英文讀書會

May 20, 2010

When Patients Don’t Fill Their Prescriptions

.By PAULINE W. CHEN, M.D

Not long ago, a doctor friend recounted the story of a patient who had recently died from complications stemming from the treatment of a chronic bleeding problem. “I felt terrible about it,” said my friend, who had cared for the patient for several years. “Something didn’t add up in this case, and I had to wonder if it was my fault, if I had done something wrong.”

Spurred on by these recurrent self-doubts, my friend went back to review the records. Nothing at first glance seemed amiss; all the recommendations, visits and discussions were consistent with what both of us knew was good, evidence-based clinical care.

But then, while reading through the pharmacy records, my friend discovered something unexpected. The patient, it turned out, hadn’t been taking all of the medications my friend had prescribed. In fact, several of the prescriptions had never even been filled.

Instead of lifting the guilt, the revelation left my friend feeling worse. “It’s not like my patient forgot or skipped a dose. The prescriptions were just never filled.” My friend then added: “Why didn’t they even tell me? And why didn’t I ask?”

Like politics, religion and sex, medication nonadherence, or noncompliance, remains a topic of conversation that most of us try to avoid. While anyone who has ever tried to complete a full course of antibiotics can understand how easy it is to skip, cut down or forget one’s medications altogether, bringing the topic up in the exam room feels more like a confession or inquisition than a rational discussion. Few of us want to talk about medication nonadherence, much less admit to it.

For doctors, learning that a patient has been nonadherent can sometimes breed resentment; it feels like a breach of good faith. For patients, there’s something frankly discomfiting about telling your doctor you haven’t taken the medications as advised. As a nondoctor friend once said, “It’s embarrassing. The goal is to get the best care and make things work, but you can’t get your act together enough to take your meds.”

But medication nonadherence exists. And in good measure and with significant costs. In one study, as many as half of all patients did not follow their doctors’ advice when it came to medications. Other studies have shown that patients who were nonadherent with medications for chronic diseases like diabetes and high blood pressure were likely to be sicker, suffer from more complications and have higher mortality rates. The overall cost of medication nonadherence? More than $170 billion annually in the United States alone.

Medication nonadherence undermines even the best cost-saving and clinical intentions of evidence-based care.

Up until more recently, research on nonadherence has focused primarily on what happens once patients have filled their prescriptions. Are they taking their pills regularly? Are they coming back for refills? Now, with the advent of better tracking systems and the more widespread use of electronic medical records, researchers have discovered that medication nonadherence often begins even before the prescription is filled.

Or not.

This past month researchers at Harvard Medical School published the largest study to date of what has been termed “primary nonadherence” and found that more than 20 percent of first-time patient prescriptions were never filled. Comparing the e-prescription data for over 75,000 patients with pharmacy insurance claims, the investigators also discovered that certain patterns of nonadherence exist. First-time prescriptions for chronic diseases like high cholesterol, high blood pressure and diabetes were more likely not to be filled, whereas those for pediatric patients 18 years of age and younger and for antibiotics were more likely to be filled.

“An awful lot of prescriptions doctors write don’t end up getting filled,” said Dr. Michael A. Fischer, lead author of the study and an assistant professor of medicine at Harvard Medical School. “We knew before that medication adherence was a concern, but we hadn’t even studied this part of the prescription process.”

While the patients in the study were also less likely to fill prescriptions written by nonprimary care specialists, women physicians, younger physicians and those doctors who were in large practices of nine or more physicians, these differences were relatively minor. According to Dr. Fischer, more important factors contributing to nonadherence are likely affordability, physician-patient communication and the cumbersome process of filling out a prescription.

That process — taking a prescription to a pharmacy or waiting for it to be faxed, getting it filled, then returning to pick it up — likely accounts for differences in prescription fill rates between Dr. Fischer’s study and studies conducted in Europe or in the more integrated care systems in the United States. For example, a study published last year examining primary nonadherence among patients enrolled in Kaiser Permanente of Northern California found that only 5 percent did not fill their initial prescriptions. While there is some cost benefit to filling prescriptions at a Kaiser pharmacy, what was probably more important was the relative ease of the process. The patients in this study could retrieve their medications almost immediately and at the same location as their doctor’s office. “One wonders if this difference reflects the fact that our system is so fragmented and if better integration would improve adherence rates,” Dr. Fischer said.

One key to improving health care integration may be the very data gathering methods that Dr. Fischer and his co-investigators used for their study: the electronic medical records system. While many of the electronic records systems currently in use in clinics and doctors’ offices are not designed to improve medication adherence, “it should become increasingly possible for doctors to have data about whether their patients are filling prescriptions or not,” Dr. Fischer said.

And that information could serve as a means of introducing a formerly taboo topic into the patient-doctor relationship: the decision, and the challenges, of starting and continuing a medication. “We need to find constructive and therapeutic ways of continuing to work through those decisions,” Dr. Fischer noted. “We need to take this information and use it to address missed opportunities.”

“Not every unfilled prescription is a problem,” Dr. Fischer added. “But the great challenge for all of us is figuring out how to design and integrate a model of care that works best for the patients and lets the doctors do what is really important.”