Thursday, June 16, 2011

Drug adherence still falters

I had the pleasure of sharing a podium this week with Dr. Daniel Teres, Senior Director, Field Medical Physician, at AstraZeneca Pharmaceuticals, to discuss the topic of adherence to medication. We used the August 4, 2005, NEJM article by Osterberg and Blaschke as our starting point, but then went on from there to explore the topic more fully.

Regular readers with a good memory will recall that I covered this topic three years ago, quoting George Paz, CEO of Express Scrips. Well, Daniel had similar numbers to report, citing a study showing that after one year, only half of all patients with chronic conditions are taking medications as recommended by their doctors. While the NEJM article gives some of the reasons, he also explained some additional ones.

Denial of disease heads the list among patients with some conditions. Clinical depression is another. The stigma of the disease is another (e.g., among those taking psychiatric drugs.) Complexity of the prescription regime is another: "One per day is the best," he noted.

Daniel asked the audience to guess for which disease there is virtually 100% drug adherence. Quick, you guess, before reading further!

The answer is below.*

We also discussed how technology might be used to enhance adherence. I mentioned advanced design pillboxes, human or computer-aided calls to patients, and texting on cell phones. You would think that electronic prescribing of drugs would enable physicians to see if their patients had picked up their orders, but the full capability of e-prescribing is not generally in use. Most pharmacies do not fill in that portion of the electronic record, and there is no way for an individual clinician to request a fill status for a specific patient or drug order.

The setting for this discussion was a Life Sciences Insight Summit for IT professionals. The audience was engaged and offered many cogent observations.

*Answer. Tuberculosis. Why? The drug is administered in person on schedule by a public health nurse, who stays with the patient long enough to ensure that the pill is taken, that it is swallowed, and that it is not vomited up.


dk said...

I've been working on designing for adherence for a while, and there's a big push to throwing technology at the problem, without always being super clear on what the problem is and how the technology would solve it.

If people are forgetting, then yes, some of those solutions would help. But a lot of times, the problem is is that people don't believe they need it. Or aren't convinced it is working. And all the text messages in the world won't help with that.

Anonymous said...

dk; I note that one of the commenters on Paul's previous post on this subject indicated that doctors spend 2.3 minutes discussing their prescribed medications with their patients during a visit. Even allowing for the fact that the commenter worked for a vendor of medical adherence technology, this number doesn't surprise me.
Perhaps the new era of engaged e-patients will help people do their own research to decide if they should adhere or not. Personally, I suspect that a fair percentage of the issue is forgetting.

nonlocal MD

Anonymous said...

Cost shifting to patients, and increase in daily commodities creates additional tradeoffs. The poor scientific eduction of the population, and limited (and didactic) education time (that cannot offset a lack of biological knowledge, evolution of pathogens, etc.) tips the equation farther. Sometimes I 'forget' because it really doesn't make me feel any different. Sometimes I 'forget' because I made the choice to go to the grocery store or fill the gas tank on the way home. People have been telling us for years why they ignore doctors advice. It would be interesting to compare these data to adherence to 'texts'.

Anonymous said...

Tuberculosis treatment does not have anything approaching 100% adherence; the half a million or so cases of multidrug-resistant TB (MDR-TB) are inarguable evidene of the lack of adherence to TB treatment. The standard treatment for drug-sensitive TB consists of multiple pills taken for period of 6 months, as per WHO treatment guidelines (some regions treat for even longer in local practice). Many patients default before completing treatment.

DOTS programs do not have 100% reach. And, further, in many TB endemic countries there exist large private markets that do not adhere to the treatment norms of public programs.

Anonymous said...

Isn't this the great white space of Paul's descendant post? There is a lot of investment on 'proven' 'behavioral' 'cognitive' approaches to changing health. If science and industry were so successful, wouldn't tuberculosis (and whopping cough) be extinct, or nearly so?

Feeding the beast doesn't get you to the next Rorchasct test. Creativity, innovation, and integration does. Where are the tuberculosis patients who can change the way that science is delivered? Who will give them voice?