Improving Medication Adherence: A Physician’s Perspective (continued)

“I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be better for mankind-and all the worse for the fishes.”
Dr. Oliver Wendell Holmes, Sr.
American physician, writer, poet
from Address to Massachusetts Medical Society, 1860

Much has changed in the last 150 years, and medication now does a great deal to improve health and reduce suffering. Yet non-adherence to prescribed medication is the elephant in the room whenever we talk about healthcare. In the US alone, lack of adherence to medication harms or kills 700,000 people a year, and costs our national healthcare system hundreds of billions of dollars annually. Taking medications, on time and correctly, can be the difference between health and illness, life and death of patients.

I discussed my perspectives on medication adherence challenges in a prior post. In this post I will discuss approaches to improving adherence.
As a practicing physician, I know that the moment an course of medication is decided upon, the patient starts down a thorny path, and the success of my treatment depends to a large extent on their ability to navigate it. So what are the potential pitfalls on the path to adherence?
The first potential derailment occurs when the medication is prescribed, even before our patient walks out of the clinic, and it is patient motivation. Here physicians play an important role. We must involve patients in a shared decision making process around the use and selection of medications, which should include educating the patient about their options and information about the prescribed medication. Patients who understand what they are prescribed and the purpose of the drugs are more likely to take them.

The second hazard is that the prescription may never reach the pharmacy. E-prescribing, through which prescribers use computer systems to write and transmit prescriptions, is useful to ensure patients don’t lose paper prescriptions and can help ensure that medications are permitted by the patients’ health plans. When this fails, having efficient systems in the practice to change to permitted medications and to process prior authorizations required by the drug plans will help patients get the drugs they need more rapidly.
Next the patient needs to retrieve their filled prescription from the pharmacy. They fail to do so more than 40% of the time, something that became apparent when we were able to easily track prescriptions electronically transmitted to the pharmacy. Patients often forget to pick up prescriptions, particularly when they are ambivalent about taking them. Automated alerts from pharmacies may help with this. But when patients find out how much they have to spend out of pocket (due to co-pays and deductibles) it may be an additional disincentive. To the extent we are able, we should discuss the cost of prescriptions with our patients at the time of prescribing and be open to conversations about lowering prescription charges when patients raise these issues. Sometimes we can prescribe alternate drugs and sometimes patients can benefit from drug discount programs and sources such as GoodRx, BlinkHealth, Marley Drug, and individual programs offered by pharmaceutical companies.
Another critical stage in the process arises when the patient runs out of the medication, and needs to refill or renew a prescription. Pharmacies have made it ever easier to refill medications when they run out, sending text messages and other reminders to patients, and allowing them to use automated phone systems and apps to order refills. Systems in the practice, both telephone and patient portal-based, that make it easier for patients to renew their prescriptions are also critical to ensure that patients have a supply of medication.
So now that patients have their supply of medication, each time they are supposed to take their medication they choose to take or not to take their medication, take less or more than the amount prescribed, or use their medication less or more frequently than instructed. For high-risk patients I am sometimes able to assign a case manager to help with adherence to their medications and care plan. I also will see some patients more frequently to reinforce the importance of medication adherence.
For some patients, often those on many medications or the elderly, we recommend medication lists and the use of pillboxes as memory aids. Sometimes we order medications pre-packaged into packets of medications meant for various times of day. For some high-risk conditions we have public health workers who directly observe patients taking medications (which now can be done by video) and there is even a device embedded in a tablet that emits a signal when some medications are swallowed.
But we also have more widely available tools at our disposal.
Medisafe is a free app (for both iOS and Android devices) that allows users to enter their medication information (or import it from Apple Health Kit or other interfaces). The app provides customized education about their medications and alerts the user when it is time to take medications. If a user is not taking his or her medications, the systems asks why and tries to address their concerns, including helping with drug discounts. Finally, users can choose a network of friends and family (“MedFriends”) to be alerted when they forget to take their medications. Each month, it is being used by a half-million people around the world, and consumers are reacting very positively to their experience with the app.
Studies show that Medisafe users refill their prescription more often and increase their adherence substantially when using the app and even after they stop using it, showing that positive adherence behaviors persist.
Medication adherence is a challenge and frustration for patients and physicians alike. By educating patients, engaging in shared decision making, adopting practice procedures to lower the friction for patients to take and continue to take their medication, and recommending apps like Medisafe we can improve adherence, improve outcomes, and reduce morbidity and mortality.