While governments and markets can offer strategies and incentives for patients to take their medication, there are some quick and easy steps that physicians can take to address the problem right in the doctor’s office. In this article, the fifth in our continuing series on medication nonadherence, we’ll discuss some of those steps and how they work.
The overall strategy revolves around sharpening communication skills and consists of three components: First, monitoring adherence; second, promoting adherence; and third, providing effective interventions.
Monitoring and Evaluating Adherence
The simplest way to evaluate adherence is to ask patients directly about it at every visit. A problem here is that patients—either deliberately or inadvertently—may not self-report their medication-taking behavior accurately. As a result, is it might not be clear whether a poor outcome is due to drug ineffectiveness or to incomplete administration. Checking the renewal dates on a patient’s medication containers can provide some insight as to adherence, as can pill counting. Electronic pharmacy data as part of an electronic health record system can be used to monitor adherence, although this information is not always available to providers or other stakeholders in the health system.
The average time that a physician spends talking with a patient about a newly prescribed medication is reported to be 49 seconds—and on one-fourth of occasions, no medication instructions are given at all.
After speaking to a patient about his or her complaint or illness, the physician should provide clear and direct information to help him or her understand the benefits and risks of treatment and the consequences of nonadherence. Allow time for questions and don’t be too quick to interrupt. This is also a good time to provide written materials and illustrations.
Employ the same active listening skills and open-ended questions that you would use to make a diagnosis when evaluating medication-taking beliefs and behaviors. Pay attention to nonverbal cues—such as facial expressions, sounds, and body language—to alert you to what the patient is really thinking when you mention possible side effects, especially those that interfere with lifestyle—such as heartburn, diarrhea, or impotence.
Improving medication adherence is generally not an easy fix. Success depends on tailoring the intervention to the cause: forgetfulness may be ameliorated by alarms, but overt resistance may require counseling. Often, a multicomponent intervention plan—using reminders, medication adjustments, counseling, and financial support—may yield the best results.
Pill Organizers and Reminders
Old-fashioned pill-dispensing boxes—be they organized on a daily, weekly, or monthly basis—can work for high-functioning patients. For those who tend to forget, alarms that use noise, light, or vibration can help, including those integrated into watches, pillboxes, pill bottle caps, alarm clocks, timers, and pill dispensers. Some plans are now connected to electronic monitoring systems, such as the Wisepill electronic dispenser, which will send a message to the patient’s mobile phone (or to that of a family member or caregiver) if a scheduled dose is not taken. Websites are also available to help patients organize their medications (e.g., www.mypillbox.org/mypillbox.php).
For patients who find taking medications inconvenient, unpleasant, or confusing—especially patients who take several medications a day—changes in dosing regimens or formulations may help adherence. For example, consider once-daily dosing, long-acting dosing, 90-day refills, or “polypills” containing more than one medication, such as a calcium channel blocker for hypertension combined with a statin for lowering lipids. Encourage patients to take their medications at the same time each day and match regimens to the patients’ activities of daily living, including at mealtimes or bedtime. Ask the pharmacist to synchronize refills. Ask patients about side effects and try to find solutions. Make sure they understand what they must do to take their medications successfully by simplifying the instructions, having patients repeat instructions back to you, providing written instructions, and evaluating whether they have both the ability to read medication labels on containers and the manual dexterity to actually take the medication.
Education and Counseling
Patients who do not understand the importance of medication adherence, as well as those who do not understand how they should be using their medications, need tailored interventions, including patient education and counseling. Education is considered to be one of the best methods for improving adherence, especially for those taking several medications at the same time. In addition to face-to-face discussions and written materials, physicians may direct patients to online resources provided by disease-advocacy groups such as the American Diabetes Association. Practices may also develop support groups, such as for pregnant diabetic patients, and set up virtual videoconferences.
Last but certainly not least, medication affordability should be discussed with all patients, especially during difficult economic times. Explore options such as lower-cost medication alternatives and pharmacy options (e.g., generics or mail order suppliers). Some pharmaceutical companies promote their products by offering copay assistance programs.