 Blaming
patients for non-compliance is a cop-out. It's time
for physicians to look at their own role in creating
the problem, and what they can do to help patients take
their medicine as prescribed. That's the key message
of a whole slew of research into non-compliance published
in the latest issue of the Archives of Internal Medicine.
"Doctors should be telling patients
the name of the drug [they're prescribing], why they're
getting it, how to take it and discuss potential adverse
effects," says Dr Derjung Tarn of UCLA's David Geffen
School of Medicine, lead author of one of the studies.
"We're just not seeing this happen consistently."
Of course, poor physician communication
is not the sole culprit. Cost concerns, side effects,
lack of perceived benefit and lack of continuity in
treatment all play a part in non-compliance, and the
consequences can be devastating.
TO
SAY THE LEAST
Dr Tarn and colleagues recorded 185 outpatient visits
to assess the quality of communication in prescribing.
The visits involved 16 family physicians, 18 internists
and 11 cardiologists giving out 243 new prescriptions.
The doctors told patients the name
of the drug they were prescribing 74% of the time and
explained what it was for 87% of the time. They talked
about adverse effects in 35% of cases, and said how
long to take the medication in 34%. They told 55% of
patients how many pills to take and how or when to take
them 58% of the time.
When all was said and done, the
average physician mentioned 3.1 of the five above criteria.
Psychiatric drugs were most likely to get the full run-down,
with the doctors averaging 3.7 of the five points of
explanation. Pulmonary and cardiovascular prescriptions
were also more likely to be accompanied by a good explanation.
But the gaps in the patient's knowledge
about the medications they're taking have a direct effect
on compliance, according to Dr Tarn.
DON'T
GIVE UP
The adverse effects of non-compliance are only likely
to grow with the spread of prophylactic drugs like statins
that offer no immediate relief of symptoms. But even
patients who have just suffered a life-threatening heart
attack aren't always scared into submission, and the
effects of non-compliance on their mortality are dramatic.
Dr P Michael Ho of the Denver VA Medical Center and
colleagues looked at compliance at one month among some
1,500 myocardial infarction patients discharged with
prescriptions for three drugs: aspirin, a beta-blocker
and a statin.
A month after their heart attack,
184 of these patients had discontinued all three drugs,
56 had stopped taking two and 272 had dropped one. Just
66% were still taking all three drugs.
Patients who had given up on all
three medications had a one-year survival rate of 88.5%,
compared to 97.7% among those who were still taking
at least one. In other words, they were more than four
times as likely to die.
MONEY
TALKS
Drug cost also has a profound effect on compliance,
as demonstrated in a third study in the same journal.
Just over half of US study participants who lacked Medicaid
coverage reported skipping doses or medications, compared
to 26% of those who were covered.
The study also revealed that the
presence of several comorbid conditions often predicted
non-compliance. The likeliest explanation is simply
that these patients had more drugs to take and more
to pay for. The more complicated the regimen, the harder
it is to follow.
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