about half the information provided 15 minutes after meeting with a doctor. They remember the first third of the discussion best and remember more about diagnosis than about the details of treatment.7 Fear that medication may harm, rather than help is pervasive -- the most frequently used health-related google search term is ‘drug side-effects.’ 8 And while much information on the Internet is accurate, much of it is not, requiring physicians to rebut mis-information, as well as convey accurate instructions. A significant portion of each practice day is devoted to ‘question-driven’ follow-up. A recent study conducted by Richard Baron, MD and published in The New England Journal of Medicine documented that the average family practice physician is now fielding an average of 23 calls per day, many of which are medication-related.9 As office-visit co-pays climb higher, increasing numbers of patients seek telephone and e-mail follow-up from their physician between scheduled office visits to reduce out-of-pocket costs. But, as Doctor Baron notes, under the current system of reimbursement, telephone and e-mail interactions with patients, no matter how time-consuming for the physician and valuable for the patients, are not billable. And since most of the interactions take place on the phone, patients are still left without written instructions they can easily refer to in the future. Medication Costs For most patients, it is impossible to predict what the cost of a newly prescribed medication will be, and out-of-pocket costs are a concern and potential barrier for many patients, especially in today’s strained economy. There is a wide range of resources available to help insured and uninsured patients afford prescribed medications, most notably The Partnership for Prescription Assistance clearinghouse, but relatively few physicians and patients know how to access the resources. Limited Use of Pharmacist-Patient Counseling When patients pick up their prescriptions, pharmacies are required to offer verbal counseling on the safe use of the medication, but in today’s high-volume pharmacy environment -- busy check-out counters, drive-thrus and mail order delivery, in-depth pharmacist-to-patient counseling is no longer the norm.10 Wide Variability in Written Instructions from Pharmacies Medication labeling policies are mandated by Federal and state laws, but generally require only the inclusion of the very brief information that appears on the sticker affixed to the medication container. Additional information is provided at the discretion of each dispensing pharmacy. A study funded by The American Academy of Family Physicians Foundation and published in The Archives of Internal Medicine11 examined identically written prescriptions for four leading medications that were filled on the same day by chain, grocery, department store and independent pharmacies in four major cities. The results were sobering – crucial safety warnings were frequently omitted and tiny type and medical jargon made reading and understanding the instructions difficult, at best. Medication errors are at epidemic levels, with most occurring in the home setting, resulting in an estimated 530,000 preventable injuries per year - just among Medicare recipients in outpatient clinics.12 Skills and Systems Doctors Use to Advance Adherence Exam Room Dialogue As previously mentioned, specific exam room dialogue delivered to the right patient at the right time can dramatically increase adherence. But what about more general characteristics of bedside manner? Many studies have shown that patients who perceive that their physician is highly committed to a prescribed treatment, and will be monitoring their compliance are significantly more adherent. Whether a physician emphasized the positive, or warned against negative consequences did not matter in a study of adherence to an osteoporosis medication, in which both cohorts saw immediate and sustained adherence gains of 50% above average adherence levels.13 Physician-Delivered Written Instructions In the absence of new rules and strict enforcement of dispensing of complete written instructions to patients at the pharmacy, the aforementioned AAFP-funded study points to the need for physicians to improve their delivery of medication instructions to their own patients. Since patients may choose any pharmacy, and may fill some prescriptions at one pharmacy and other prescriptions at another, it is only at the physician point-of-care that physicians can ensure the delivery of complete and accurate written instructions to their patients. Emerging automated follow-up system solutions, including that offered by ProActive for Patients Media can deliver standardized medication instruction follow-up, and co-pay offers to patients who