June 12, 2006
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Noncompliance: Weak Link in the Chain of Treatment
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by Graham Ramsay
Erica Seiguer |
“I don’t know what any of those drugs do. I don’t even like the word ‘drugs.’”
I had just met Ms. C, a 71-year-old lady with a history of coronary artery disease, diabetes, and hypertension, who had come into the hospital with what appeared to be her third heart attack. In the emergency department, sitting up in a stretcher looking comfortable if not annoyed, she asked me straight away when she could leave the hospital. I told her that it appeared she had had another heart attack and, since she had already declined more invasive treatments such as catheterization, we wanted to admit her to be managed medically.
In the past, she had been prescribed a litany of drugs to protect her heart, but she had refused to take them. She confided in me that she had not taken any of her medications in years. Her medical record was littered with emergency room visits ever since her first heart attack about 10 years ago, and the discharge summaries pressed the point of Ms. C’s lack of compliance with even the most essential medications.
She explained that she just did not like medications. She seemed suspicious about whether or not they were effective, since they did not seem to change the way she felt. I assured her that the host of medications prescribed were standard of care, and there was very good evidence for the use of aspirin, beta-blockers, and cholesterol-lowering drugs for patients like her. I went through each drug on her list and explained what each was intended to do and how they could help reduce her risk of future heart attacks and her recurrent visits to the emergency department.
Gaps in Therapy
While Ms. C may be an extreme case of a patient who outright refuses
to take medications despite all the evidence and the exhortations of
family
and physicians,
patient noncompliance with medications is widespread. According to
a 2003 survey by the Boston Consulting Group, about a third of patients
take their
medications
less often than prescribed, a fifth skip filling a prescription, and
another fifth stop taking a prescribed medicine before its full course,
leading
to undertreatment. While about a quarter of patients cite forgetfulness
as the
reason for missing pills, the majority of patients report that unwanted
side effects, cost, belief that the drug is not necessary, difficulties
in filling
the prescription, and lack of knowledge of how to use the medication
all contribute to noncompliance.
|
“About a third of patients take their medications less often than prescribed, a fifth skip filling a prescription, and another fifth stop taking a prescribed medicine before its full course, leading to undertreatment.” |
When patients are undertreated for whatever reason, it stands to reason that their health will be adversely affected. Studies in patients with schizophrenia have shown that poor compliance results in higher rates of relapse as well as higher costs of treatment. Repeat hospitalization is another symptom of poor compliance.
Getting to Patients
Because of the impact on patient health and health care dollars,
efforts to improve patient compliance are under way. Researchers
have been
testing various
programs to approach compliance in a scientifically rigorous way.
A group at UCLA, for example, spurred by low rates of compliance
among
patients
with heart
disease, began in the mid-1990s to implement algorithms for treating
patients presenting with coronary artery disease, with the aim
of increasing compliance
with four classes of drugs: aspirin, beta-blockers, angiotensin
converting enzyme (ACE) inhibitors, and antilipid therapies (statins).
They
developed the Cardiovascular Hospitalization Atherosclerosis Management
Program
(CHAMP), which emphasizes standard treatment guidelines along with
intensive counseling
and education for patients.
The results were impressive: compliance with all four medications increased dramatically from the pre- and post-CHAMP period. Beta-blocker use on discharge and one year later in the pre-CHAMP period was 12 percent and 18 percent, respectively. Post-CHAMP, these rates climbed to 61 percent and 57 percent. Use of ACE inhibitors and statins demonstrated even more dramatic increases.
The CHAMP researchers also looked at health outcomes—specifically, recurrent heart attacks, heart failure, hospitalization, and total mortality. They found declines across all four and statistically significant declines for all but heart failure. In fact, hospitalization rates were cut in half, and total mortality and heart attacks declined by more than half. While not a randomized, controlled trial, the evidence was convincing, and the program was to be adapted by the American Heart Association, under the auspices of their Get With The Guidelines program, now in use in more than 1,500 hospitals.
Back to Ms. C: a day later, in preparing her for discharge, the medical team went through the list of medications to pare it down to the bare essentials, with the hope that a simplified regimen would increase the likelihood of compliance and improve Ms. C’s health prospects. Several team members spoke with her about compliance. She promised to take her medications and follow up with her primary care doctor.
Related Websites:
American Heart Association Get With the Guidelines (GWTG) Program: www.americanheart.org/presenter.jhtml?identifier=1165
CHAMP: www.med.ucla.edu/champ
The Hidden Epidemic: Finding a Cure for Unfilled Prescriptions and Missed Doses
(BCG): www.bcg.com/publications/files/TheHiddenEpidemic_Rpt_HCDec03.pdf
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
Copyright 2006 by the President and Fellows of Harvard College