Tag Archives: medication taking

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

[tweetmeme source=”Healthmessaging” only_single=false]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?

Accountable Care and Effective Physician-Patient Communications – You Can’t Have One Without the Other

[tweetmeme source=”Healthmessaging” only_single=false]Accountable Care Organizations (ACOs) figure prominently in the new Patient Protection and Affordable Care Act.   The concept behind Accountable Care Organizations is that by tying both physician and hospital compensation to outcomes via a bundled fee (say for pneumonia), we can expect to see an improvement in quality and value.

In principal accountable care makes a lot of sense.   Practically speaking however, doctors and hospitals must address a huge challenge before they can expect benefit financially.

Before doctors can be held accountable for the care they deliver, they first must be held accountable for the quality of their communication with patients.

Take hospital re-admissions which are a big cost-driver today.   According to a recent study in the New England Journal of Medicine, 20% of all Medicare patients discharged from hospitals were readmitted within 30 days, and 34% percent within 90 days.

The Joint Commission and others believe rightly believe that inadequate communication between physicians, as well as between physicians and patients, is a major contributing factor.

Here’s an example.   In a small study of 47 patients surveyed at time of hospital discharge (Commercial and Medicare), 72.1% of patients were unable to list all their discharge medications.  86% were unable to describe the common side effect(s) of all their medications, and 58.1% did not know the diagnoses that put them in the hospital in the first place.  These trends are consistent with the findings from a number of similar studies, including studies of discharged ER patients.

Physician-patient communications shortcomings abound in the doctor’s office as well.    Approximately 20–50% of patients do not take medications as prescribed.  It’s not necessarily because patients are non-compliant.  Patients don’t take medications out of fear of drug interactions, perceived lack of effectiveness, adverse effects, misunderstanding regarding necessity, or concerns about costs.

Patients who report better general communication with their doctor, i.e.,  better instructions on how to take a medication, and who receive more medication information, are more likely to take medications as prescribed.

The success of new financing and delivery models like Accountable Care Organizations and Medical Homes depends heavily upon significant address the quality of the current state of physician-patient communications. I wonder when today’s physician and hospital leaders will get a clue.

Sources:

Makaryus, A., et al. Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge.  Mayo Clinic Preceedings, 2005.

Coleman, E., Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine. 2009.

Kripalani, S., et al. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians.  JAMA 2008.

Paying Patients to Take Their Medications Is Stupid

The New York Time reported recently on efforts by providers and payers to increase patient medication adherence through the use financial incentives paid to patients.  The article cited the use of small financial payments (<$100), awarded via lotteries, to patients that take Warfarin – an anti blood clotting medication.

There is certainly nothing wrong with financial incentives.  Incentives have been proven successful in changing selected provider (quality and safety improvement) and patient behavior (stop smoking, weight loss and taking health risk surveys).   But paying patients to take their medication is different.  Actually, the evidence suggests that it is a just plain stupid idea for a whole lot of reasons.

Why Paying Patients to Take Their Medications is Wrong-headed

According to published research, physicians only spend 26 seconds of the average patient visit on discussing new medications with patients.  26 seconds! That’s not enough time.  Studies show that physicians often do not discuss important aspects of new medication, such as how to take the medication and how long to keep taking it.

In a previous post, I cited a study that demonstrated that poor physician-patient communication not recalcitrant patients, resulted in poor patient adherence with taking Warfarin.  As I reported, 50% of all patients in that study differed from their doctor in term of understanding how they we supposed to take the medication.  In other words, one half of the study population was taking a Warfarin incorrectly.

These finding are not new.  Numerous studies over the years have shown that many patients often don’t know the name of the medications they are taking, not to mention how to take them, or when to stop taking them.

The odds of patient medication adherence are 2.16 times higher if a physician communicates effectively with the patient.

Rather than paying patients, why not pay primary care physicians more for taking the time to: 1) explore the patient’s beliefs about medication-taking and 2) make a more compelling case for how and why patients should taking needed medications in the first place.

Sources

For Forgetful, Cash Helps the Medicine Go Down, New York Times. June 13, 2010.

Zolnierek, K., et al.  Physician Communication and Patient Adherence to Treatment. Medical Care 2009;47: 826–834.

Tarn, D., et al. How much time does it take to prescribe a new medication? Patient Education and Counseling 72 (2008) 311–319.