Study: Customizing simple regimen raises adherence

Those with acute conditions stick to plan more often

Hospital admissions related to poor medication adherence cost the United States billions of dollars a year. Two physicians reviewed the literature and discussed adherence to medication in the Aug. 5 issue of The New England Journal of Medicine.

The rates of patients with acute conditions adhering to their medication regimen are typically higher than those with chronic conditions, say Lars Osterberg, MD, and Terrence Blaschke, MD. Osterberg is chief of general medicine at VA Palo Alto (CA) Health Care System and clinical assistant professor of medicine at Stanford (CA) University School of Medicine. Blaschke is professor of medicine and molecular pharmacology at Stanford.

Studies show that adherence to medications for patients with chronic conditions drops the most after the first six months of therapy.

Physicians don't have a strong ability to recognize medication nonadherence, the authors say. To help physicians, Osterberg and Blaschke compiled a list of the major predictors of poor adherence to medication, according to studies of predictors.

In the article, the authors also included the references for each study.

Here are some of the items on the list:

  • Presence of psychological problems, particularly depression.
  • Side effects of medication.
  • Patient's lack of belief in benefit of treatment.
  • Presence of barriers to care or medications.
  • Complexity of treatment.
  • Cost of medication, copayment, or both.

However, even patients who lack these indicators may miss taking medications as prescribed, the authors say. "Thus, poor adherence should always be considered when a patient's condition is not responding to therapy."

The authors then discuss interventions that can be used to improve adherence. These can be grouped into four general categories: patient education, improved dosing schedules, increased hours when the clinic is open (including evening hours), and improved communication between physicians and patients.

Since many factors can contribute to a patient not adhering to a medication regimen, a single approach will not be effective for all patients, they say. The authors have adapted some strategies for improving adherence to a medication regimen. Here are a few:

  • Identify poor adherence.
    • Look for markers of nonadherence: missed appointments ("no-shows"), lack of response to medication, missed refills.
    • Ask about barriers to adherence without being confrontational.
  • Provide simple, clear instructions and simplify the regimen as much as possible.
  • Encourage the use of a medication-taking system.
  • Listen to the patient, and customize the regimen in accordance with the patient's wishes.
  • Consider more "forgiving" medications when adherence appears unlikely.
    • Medications with long half-lives.
    • Depot medications.
    • Transdermal medications.

Practitioners should always look for poor adherence and can enhance adherence by emphasizing the value of a patient's regimen, making the regimen simple, and customizing the regimen to the patient's lifestyle, the authors conclude. "Patients who have difficulty maintaining adequate adherence need more intensive strategies than do patients who have less difficulty with adherence, a more forgiving medication regimen, or both."