Educating Our "Captive" Audience About Adherence

James C. McAllister III, MS, FASHP
Published Online: Friday, May 15, 2009
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Mr. McAllister is a health-systems consultant based in Chapel Hill, North Carolina.


It rankles me when our patients are described as “consumers,” but at least it is not as distasteful as “customer.” I highlight this issue because when we refer to those we serve as patients, it reminds us that pharmacists have a professional responsibility for our actions in the medication use process. Patients in hospitals take their drug therapy as directed because they are a captive audience, but once we cease to have control over the patients, adherence begins to slide.

A recent report revealed that prescription abandonment spiked 34% in the last quarter of 2008. Failing to pick up prescriptions may reflect financial pressures associated with copays or out-of-pocket expenses, but abandonment represents only a portion of the growing adherence problem. When a patient chooses not to take his or her medicine, it is a failure of the health care system overall, but the ultimate responsibility rests with the profession of pharmacy.

What, then, are we doing to improve adherence and optimize drug therapy outcomes?

Disincentives to Adherence
Prescription benefit plans have a profound influence on patient adherence through various financial incentives and disincentives. Prescription denials have increased by >25% since 2006, while prescription drug prices for new therapies have increased more quickly than inflation.

Manufacturers and pharmacy benefit managers employ a variety of strategies to drive prescription drug use in directions that benefit them financially. To be fair, some of their strategies, such as indigent access, coupons that reduce out-of-pocket expenses, and encouraging the use of quality generics, have been valuable. Few of their efforts are truly intended to improve patients’ drug therapy outcomes, but stockholders and corporate executives don’t see patient wellness as a top priority. The medication use system as it is currently designed expects providers to assume responsibility for maximizing drug therapy outcomes… it is the central expectation of our societal mission.

What is missing is that most patients don’t appreciate the importance of their drug therapy regimen, the consequences of failing to adhere to the plan, and the need to communicate with their pharmacist or physician when they decide (or are told) that they cannot get their prescriptions filled.

The failure is ours. Physicians and pharmacists inconsistently communicate with patients about their drug therapy regimen, including stressing the importance of adherence, expected outcomes, and possible side effects, as well as asking if patients have any questions or anticipate any reason why they might not get their prescriptions filled. This failure isn’t the sole responsibility of community pharmacists, but rests with all of us.

Seizing the Opportunity
Patients in hospitals are a “captive” audience, and we should develop strategies to ensure that they understand their drug therapy plan before they are discharged. If issues are identified that might affect adherence, resolution is much more efficient while the patient, the family, the physician, and the pharmacist are more readily available. By the same token, community pharmacists must proactively engage the patient to ensure that patients understand the therapeutic plan and assume responsibility for communicating with the prescriber if adherence is compromised.

The Joint Commission (TJC) requires hospitals to assume responsibility for medication reconciliation. How many hospitals are focused on optimizing drug therapy and resolving issues related to the drug therapy regimen as opposed to avoiding a TJC citation? Are hospital pharmacists and community pharmacists collaborating to improve patient care?

We can minimize prescription abandonment and increase adherence (and improve a pharmacy’s financial performance) if we truly take our responsibility seriously. I think it is time for all of us to step up to the plate. What do you think? ■



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