Rx Non-Compliance and Ineffective Physician-Patient Communication – Two Sides Of The Same Coin

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Lots of smart people over the years have been trying to figure out why people stop taking their medications within the first 12 months.  Within the first 12-months of starting a new prescription, patient compliance rates drop to less than 50%.  This rate is even lower for people with multiple chronic conditions taking one or more prescription medications.

If these medications are so important to patients, why do they just stop taking them? It defies common sense. Sure issues like medication cost, forgetfulness, lack of symptoms, and psychosocial issues like depression play a role in patient non-compliance. But there also something else going on…or in this case not going on.

The problem is that doctors and patients simply don’t talk much about new medications once prescribed. Here’s what I mean.  Let’s say that at a routine check-up a physician tells a patient that he/she wants to put them on a medication to help them control their cholesterol.  The doctor spends about 50 seconds telling the patient about the medication.  The patient nods their head takes the prescription and boom…the visit is over.

Let’s say the patient actually gets the prescription filled.  For some people that is a leap of faith considering the likely chain of events up to that moment:

  • The physician didn’t really make a good case for why they needed the medication (if the doctor wanted me to take it he/she should have been emphatic about it as in “I recommend you take this” – not simple “I want to try something”), what it would do or what would happen if the patient didn’t take it.
  • The doctor didn’t mention how the new medication would interact with the 2 other pills I am already taking.
  • Consequentially the patient may not believe they really need the medication.

Fast forward 12 months. The patient has been back to see the same doctor twice for problem unrelated to cholesterol. At neither of these appointments did the doctor mentioned or ask how the patient was doing with the new medication. The doctor did mention the need for a blood test to check for liver issues and that they should recheck the cholesterol levels at the next visit.

So at this point the patient concludes the following about the new medication:

  • The doctor never talks about cholesterol or brings up the subject of the medication. I assume I am taking it correctly.
  • If the doctor doesn’t mention it (the medication) it must not be important.
  • I haven’t notice any difference in my health – I guess I don’t need the medication.

Sure the patient should have asked their doctor if they had any questions about the new medication. But patients seldom ask their doctor questions. Sure they could ask the pharmacist…but the pharmacist would tell them to just ask their doctor.

It so much easier for the patient to just not refill the prescription.

We have all heard the expression that whatever doesn’t get measured doesn’t get done.  Well the same thing is true for when it comes to physician-patient communications.  Whatever issues doctors don’t talk with patients about will not get done over the long haul either.  In this case patient’s simply stop taking prescribed medications.

As primary care slowly shifts from episodic, acute care to continuous care with the aid of EMRs and the focus of patient-centered care things should get better with respect to patient compliance. It needs to. Give the current focus on episodic acute care too many chronic health issues simply are not being addressed for one visit to the next.

That’s what I think. What’s your opinion?

8 Comments

  1. JF says:

    Another cause pointed to poor medication compliance is the cost of the prescription – and that physicians have no idea how much a prescription really costs a patient out-of-pocket. I don’t know the exact study, but I am aware of at least one in which found that medication adherence is related to the patient’s out-of-pocket cost.
    I am glad to see that you mention patient-centered care and EMR use as ways that will improve compliance. There are a couple studies and Patient-Centered Medical Home pilot programs underway that are beginning to show early results. Nice discussion you have.

    • JF,

      Thanks for the kind words. You are exactly right about cost of care being another barrier to patient compliance. Turns out patients are too embarrassed to bring up the subject…and physicians seldom ask.

      Where implemented properly, with the appropriate training and systems integration, there’s no reason why EMRs should not work. Same with patient centered care. If you are aware of medical home pilots that are doing well let me know. Maybe I can profile them here.

      Steve Wilkins

      • Emily says:

        When it comes to cost, I think patients are embarrassed to admit they are having trouble with costs. I also think it would be a challenge for doctors to keep up with what medications cost. There is often a lot of variation, more than most people would think.

        Look here at http://www.frugalpharmacies.com If you purchased topiramate (generic for Topamax) from Walgreens you would pay about $380. At Costco, you would pay only about $20. A friend of mine found that out the expensive way. Simvastatin at Walgreens is approx. $60, at Walmart $25, at Costco $7. It is quite possible to pay a cheaper cash price than insurance copay.

  2. Finn says:

    One thing you forgot to mention: If the patient twigs to the fact that the liver tests are needed because the cholesterol medication may be damaging his liver, that’s even more reason to stop taking it–particularly since he’s not convinced he needs it in the first place.

  3. David Hold says:

    You hit it on the head. There is no communication or interaction between the doctor and the patient once the prescription has been written. We have studied a lot of medication management systems for our Global Monitoring Program but unfortunately the people who are writing this programs in order to justify the cost of their system develop solutions that are so complicated that even PhD’s have problem with it. We have to keep in mind that the average person is either elderly and is not computer savvy or sick and does not have the patience for complicated systems, but in general we do not want to waste a lot of our time on either a computer or phone on this issue. As a result we had no choice but to develop our own system that is easy not time consuming but will deliver the results that we are after. One to separate the compliant ones from the non compliant and than address the reasons of the none compliance.

  4. Christine says:

    I disagree that physicians don’t know the real out-of-pocket costs of the medications they prescribe. Some doctors ask their patients if they have prescription drug coverage before they prescribe a medication. They may not know the real out-of-pocket cost, but they may know which treatment options are usually covered by insurance.

    If a physician doesn’t take into account my ability to pay for a medication when he chooses a drug treatment, how can he expect me to take it?

  5. mgilmore says:

    I was non compliant with hypertensive drugs because they had no effect on reducing my blood pressure and made me very sick with side effects. Then my dx became hypertension due to non-compliance. Many people have drug resistance hypertension . They get stuck with the label of non compliant when they stop taking the useless drugs.

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