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Akron Univ. School of Law

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Tuesday, April 1, 2008

Non-compliant Patients

rSlate.com has an article discussing new technologies that help patients remember to take their medications or provide a record of when they do take them.  The article also discusses a recent study appearing in Health Affairs on dialysis patients and their compliance with treatment regimes in 12 different countries.  Apparently it wasn't just that Americans must pay more for their medications that led to greater noncompliance, there exist some cultural factors as well.  Jessica Wapner writes,

Earlier this month, scientists at Georgia Tech announced their invention of a necklace that records the date and time at which a person swallows his prescription medicine. The device (which looks more like a dog collar than jewelry) responds to a tiny magnet in the pill as it travels down the esophagus. Other recently developed similar technologies include a drug-filled prosthetic tooth that slowly drips medicine into the mouth and a pill bottle that sends a wireless message to your pharmacist every time it's opened.

Are we so bad at taking medicine that we need false teeth to do it for us and pill bottles that tattle on us when we don't? It would seem so. About 50 percent of patients fail to correctly follow prescriptions: We forget to take pills, we alter doses, we take breaks. Nonadherence—the medical term for neglecting to abide by a doctor's orders—is rampant, resulting in up to one-quarter of all hospital and nursing home admissions. It's also expensive. The problem persists despite monumental efforts to prevent it. Why? For one thing, it's impossible to predict which patients are likely to deviate from their orders. And while the problem seems like it should have a simple solution, it doesn't. Nonadherence, it turns out, is one more reason to heed the call for better American health care.

Blowing off a doctor's instructions might seem like the act of a basically healthy person. Who hasn't neglected to take that last antibiotic or exercised less than the doctor said to? But treatment drop-off rates are high among the seriously ill, too. About half the people who undergo kidney transplants do not adequately adhere to the regimen necessary to thwart rejection of their new organ. A 1970s study found that 43 percent of glaucoma patients refused to take the doctor-ordered measures necessary to prevent blindness, even when that refusal had already led to blindness in one eye.

Cost of medication is an obvious consideration. A recent study in Health Affairs reported that 29 percent of patients with chronic kidney failure in the United States did not purchase needed drugs because they were too expensive. It's understandable: Their co-pay of $114 for a month of medication was the highest of all 12 countries included in the analysis. By contrast, British patients, who had the lowest out-of-pocket costs, were the best at sticking with treatment.

But cost wasn't the only factor that determined whether patients took their medicine. Swedish patients also had high monthly co-pays, but they were great at following their prescriptions. And good adherence among Japanese patients was only partially explained by low costs. The authors of the Health Affairs study wondered about the influence of cultural factors but also pointed to the health system structure: Since Japanese doctors earn income by selling medicine directly to patients, they have an incentive to make sure prescriptions get filled . . . .

As it turns out, there is one predictive factor: experience with the health care system. A study of 186 doctors and their patients with diabetes, heart disease, and hypertension found that whether patients got their questions answered correlated strongly with whether they would stick with treatment. Other factors that mattered included the doctor's level of job satisfaction, how many patients he or she sees per week, and whether patients scheduled a follow-up appointment. As health care consultant Kip Piper explains, the average doctor's visit clocks in at less than 20 minutes, leaving little time for discussion. And when patients do ask questions, they are usually interrupted within 18 seconds. With little explanation, tricky regimens may not be followed correctly, or a person may take a break from a drug, not understanding the importance of completing the regimen. Many times, patients simply don't understand the doctor's orders. Requiring patients to use mail-order companies to order some drugs, as health insurers are increasingly doing, will probably make matters worse.

The legion of gadgets helps some patients but doesn't make a big enough dent because the contraptions don't address these underlying issues. Concierge medicine is a more successful fix: For an annual fee, doctors promise to limit the number of patients they treat and provide a higher level of care. But, while effective, this approach is inherently limited. The fee of up to $1,500 is prohibitive for many people, and in any case, there aren't that many VIP doctors out there. Adherence, then, is unlikely to improve much unless something changes dramatically in the health care system. Or else, we need to invent a drug for nonadherence. If only anyone would take it.

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