enroll during check-in, making it possible for physicians to provide an important patient-care follow-up service, at no charge to themselves or their patients, without adding any more minutes to their already busy days. Electronic Medical Records EMR systems help physicians track patient care, however, most systems are not designed to proactively educate and motivate patients, but rather facilitate e-mail response to patient inquiries. As a result, these systems are helpful, but only serve patients who call or e-mail to request information from their physician. Refill Tracking To Identify Non-Adherent Patients Non-adherence is a behavior that occurs among all types of patients, at all ages, education and income levels. Studies show that physicians cannot accurately predict which of their patients will be non-adherent14 – though some physicians alter or withhold therapeutic regimens based on their belief that a patient won’t be adherent.15 But just as ‘universal precautions’ require that medical personnel treat all patients as potentially infectious, a similar approach that acknowledges that all patients are potentially non-adherent could reduce non-adherence. Sophisticated computer systems now track and rank physician-specific adherence rates and patient outcomes, and patients who do not take their medications, and do not inform their physicians can lower their physician’s quality ratings. A recent study gave physicians the opportunity to access their patients’ refill records, and significant adherence gains were seen in patients of physicians who accessed the data. But very few physicians in the study reviewed their patient’s adherence data, even though access was instantaneous through e-prescribing systems.16 What prevents physicians from taking this type of opportunity, which is increasingly available through managed care providers, to diagnose and treat non-adherence? Do physicians fear that their patients will view them as white-coated police officers if they inquire about adherence? A number of medical professionals are leading the way to create educational opportunities that help physicians move beyond the ‘don’t ask - don’t tell’ status quo, and tactfully discuss and resolve barriers to adherence. Motivational Interviewing In his book, Motivational Interviewing in Healthcare, Dr. Stephen Rollnick describes the skillful practitioner of motivational interviewing as “one who can shift flexibly among directing, guiding and following styles, in response to patients’ needs.” The author believes that when time is short and behavior change is vital, a guiding style is most likely to produce better outcomes for patients and practitioners alike. In an article by Robert Lowes that appeared in the journal Family Practice Management, the author quotes John Hawks, president of Comsort, a Baltimore-based group that trains physicians in communication skills, who believes that the most effective physicians ask about non-adherence in a nonjudgmental way. “A lot of people find it difficult to take their pills 100 percent of the time. Tell me about your experience' is an open-ended question that elicits far more information than just asking, "Are you taking your pills?"
The ever-increasing ability of payers to discern differences among physicians in terms of patient satisfaction and outcomes, and management of costs of care, has fueled a new wave of performance incentives that are driving physicians to innovate in their practices to find new methods to improve patient care. Payers are experimenting with bonuses for achieving stated benchmark goals related to the Medical Home concept, which aims to more fully coordinate patient care. Physicians who use a qualified e-prescribing system for their Medicare patients will be eligible to receive a bonus of 2% of their Medicare revenue in 2009 and 2010. The bonus amount will decrease to 1% of total Medicare revenue in 2011 and 2012, and to 0.5% in 2013. A Centers for Medicare and Medicaid Services administrator noted in an interview that the average e-prescribing primary care doctor collected between $2,000 and $3,000 in bonuses in 2009. An added benefit is the reduction of phone calls from pharmacists by up to 75%. The now rapid evolution to e-prescribing was greatly accelerated by this generous physician reward, but beginning in 2014, physicians who are not prescribing electronically will see their Medicare payments reduced by as much as 2%. 