Many physicians are surprised their patients are not open about taking their medication. Recent studies show most patients only take their medicine as prescribed about half the time and are often reluctant to tell their doctor while a quarter of new prescriptions are never filled. Medication adherence is a growing concern among physicians and health care systems—nonadherence can lead to harm to patients, increased costs of care and unnecessary, time-consuming work for the practice.
An AMA STEPS Forward™ module aims to help physicians and their teams improve the health of their patients while reducing overall costs. A patient is considered non-adherent if they take less than 80 percent of their prescribed medications. This module offers eight steps to decrease medication nonadherence through staff involvement, patient engagement and behavior change.
Marie T. Brown, MD, is a geriatric and internal medicine specialist at Rush University practicing in Oak Park, Illinois, who co-wrote the module. She has successfully improved her patients’ medication adherence and their trust with her team. To improve medication adherence in her practice, Dr. Brown helped her team understand nonadherence in patients and encouraged a change in attitude toward patients and their medication taking behavior.
“Too often we assume the patient is taking their medicine and we don’t uncover the nonadherence,” she said.
It is common for most physicians to assume that the most common reason for nonadherence is forgetfulness or access/cost, however this accounts for a small amount of nonadherence. Physicians are often surprised to learn that most nonadherence is intentional based on personal beliefs. Understanding the rationale behind their patient’s decision to not take their medication helps the care team better prepare for conversations to steer them towards adherence.
To begin, Dr. Brown recommends physicians and their teams learn more about medication nonadherence and to “appreciate the rationale that led a patient to choosing to not take their medicine.”
“Too often our reaction encourages the patient to conceal their nonadherence and when that happens, it is very dangerous because the physician will think the blood pressure is resistant or their diabetes requires an additional medicine,” Dr. Brown said. “As a result, the patient may be prescribed second and third meds when they are not taking the full dose of the first medicine. If adherence suddenly improves, for example upon hospital admission, blood pressure and glucose levels could drop precipitously.”
Once awareness of how common nonadherence is among patients, physicians and their teams need to develop a blame-free environment to uncover it. The reasons patients don’t take their medicines are numerous, but it is important to make them feel comfortable sharing their true medication taking behavior.
“The greatest challenge is first to change the attitudes of the health care team,” Dr. Brown said. “Many physicians feel that they have completed their duty—their responsibility to the patient—by prescribing the appropriate medicine and feeling that it is now the sole responsibility of the patient to follow their advice. A physician’s belief in the benefit of the therapy often exceeds the patient’s understanding of that benefit.”
“Knowing how effective the medicine is and how it saves lives, it’s very difficult for physicians to understand why someone wouldn’t take a medicine that would prevent a stroke or heart attack,” she added.
After understanding the numerous causes of medication nonadherence among her patients, Dr. Brown developed a new attitude and let her patients know she was not going to scold them—she wanted to know what they were actually doing and why. She now thanks the patient for sharing the information with her. Only then can the specific cause be addressed.
“Phrase the questions so the patient can answer affirmatively,” she said. “Frame it so that it’s OK for them to tell you what they’re doing—it saves an enormous amount of time because you’re not starting a whole new workup or prescribing that second line drug that might need preauthorization.”
Asking patients, “Why aren’t you taking the medications I prescribed?” often feels confrontational and suggests that the patient’s nonadherence is because they are defying the physician’s recommendations. Instead, try saying, “Many people have trouble taking their medications on a regular basis. Do you find this is the case for any of your medications?” This removes blame from the patient to allow them to open up about their particular situation and gives the physician and the care team the opportunity to appropriately intervene.
If physicians have effectively uncovered nonadherence and begin to improve the medication taking behavior of the patient, it is important to decrease or even discontinue some of the medicines in order to avoid over treating a chronic condition.
“Now that I’ve changed my attitude, when I see someone whose blood pressure or diabetes is out of control and I suspect that they are not taking their medicine, I look forward to working with that patient rather than being frustrated,” Dr. Brown said. “It has brought tremendous more joy to my practice.”
Several modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve large-scale health transformation through TCPI’s Practice Transformation Networks. The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support by way of STEPS Forward resources to enrolled practices. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules.