Following orders

New solutions to the age-old problem of patient noncompliance with prescription drug orders.

By Christine Wiebe, amednews correspondent. Dec. 20, 1999. - Additional information.

Many doctors are satisfied that their work is done when a patient walks out the door with a diagnosis and a prescription or treatment plan in hand. But most know that some patients will ignore their instructions.

"Your patients may not be doing what you're telling them to do," warns Jerome Avorn, MD, associate professor of medicine at Harvard Medical School and chief of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital in Boston.

Some will set the prescription on a counter at home and forget to have it filled. Or they will intentionally not fill the prescription because of concerns about side effects. Others will decide that the recommended lifestyle changes are too overwhelming or unpleasant to implement. Still others will discover that there isn't enough money in the budget to see a specialist or physical therapist.

A growing body of research reveals that patient compliance is a bigger issue than many physicians think.

"As much as 50% of medications prescribed for chronic use never get taken," Dr. Avorn says. Researchers are finding that the severity of a patient's illness is less a factor in compliance than the chronic nature of the disease. That explains why compliance is a particularly difficult issue in treating patients with diseases such as diabetes, asthma and hypertension.

The full impact of this problem is difficult to measure, but various studies show it is far-reaching. Millions of hospitalizations and a quarter of all nursing home admissions are linked to incorrect usage of prescribed medications. The cost of patient noncompliance in terms of additional health care and in lost productivity has been estimated at more than $100 billion a year in the United States.

In an age of cost cutting, quality improvement and outcomes measurements, patient compliance is receiving greater scrutiny. Like the age-old conundrum that asks whether a falling tree makes a noise if no one hears it, health care experts are beginning to question whether a patient who fails to fulfill a physician's orders can really be considered treated. "All of the elegant diagnostic maneuvering physicians do can be completely undercut if the patient doesn't take the therapy," Dr. Avorn says.

Of course, even patient advocates agree that patients must assume much responsibility for their own health care. But physicians can and should do more to ensure that the process that starts in their office or at the bedside actually reaches fruition.

"You can't make patients take their medication," says Ronald Ferdman, MD, an asthma and immunology specialist at the Children's Hospital of Los Angeles. "But we're the only ones who can convince patients and make them feel the importance of taking a medication."

Getting the picture

The first step in attacking the compliance problem is improving physician awareness, experts say.

"Some docs still have the old-fashioned idea that, 'If I tell someone to do something, then they'll do it,' " Dr. Avorn says. Instead, patients face a number of barriers when they leave the physician's office. Some are unable even to read a doctor's orders, for instance, and cultural issues such as dietary restrictions may prevent them from following through.

The main obstacle for some patients is the cost of the prescribed treatment, especially if they are uninsured, Dr. Avorn says. On the other hand, studies have found high noncompliance among patients with good coverage, indicating that cost is not the only issue.

Communication is another major factor. Many patients simply do not understand their prescribed course of treatment. "We need to do a better job of communicating to patients why they're on this medicine and why they need to be taking it," Dr. Avorn says.

Some therapies are a "tough sell," he says, such as those with only modest benefits and bad side effects. When physicians fail to warn patients about potential problems, patients often use those complications as a reason to quit taking the medicine, he says.

On the other hand, patients also use positive outcomes as a reason to discontinue their therapy, says Dr. Ferdman. "People still treat asthma as an episodic disease." And they forget to do preventive tasks once they are feeling better. Of course, a perennial problem is patients who don't take their entire regimen of antibiotics. To reinforce a patient's long-term care plan, he discusses at least part of it at every patient visit.

"We ask, 'Are you taking the medicine?,' and then we ask, 'Are you really taking the medicine?' " Dr. Ferdman says. "In fact, I've started asking, 'How often do you miss it?' " Raising such issues in a nonthreatening manner is essential to getting a good response, he adds.

Physicians often are afraid they will open Pandora's box by asking patients about compliance, he says, but he believes it is vital to know the truth. "I'd rather they tell me, because then we can deal with it."

In fact, many of the asthma patients he sees were referred by other physicians because they were not doing well. "Very often it turns out that they weren't really using the medicine or they were using it incorrectly," Dr. Ferdman says. Often, those patients were seen at a busy pediatric practice and were not adequately informed about their prescribed care.

The danger is that physicians may increase the dosage or add other medications to a patient's regimen if they believe the current therapy is not working, Dr. Ferdman adds.

Compliance experts understand that physicians may believe they do not have time to counsel every patient about every obstacle they face in fulfilling the doctor's orders. However, they say physicians can improve compliance without adding more pressure to existing time constraints.

"There are tools that physicians can use to help minimize the amount of time that being thorough requires," says Barbara Felt, MD, assistant professor of pediatrics at the University of Michigan Medical School in Ann Arbor. For instance, patient questionnaires can elicit concerns prior to the physician visit.

Preprinted treatment plans eliminate the need to reinvent a form at each patient visit, Dr. Ferdman says. "Every patient should have written instructions." He uses a version of the popular "Asthma Action Plan" to guide patients and relies on allied health care professionals to continue the patient education process.

But although printed materials can provide some shortcuts, experts agree there is no substitute for a physician devoting a few personalized minutes to compliance issues. Otherwise, the rest of the physician intervention might be moot.

Ira Ockene, MD, professor of medicine and director of the preventive cardiology program at the University of Massachusetts Medical School in Worcester, is one who believes that doctors need to devote more time to listening to their patients. He has researched various aspects of patient compliance and trains physicians on patient-centered counseling.

Most physicians engage in some small talk with patients, he says, when they could use that time to discuss treatment issues. "Instead of talking about the Red Sox for two minutes, you can do this."

In some cases, physicians should even schedule additional visits to monitor compliance, says pediatrician Dr. Felt. Her research has identified noncompliance with dietary guidelines to be a major problem in treating pediatric constipation.

A systematic approach

In addition to enlisting better patient and physician involvement, advocates argue that changes need to be made in the health care system to ensure better compliance. "The environment has to make it possible for the physician to do the right thing," Dr. Ockene says. He is developing office systems and tracking tools that will help physicians address compliance issues.

Dr. Ockene and others believe more resources will be directed toward improving compliance as evidence grows about its long-term impact. Already, improvements in electronic monitoring make tracking compliance easier. Electronic ties to pharmacies can tell doctors which prescriptions are being filled and refilled. Pagers are available to remind patients to take their medications. And electronic caps for pillboxes help document patients' pill-taking habits. How commonplace such devices become in physicians' practices and patients' homes will depend partly on their proven outcomes.

"Eventually, who pays will depend on whoever benefits," says John Urquhart, MD, chief scientist at AARDEX (Advanced Analytical Research on Drug Exposure), a Swiss manufacturer of electronic pillboxes. He envisions insurers covering devices that achieve long-term cost savings, whereas pharmaceutical companies may underwrite those that lead to increased drug usage.

"Prescription drug compliance is a painfully obvious issue, but one that's been marginalized for years," Dr. Urquhart maintains.

A number of public health organizations, including the American Heart Assn., have launched campaigns to increase awareness of the problem. But all efforts are anchored on the partnership of physicians.

"Compliance is not just a patient problem," Dr. Ockene says. Physicians who take the time and follow established guidelines can have a very significant impact on their patients' lives and on the greater public health, he emphasizes. "Doctors have to believe that they can do this and that it's important.