When Patients Don't Take Their Medicine

"Medicine left in the bottle can't help."

— Yoruba proverb

Lack of adherence to prescriptions (that is, patients failing to take medicine either as instructed or at all) afflicts medical care in the United States. Nonadherence affects up to 40 percent of older adults, especially those with chronic conditions, and is associated with poor outcomes, more hospitalizations, and higher mortality. The health care cost of nonadherence is estimated at $290 billion per year. Prior RAND research has shown that some nonadherence is cost-related and can be addressed through insurance benefit designs that keep copayments low.^[1]

Physicians also play a key role in addressing nonadherence. Yet physician perspectives on their responsibility for nonadherence and strategies for promoting adherence are not well understood. A team from RAND; the University of California, Los Angeles; and the University of California, Davis, examined physicians' views about their responsibility for medication adherence and explored how physicians and patients discuss nonadherence. The team conducted focus groups with physicians in New Jersey and Washington, D.C., and audiotaped primary care visits in Northern California doctors' offices.

The results point to a contrast between what physicians believe and what they do:

• Although physicians uniformly felt responsible for assessing and promoting medication adherence, only a minority of them asked detailed questions about adherence.
• Although providers often checked which medications a patient was taking, they rarely explicitly assessed adherence to these medications.
• Many physicians expressed discomfort about intruding on patients' privacy to detect nonadherence. In the office, they rarely asked about missed medication doses.
• Most cases of nonadherence detected during office visits were revealed through unprompted patient comments.

Physicians' reluctance to intrude has important implications for the vast array of new information that is becoming available from pharmacy benefit plans, managed care plans, and other data repositories. In addition, the reluctance to inquire that the physicians described contrasts sharply with the physician role in the increasingly prominent concept of the medical home, where primary care doctors are envisioned as playing a central and active role in managing and coordinating care.

The authors conclude that addressing nonadherence will require a different approach than the one they observed in the study. Given the importance of patients' shared responsibility, a new paradigm that clarifies joint provider-patient responsibility may be needed to better guide communication about medication adherence. In this context, developing new protocols to guide discussions of adherence is worth exploring.

Notes

• [1] Solomon MD, Goldman DP, Joyce GF, and Escarce JJ, "When Drug Cost-Sharing Increases, Patients Newly Diagnosed with a Chronic Illness Delay Starting Medication," Santa Monica, Calif.: RAND Corporation, RB-9453, 2009.