Informed Engagement: Unpacking and Addressing Patients' Reasons for Nonadherence

MAY 18, 2015
Elizabeth Whalley Buono, BSN, RN, MBA, JD
There is no one-size-fits-all solution to the problem of medication nonadherence.
If the problem of patient medication nonadherence has just as many complexities as any other human behavioral challenge, why have we attempted to address it as a systems efficiency issue? I would argue that we’ve done so for many reasons that are grounded in the economics of health care, an approach that inadvertently does a grave disservice to patients. Clearly, on an academic level, we have for decades taken a more reasonable and sound approach to understanding and addressing patient medication nonadherence. That individualized care, however, has often failed to translate into overarching policy and thus, reimbursement practices.

The past decade has seen broadscale health care decision making and policy driven purely by economic considerations— enlightened by neither medicine nor pharmacy. During this period, we have measured adherence in the United States predominantly in terms of pharmacy efficiency (ie, scripts leaving the building). Accordingly, it makes perfect sense that we have addressed nonadherence as a systems efficiency problem. If, for example, retrospective pharmacy claims analyses tell us that the problem is one of “a quota not being filled,” then business logic would argue that increased dispensing rates equals problem solved. We know better, however. A world of automatic refills does not equate to medication taken correctly, or at all. Common sense tells us that availability is but one hurdle to medication adherence.

The systems built to address the problem are likewise complicated. The time lag and lack of direct correlation between nonadherence and negative health outcomes hinder enlightened policy making, and the fragmentation and discord between pharmacy, medical practice, and benefit design have chilled the collaboration necessary to make sense out of this mess. Large health systems and payer organizations have suffered and, to a certain extent, continue to suffer from the delusion that an elusive one-size-fitsall solution to medication nonadherence exists. Alignment across stakeholders is not always collaborative, with payers, providers, and health policy groups working alongside one another, relatively uninformed by each other’s advances and failures. As a result, resources pour into familiar and scalable practices that we know do not work.

Even where the importance of consistency in the care continuum is obvious to all players, tactical implementation across that same continuum has proven to be daunting. Only organizations less encumbered by the pressures of segmentation and scalability (namely, the few larger “closed” health care systems, the Centers for Medicare & Medicaid Services–driven innovation pilots, and the very small number of truly innovative systems working in the space) have recognized and honored the values that come from delivering health care services in an interdependent manner— and at the individual level. These success stories, albeit few and far between, remind us that the key to success lies with informed patient engagement: when innovation is focused squarely at the individual patient the problem of nonadherence becomes entirely solvable.

There is brilliance in C. Everett Koop’s simple reduction of the adherence problem to “Drugs don’t work in patients who don’t take them.” It was only an introduction, however, to the problem at a national level in a form digestible to the masses. We’re beyond that now. We know from behavioral economics research that people make decisions in the face of incomplete information, limited cognitive resources, and decision biases. Decision-making research tells us that people do not always act in their own best interest. While it is true that there are arguably more drivers than ever calling upon patients to take charge of their own well-being and pressuring health systems and payer organizations to improve quality and efficacy, we see no meaningful trend toward improved medication adherence.

Pharmacists are in a unique position to inform today’s much-needed health care transformation. As the true meaning of health care innovation begins to permeate systems practice, pharmacists are returning to the basics of patient engagement to effectively inform adherence intervention plans.

Human Behavioral Complexities Require an Individualized Approach
When patient medication nonadherence first began to emerge as a recognized public health issue, inconsistent terminology existed, with terms such as “compliance” carrying negative connotations and translational challenges that led to confusion and impeded research and practical application.1 Evaluation of a problem as complex as nonadherence requires effective communication among all stakeholders to deliver solutions that align to individual patient needs.

Recognizing the importance of establishing a common language that could support such an individualized approach, the European consensus meeting on taxonomy and terminology of patient compliance convened in 2009 to propose a new taxonomy based on behavioral and pharmacological science. This taxonomy has become almost universally adopted, promoting consistency, aiding in adherence-related research, and helping define the complexities of the problem:
  • Adherence to medication is the process by which patients take their medications as prescribed, composed of initiation, implementation, and discontinuation.
  • Initiation occurs when the patient takes the first dose of a prescribed medication.
  • Implementation is the extent to which a patient’s actual dosing corresponds to the prescribed dosing regimen, from initiation until the last dose.
  • Discontinuation occurs when the patient stops taking the prescribed medication, for whatever reason(s).
  • Persistence is the length of time between initiation and the last dose, which immediately precedes discontinuation.
  • Management of adherence is the process of monitoring and supporting patients’ adherence to medications by health care systems, providers, patients, and their social networks.
  • Adherence-related sciences are the disciplines that seek understanding of the causes or consequences of the differences between prescribed (ie, intended) and actual exposures to medicines.2

Once adopted, the common language not only advanced a public dialogue on (and thus recognition of) the myriad of costs associated with nonadherence, but also made evident the need to consider carefully the method by which adherence is assessed. A market driven by pharmacy claims data metrics began to wake up to the fact that while available and convenient, these measures told only part of the story. True, script abandonment and refill rates provided some insight into the problems of noninitiation and discontinuation; however, they told us almost nothing about comprehensive individual implementation patterns.

This new taxonomy also made clear that successful management of nonadherence was a shared responsibility, involving not only players in the health care system but also patient social networks. The recognized extension beyond the patient–provider relationship reminded us that as we considered the causes of nonadherence, a holistic approach would help us understand the real world challenges faced by individual patients and permit us to capitalize on the value of secondary caregivers.