Everyone knows patients don’t do what they are told. Jacky Law looks at what can be done about it.
There can be few areas of research that are as extensive and as inconclusive as that which seeks to understand why patients don’t follow doctors’ orders. According to an April 2008 IMS Health analysis of the Medline database, at that point no fewer than 25,000 articles had been published in English on the subject since 1996.
Research continues to proliferate if only because pharma has realised that in the absence of new drugs, it pays to ensure patients refill scrips of their old ones. That and the fact adherence to treatment usually improves outcomes.
For all this research, however, very little is known. Estimates of what noncompliance costs healthcare services differ widely, for example, from $70 billion to $300 billion a year in the US, highlighting such massive differences in assumptions and methodologies to render the figures virtually meaningless. And the picture is no clearer in the UK, with the National Institute for Health and Clinical Excellence (NICE) stating in the most general of terms that “it is thought that between a third and a half of all medicines prescribed for long-term conditions are not taken as recommended.”1
AlignMap.com, a website devoted to “supporting the patient’s implementation of optimal treatment,” confirms the only thing anyone knows for sure, which is that “noncompliance is massive and widespread regardless of the disorder, the nature of the treatment, the cultural or ethnic background of the patient, the personality of the clinician, the cost of the treatment, or any other studied factor.”2
It is also pervasive when the stakes are high, as was shown in a study that found 58 percent of glaucoma patients are noncompliant even when told this could result in blindness. Indeed, the study found 42 percent of patients who had already lost sight in one eye continued to defy doctor’s orders.3
Not to be defeated, most pharma companies have embarked on a range of programmes to challenge, cajole and coax patients to take their medicines properly (see sidebar). Many now use digital technologies to send out reminders to mobile phones; others have packaging solutions whereby a message is sent back to the doctor each time a patient opens a pill container; others still are investing in iPhone applications to improve disease management by making it easier for patients to remember to take their medicine, monitor their sugar levels, track injection sites and so on.
Then there is plain old bribery. According to a new report from FirstWord,4 Novartis has indicated it is working on a project with telecommunication companies that rewards patients with free talk time if they can demonstrate they have taken their medication as indicated.
But for all this effort, my personal suspicion is that companies are simply not hearing what patients are saying, which is that they need reminders, information, free talk time and so on, in the same way they need perfect health. They don’t. Most people on medication have lived to whatever age they are being overweight, having raised sugar levels, excess cholesterol and, in a million other ways, less than perfect health. They adjust their lifestyles and expectations to deal with imperfect health in ways that are meaningful to them. Medicines are part of their lifestyles and adjustments are made in an effort to understand and retain some control of what is happening to them.
It doesn’t help that denial of being ill or of needing drugs is also prevalent. It is well known that patients regularly overestimate their rate of compliance, perhaps in the same way they underestimate how much they eat or smoke. They may want perfect health, but drugs, being only one factor in that outcome and a complex one at that, are easily toyed with. Why that should be is the real question pharma should be asking itself.
1. NICE guidance: ‘Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence’ (CG76).
4 ‘Digital technologies to boost patient compliance’, FirstWord, October 2010.