Prescription drugs will work only if you take them

By Marian Uhlman
Knight Ridder Newspapers

	BONNIE WELLER / KRT Marie Notaro shows the regimen of pills she must take daily. The failure of patients to take their medicines — because of forgetfulness or cost — is widespread and is undermining many medical advances.
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After all, he runs an industry trade group that helps people follow medical advice.

But even he misses doses.

"I was busy," said Todd, 59, of his failure to take his antibiotics for Lyme disease. "I had them tucked in my pocket, and I'd just forget."

It is a familiar and vexing lament. The failure of patients to take their medicines — because of forgetfulness or cost or other reasons — is widespread and is undermining many medical advances.

Patients follow directions only about half the time. Some forget. Others fear side effects, deny they need the medicine, are unsure of the regimen, can't afford them or can't get to the pharmacy.

"The stats on compliance have been horrible for years," said Todd, executive director of the Disease Management Association of America.

The problem, referred to as non-adherence, needs to be addressed, or "advances in biomedical technology will fail to realize their potential to reduce the burden of chronic illness," according to the World Health Organization.

High blood pressure, for instance, significantly increases the risk of heart attacks or strokes. But studies indicate that only 30 percent of U.S. patients have good control of their blood pressure, according to the WHO report. The agency blamed poor adherence as a big reason.

"It is more of a problem than 20 years ago because we have so many more drugs," said Tom Snedden, director of the Pharmaceutical Assistance Contract for the Elderly program, Pennsylvania's prescription-drug benefit for low-income seniors. "The more people have to take, the more difficult it becomes to be compliant."

'I thought I didn't need it'
 
Ethel Johnson, 77, of Philadelphia, said she sometimes skips her cholesterol drug. It is one of six drugs she is to take every day.

"I just thought I didn't need it," Johnson said. "I cut down on the greasy stuff."

But some mornings she forgets to take any medicines, she said, even though they are lined up on her kitchen counter. "I have a lot on my mind some days," she said.

Sollie Foster said she takes four different medicines every day and wears a patch for high blood pressure, which she changes weekly. Until a fainting episode two months ago, she loaded up her pills early in the day instead of taking them as directed — some in the morning and some at night.

"I learned the hard way," said Foster, 76, of Philadelphia.

Expense vs. compliance

A recent study found cost was often a factor for patients. When patients were forced to pay higher insurance co-pays, they were more likely to stop taking the drugs — including those for chronic illnesses such as heart disease.

The study was conducted by researchers at Harvard Medical School and Medco Health Solutions, the nation's largest pharmacy-benefit-management company, and was reported last year in the New England Journal of Medicine.

The problem is capturing the attention of insurers, health plans and other groups footing medical bills, said David Nash, professor at Jefferson Medical College.

"It is literally money down the drain if people don't take medication," said Nash, who is the editor of the journal Disease Management. "If this weren't a big economic issue, the companies wouldn't be focused on it."

The goal is to identify patients who need help with medications rather than wait for a problem.

"Every patient is different," said Dr. Dena McFadden, medical director of Boston-based Health Dialog, a disease-management firm that offers nurse counseling by phone. "Every patient has his own understanding of his condition and his own barrier to adherence."

Nancy Houston Miller, an associate director of the Stanford Cardiac Rehabilitation Program, said people are starting to realize taking a medicine is "as difficult as changing one's diet."

Miller has identified at least 16 steps in the process that easily can be thwarted, including: A family member fails to order the drug in timely manner. The patient discovers he is unable to open a pill bottle. Or, the patient is confused about the dosage.

Miller said what is often missed is asking basic questions. How much do the medicines cost? Has the patient received written instructions? Has anyone checked on the patient's refills?

"For the last 10 years or so, we are so focused on technology and what (it) can do that we have lost the bedside test," Miller said.

Methods to improve adherence are "complex," concluded a scientific review of studies published since the late 1960s. The interventions that worked included "combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement and family therapy."

Even those that worked, however, did not lead to improvements in the number of people taking their medicines, according to the medical review, which appeared in 2002 in the Journal of the American Medical Association. The authors also could not find patterns that would predict success.

A new industry

An emerging industry called disease management is betting it can prod people to take drugs properly and follow other medical advice. By tracking pharmacy refills and insurance data, firms can identify patients who are having trouble with their medicines. They can be targeted with reminders and disease-related information. Some patients are assigned to phone nurses, who become coaches of sorts. Patients can call their nurses, and nurses can check on their patients.

"If we just succeeded to get people to do what is recommended, that would have such a profound impact on people with chronic conditions," said Dr. Sandeep Wadhwa, a vice president at McKesson Health Solutions, which provides disease-management services to health plans and state Medicaid programs.

Copyright © 2004 The Seattle Times Company