It was a sunny Wednesday afternoon — a day filled with enthusiasm — as I headed for my shift at clinic. I looked forward to being challenged by various patient clinical presentations, integrating textbook knowledge with real patient cases and learning medicine from my attending. The first patient of the day was a 43-year-old male who came to clinic for evaluation of his diabetes mellitus type II (DMII). When reviewing the chart, I noted that previous lab work indicated the patient had a hemoglobin A1C of 12%. Upon entering the room, I saw that the patient was sitting on the exam table accompanied by his wife and teenage son. As I conducted the history, he revealed that he neither regularly checks his blood sugar nor takes his metformin. He is sedentary and does not follow a diabetic diet. As we talked, it became apparent that the patient was coming into clinic to satisfy his wife’s concerns rather than his own interest in his health. Integrating methods I learned throughout medical school for motivating patients, I sought to understand the reasoning behind the patient’s lifestyle choices and lack of medication adherence in order to develop solutions with the patient collaboratively.
He simply responded, “I feel fine. I take life one day at a time.”
Applying a different approach, I attempted to educate the patient on lifestyle modifications associated with proper diabetic control such as incorporating daily exercise and eating more foods with low glycemic indices, as well as stressed the importance of medication. Despite teaching him about the long-term effects of poorly controlled diabetes such as renal failure, blindness, peripheral neuropathy and cardiovascular disease, the patient maintained his position.
“I feel fine. I take life one day at a time.”
We spoke for nearly an hour, but he continued to hold his position. As one of my most difficult clinical experiences, this encounter challenged me to question the elements involved in patient medication adherence, which is a theme that had been explored in one of my public health lectures. I was interested in further understanding this phenomenon.
Diabetes mellitus type II remains one of the top chronic medical conditions in the United States, affecting over twenty million people. Optimal management of DMII relies on the involvement of the patients in their own treatment plans. According to the third National Health and Nutrition Examination Survey (NHANES III) conducted between 1992 and 2002, 42.3% of adults with DMII had a hemoglobin A1C less than 7%, which is ideal for controlled glucose levels established by the American Diabetes Association.
Medication regimens encompass both disease prevention and treatment making adherence an important consideration in patient care. Non-adherence to medication is one of the leading public health obstacles facing the United States. It is estimated that half of patients with chronic disease do not take medications as prescribed. In a study following electronic prescriptions of over 75,000 patients with DMII throughout a twelve-month period, it was found that 31.4% of new prescriptions for diabetes medication were never filled. This issue is referred to as primary non-adherence, and common reasons for such include refusal to initiate injection therapy, inconvenience and lack of physician communication. This issue of widespread non-adherence can lead to negative outcomes for health care systems.
Significance of the Problem
Outcomes resulting from medication non-adherence include 275 million annual medical visits, 125,000 deaths and medical costs of $290-$300 billion in avoidable complications, emergency department visits, and hospitalizations on an annual basis for the United States health care system. In DMII specifically, the reported incidence of medication adherence varied from 38% to 93%. A systematic review conducted to evaluate the economic impact of medication adherence in DMII found that average annual cost per patient varied from $4,570 to $17,338. Medication adherence was noted to be inversely associated with total health care costs and the need for hospitalizations. Non-adherence has been correlated with poor health outcomes and progression of disease status. As a result of deteriorating outcomes, increased utilization of health care services has been a detriment to proper appropriation of limited resources.
Evaluating Causes of Poor Adherence
As physicians and health educators, we can improve medication adherence particularly among patients with DMII. A notable place to begin is by understanding causes of non-adherence to medications leading to associated phenomena including insufficient blood glucose control, elevated risks of morbidity and mortality, as well as increased complications. Elements associated with patient medication non-adherence can be vast and include demographic factors such as young age, low education level and low income level. Patients’ beliefs about their medications such as treatment efficacy, perceived protocol complexity and monetary cost may play a role.
Additional components of medication non-adherence can be categorized as either intentional or unintentional. Among intentional causes of non-adherence, absence of persistent medication use and conscious adjustment of doses are often at play. Unintentional factors include failure to understand proper use of medication, forgetfulness and an inability to follow through with medical recommendations. Unclear communication, a lack of commitment to a physician’s recommendations and an absence of a strong therapeutic relationship can all lead to non-adherence. As I consider my patient’s repeated response to my advice, it occurred to me that perhaps his non-adherence was due to a lack of diabetes-related goal attainment and a faulty assumption that the medication was not doing anything for his disease.
In a study by Odegard and Gray conducted in 2008, a cross-sectional analysis was performed in order to identify barriers to medication adherence in patients with DMII. Baseline information was obtained from randomized medical clinics surrounding the University of Washington. Non-adherence was evaluated using self-reported adherence and medication management. Results indicated that the most common barriers to medication compliance include paying for medications (34%), remembering doses (31%), reading prescription labels (21%), and obtaining refills (21%). Elements such as taking more than two doses of DMII medications per day as well as difficulty reading prescription labels were significantly correlated with higher hemoglobin A1C levels. Factors leading to medication non-adherence found in this study are modifiable with proper communication, simplification of treatment regimen, as well as more descriptive prescription labels with appropriate patient education.
Interventions for Improving Medication Adherence
Adherence to medication is complex as it is a phenomenon founded on understanding of treatment and disease, which requires motivation and commitment on behalf of the patient, as well as maintenance strategies that affect behavior change. Proper understanding and recall are essential components of medication adherence. Strategies to improve recall can include educational programs, disease management programs and counseling, behavioral support, medication reminders and specialized packaging. Multi-dimensional approaches are often found to be more effective than single-strategy methods — those which target decreased medication side effects are of significant value. In an analysis of 238,000 patients with DMII, adherence rates to oral anti-diabetic medications were as low as 47.3% with dipeptidyl peptidase-4 inhibitors, 41.2% with sulfonylureas and 36.7% with thiazolidinediones, possibly due to their side effect profiles.
As physicians, we have an opportunity to teach our patients through good communication in the hopes of increased medication adherence. Patients note they do not have enough time with their physicians and feel as though they are not listened to; thus, their primary reasons for presenting to clinic were not met. Effective communication has been identified as incredibly significant to the health care encounter by both physicians and patients and has been correlated with improved patient outcomes.
Implementation of effective communication may include avoiding the use of medical jargon as well as encouraging patients to ask questions if they do not understand. Utilizing a teaching method that allows patients to repeat in their own words the information discussed in the visit allows the provider to assess whether the patient truly understands the information presented. This process allows for clarification and correction as well as solidifying their memory of what was discussed. Conveying risks and benefits associated with treatment including addressing patient concerns and promoting a shared decision making environment may lead to improved patient-physician communication.
Motivation towards medication adherence can be influenced by factors such as a patient’s attitude and belief in the value of a medication regimen in addition to the expectations of benefits and efficacy. The importance of relationship-based patient care and understanding the patient as a human being become critical to establishing a foundation of trust and evaluating the patient’s goals and expectations for treatment. Through the use of open-ended questions, repetition of their goals and a genuine approach, making the patients active participants in their own healthcare plan will increase motivation and autonomy likely leading to improved outcomes.
Integrating a collaborative approach towards developing an individualized medication regimen while recognizing the patient’s personal goals will serve to further develop the physician-patient bond, and improve medication adherence. Aspiring to implement the techniques discussed in this article as I continue on my medical journey, I hope to be presented with another opportunity to motivate a patient with an ultimate goal to increase medication adherence, especially for diseases as common as type II diabetes mellitus.