Improving Compliance to Medical Regimens: Real Problems, Real solutions

‘The best drugs do not work … on patients who do not take them ’ is  a well-known quote by Dr Koop, the former US Surgeon-General, and which sums up the problem of compliance. In countries that can afford to make the latest medical treatments  available to their population, non-compliance, which we define as medications not taken, taken on an irregular basis, taken at the wrong dosage, or after a lapse of several days, etc, constitutes a common phenomenon often overlooked beyond research circles.

The consequences are serious : out-of-control diseases, complications, even premature death in the case of AIDS, tuberculosis, severe diabetes. The Association of American Pharmacists estimated the number of « deaths by non-compliance » at 125,000  per year. Beyond these lost lives, there is the further absurdity of expensive drugs expiring in medicine chests instead of treating patients.  Given the rise of chronic disease in aging populations, it is urgent to communicate about non-compliance and to come up with solutions.

The following study published by the Wall Street Journal in  2005 presents  « 12 ( !)  main reasons of non-compliance » in patients.

  1. I forgot to take the drugs : 64
  2. I didn’t have the symptoms/the symptoms went away: 36 %
  3. I wanted to save money: 35 %
  4. I didn’t think the drugs were effective: 33 %
  5. I didn’t think I needed to take them: 31 %
  6. I had painful or frightening side effects: 28 %
  7. The drugs prevented me from doing what I wanted to do : 25 %
  8. No one reminded me of the need to take them, even to renew the prescription: 20 %
  9. I had difficulty getting the product: 20 %
10. The drugs smelled or tasted nasty: 19 %
11. I had a hard time opening the bottle or swallowing the pills:16 %
12. I was lost as to all the drugs that I had to take: 15 %

Non-compliance with medication is multi-factorial. The patient may be ill-informed regarding the severity of his disease and the importance of his medical regimen ; he may be reluctant  to take a treatment, because there are no symptoms; non-user friendly drugs, side effects, confusion due to the high number of drugs, loss of memory all reduce the likelihood of proper compliance with treatments.

The elderly, who often require multiple therapies, are clearly a privileged target for non-compliance.  The Karolinskaya Institute, whose board determines the Nobel Prize winners,  researched  four basic questions.
Does the patient  know the drug to be taken and in what quantity,
Does the patient  know why he/she takes the drug,
Does the patient  have the capacity to read the  instructions
Can the patient correctly open the packaging.

The authors asked these questions of SWEOLD, a  representative Swedish sample of people 77 years and older.  66.3 % of the interviewees were found to be « incapable» of answering one or more of the four questions. A third of them live alone with no help.

What can be done?  The keywords are « coaching and accompaniment » or patient relationship management. In most healthcare systems, the physician remains the main initiator of the process. All patients should end a consultation with a clear understanding of their illness and the regimen to follow. The pharmacist must act as a relay, explaining and reassuring.  And theoretically, this should suffice, but the road is long, and diseases  are chronic. Dialogues with busy professionals are too brief and far apart. In chronic disease,  the patient  should receive structured support by trained and motivated personnel. The best example is illustrated by call centers staffed with health professionals, often nurses. At these centers, the staff establish personal relationships with the patient. They  accompany him in his  treatment regimen, ask questions about medication intake, the difficulties encountered, side effects. The results speak for themselves, especially when patient relationship management is established at the start of the regimen and followed over a sufficient time period.
 
The osteoporosis  program of Mondial Assistance France in partnership with Lilly Laboratories in France provides an interesting case in point.  Upon prescription of a self-injected treatment for osteoporosis,  (average age of patients is 73), rheumatologists proposed distance conversations with trained nurses. According to an initial study of 2500 persons, 93.4% of the patients in the program learned how to self administer the treatment and comply today. The program is pursued at the request of physicians, in agreement of course, with patients.

If the effectiveness of this type of program  is demonstrated, the next problem lies in   financing and integrating patient relationship management. As for any  innovation, change is not welcomed by all.  In France, an initial parliamentary debate on the subject was  suspended pending an official study of compliance programs by the government. The debate is scheduled to begin again in the fall. We hope that an objective study and open debate will clear  the way for the extension of patient relationship management in France.

Denise Silber

Denise Silber  manages Basil Strategies, an eHealth and eMedical consulting company, based in Paris, providing the latest in e-technologies, thanks to its network of partner companies.  An author, Denise Silber writes on innovation in healthcare systems (Case for eHealth – European Commission ; Hôpital Modèle Invisible – Ed. Montaigne). An ex-New Yorker, Denise is a Harvard MBA and  President of PharMBA, an association of international MBAs working in Healthcare.