Initiating an Exploration of Poor Adherence to Treatment
Enhancing Patients’ Treatment Adherence
Our medical school curriculum taught us all about human structure. We learned all sorts of pathologies and treatments for these pathologies. Our pharmacology courses covered the absorption, distribution and metabolism of drugs. But the curriculum lacked a course covering the major factor that determines the variation we commonly observe between patients in their response to the treatments we prescribe. This variation is largely caused by variation in adherence, how well (or how poorly) patients follow the recommended treatment regimen.
There was little in my medical training that prepared me for the challenge of adherence. I am a test tube physician-scientist by training and inclination. The MCATs on which I excelled did not measure my people skills. But in addition to skill in standardized test taking, I have a devotion to making sure I give patients great medical care, including accurate diagnoses and the best possible treatments. Despite that, much to my disappointment, my patients did not regularly achieve the level of success that was anticipated.
Fortunately, a research colleague mentioned a company that sells medicine bottle caps that record the day and time when patients open and close the bottle.1 Clinical trials using these caps opened a window on what had previously been totally hidden behavior. The studies found that while patients reported using their medicine regularly, actual medication use was intermittent and dropped consistently over time. We did one study to see how well children with atopic dermatitis use their medicine. To find out what real patients do, as opposed to what research subjects do, we didn’t tell the patients or their parents that this was a research study or that their medication use would be monitored.2 Even though parents love their children, medication use dropped by about 60% over the first 3 days of this trial.
Our medical care system is moving toward a greater emphasis on holding doctors and health systems accountable for patients’ outcomes. On the one hand, giving our patients the best possible outcome is what we want and expect from ourselves. On the other hand, is it fair to hold us financially accountable for their outcomes when they aren’t using the medication as directed?
Yes, it is entirely reasonable for physicians to be accountable for patients’ outcomes. In addition to being responsible to make the right diagnosis and prescribe the right treatment, we are also responsible for encouraging patients to use their medication. In this series of articles, we will explore practical techniques that physicians can easily implement to improve their patients’ adherence and treatment outcomes. Every article in the series will have useful tips. Perhaps the most important one is that we should never underestimate the potential for poor adherence as a cause of treatment failure, nor should we underestimate the control we have over what our patients do.
- Balkrishnan R, Carroll CL, Camacho FT, Feldman SR. Electronic monitoring of medication adherence in skin disease: results of a pilot study. J Am Acad Dermatol. 2003 Oct;49(4):651-4.
- Krejci-Manwaring J, Tusa MG, Carroll C, Camacho F, Kaur M, Carr D, Fleischer AB Jr, Balkrishnan R, Feldman SR. Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J Am Acad Dermatol. 2007;56:211-6.
Dr. Steven Feldman is a professor of dermatology and public health sciences at Wake Forest Baptist Medical Center in Winston-Salem, NC, where he studies patients’ adherence to treatment. He is also Chief Science Officer of Causa Reseach, an adherence solutions company (www.causaresearch.com), founder of www.DrScore.com and author of “Compartments” (www.compartmentsbook.com).