17 A variety of e-prescribing platform vendors are connecting thousands of physicians at no, or low charge to physicians, and with minimal disruption to the practice. Software vendors such as ePocrates are creating a terrific user-experience with physician-friendly real-time data exchanges that deliver patient-specific formulary and co-pay information to physicians during the e-prescription entry process – giving physicians more control over what medication is dispensed for their patient’s treatment regimen. Prematics, led by Kevin Hutchinson, the innovator who created the SureScripts hub that now serves as a clearinghouse for e-prescription routing to over 40,000 pharmacies is going that one better, with a data exchange program integrated with an e-prescribing platform that delivers a real-time “exam plan” to the physician’s hand-held, telephone or computer. Prematics provides refill history, recent test results, and information about the patient’s insurance coverage to help physicians efficiently provide comprehensive care and document information exchanges with patients. Is a Golden Age of Adherence Optimization Upon Us? As a long-term pharmaceutical marketer, I am excited by the investments and innovations being made by a variety of stakeholders to ‘build a better-prepared-and-equipped physician.’ Clearly the most effective partner in efforts to increase adherence and sustain prescriber and patient loyalty is and probably always will be each patient’s own physician. The variety and quality of emerging resources that help physicians build stronger relationships with their patients and exert greater control over the delivery of care and follow-up using the existing physician-to-patient communications infrastructure -- telephone, fax, hand-held, cell-phone, internet and e-mail -- are all welcome signs of an exciting new era in adherence optimization. That’s my opinion. What do you think? Please join the Doctor-Driven Patient Adherence Forum (DDPA) on LinkedIn and share your perspectives. Wayne Yetter is Chief Executive Officer at ProActive for Patients Media, Inc. based in West Conshohocken, PA. His career has spanned the pharmaceutical, physician and patient data industries with leadership roles at Merck, Astra Merck, Novartis, IMS, Synavant, and Verispan. Contact Mr. Yetter at wyetter@ProActivePatients.com References 1. SDI Case Study: Understanding and Maximizing Prescriber Impact on Patient Compliance and Persistency 2. “Adherence to Long-Term Therapies: Evidence for Action,” World Health Organization 2003 3. “Just What the Doctor Ordered,” produced by Interstate Postgraduate Medical Assoc. of North America. http://ipmameded.org/resources/adherenceneedsassessment.pdf 4. “Unpredictability of Deception in Compliance With Physician-Prescribed Bronchodilator Inhaler Use in a Clinical Trial” CHEST August 2000 vol. 118 no. 2 290-295 5. “Direct and Indirect Costs Of Patient Noncompliance: The No-Nonsense Summary Noncompliance Costs,” Alan Showalter, MD, http://alignmap.com/noncompliance-fact-fiction/costs/ 6. Findings presented as part of a symposium on women’s self care at 7. “Adherence to Drug Treatment,” The Merck Manuals Online Medical Library, http://www.merck.com/mmhe/sec02/ch016/ch016a.html 8. GoogleTrends, http://trends.google.com/trends?q=%22drug+side+effects%22 9. “What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice,” Richard J. Baron, M.D. New England Journal of Medicine, Volume 362:1632-1636, April 29, 2010, Number 17, http://content.nejm.org/cgi/content/full/362/17/1632 10. “Patient Counseling Provided in Community Pharmacies: Effects of State Regulation, Pharmacist Age, and Busyness,” Bonnie L. Svarstad; et al, J Am Pharm Assoc. 2004;44(1), http://www.medscape.com/viewarticle/469845 11. “The Variability and Quality of Medication Container Labels,” William H. Shrank, MSHS, MD, et al, Arch Intern Med. 2007;167(16):1760-1765, http://archinte.ama-assn.org/cgi/content/full/167/16/1760 12. “Preventing Medication Errors: Quality Chasm Series, Consensus Report,” Institute of Medicine of The National Academies, 2006, http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx 13. “Effect of Monitoring Bone Turnover Markers on Persistence with Risedronate,” Delmas, et al, J. Clin. Endocrinol. Metab. 2007 92:1296-1304, http://jcem.endojournals.org/cgi/reprint/92/4/1296.pdf 14. “Diagnosing Potential Noncompliance: Physicians Ability in a Behavioral Dimension of Medical Care,” Mushin AI, et al. Arch Intrn Med. 1977; 137: 318-321 15. “Rethinking nonadherence: historical perspectives on triple-drug therapy for HIV disease,” Lerner BH, et al, Ann Intern Med. 1998;129:573-578 16. “A cluster-randomized trial to provide clinicians inhaled corticosteroid adherence information for their patients with asthma,” Williams, LK, et al, The Journal of Allergy and Clinical Immunology - 31 May 2010 (10.1016/j.jaci.2010.03.034) 17. “A Clinician’s Guide to E-Prescribing,” October 2008, The Center for Improving Medication Management, http://www.ama-assn.org/ama1/pub/upload/mm/472/electronic-e-prescribing.pdf
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