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Podcast Library > NextGen Advisors Podcasts > Patient Adherence in the Era of COVID-19

August 3, 2021

Patient Adherence in the Era of COVID-19

Lack of adherence to a treatment regimen is estimated to cause approximately 125,000 annual deaths and cost the U.S. healthcare system between $100-289 billion per year. In this episode of the NextGen® Advisors podcast, we explore the many factors associated with non-adherence as well as strategies providers may consider to address this challenge.

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Transcript

Graham Brown:

Hello. This is Graham Brown, Principal with the NextGen Advisors. Welcome to our podcast. Today I'm joined by my colleagues, Dr. Betty Rabinowitz and Dr. Marty Lustick. Good morning and welcome, Betty and Marty.

Betty Rabinowitz:

Good morning.

Marty Lustick:

Hi Graham.

Graham Brown:

Today, we want to explore the topic of patient adherence with a care plan. There is some literature to estimate the cost of medication non-adherence, but little on the overall impact of other forms of non-adherence. An often-cited statistic from a review in the Annals of Internal Medicine reports that 20 to 30% of prescribed medications are never filled at a pharmacy. And 50% of medications for chronic conditions are not taken as prescribed. This lack of adherence, the Annals' authors wrote, is estimated to cause approximately 125,000 deaths, and at least 10% of hospitalizations. The associated cost to the American health system is estimated to be between 100 billion and 289 billion dollars a year.

Graham Brown:

The global pandemic challenged patients and providers alike to maintain regular communication and keep on top of a plan of care. For the purpose of today's discussion, we're using the term adherence, which the World Health Organization defines as the extent to which a person's behavior corresponds with agreed recommendations from a health care professional. Adherence is broadly related to instructions concerning medicine intake, use of a medical device, diet, exercise, lifestyle changes, rest, and return to scheduled appointments. So let's set the stage a little bit and explore some examples. The research suggests patient compliance and adherence depends on a number of factors. Betty, start us off with this. What are some of those key factors?

Betty Rabinowitz:

It's an interesting question. One of the main issues that patients are confronted with is the complexity of the treatment schedules we provide them. There are medication doses, different regimens with multiple medications, different cadence and intervals during the day. They've become very complicated. Those of us who are fortunate to be healthy can report how difficult it is to take a single medication for a week for an infection or a simple issue. And we send elderly patients home with 15 medications at different intervals, different times, which is extremely daunting.

Betty Rabinowitz:

Clearly, foundationally, the context in which these recommendations are made is important. So if there is a relationship of trust between the patient and the physician, it will be easier. It's been shown that patients are more likely to pick up the medication and actually take them. If a mistrust or unfamiliarity is there, the patient doesn't know the physician, that's less likely to happen. Certain conditions have regimens that are easier to adhere to or less. So for example, patients with dementia struggle specifically with adhering to medications. And then there is obviously a slew of socio-economic and biopsychosocial elements, like portability, the complexity of even attaining the medication, elderly home-bound patients who don't have pharmacies that deliver the medication. We kind of bundle those in environmental factors that make adhering to a complex regimen, extremely difficult.

Graham Brown:

I was interested to learn, in preparing for this, that there's also some research that indicates that individuals that are of an older age, have a higher level of education, have higher socioeconomic status, or are retired or married, are associated with better compliance with the treatment. And another study from [inaudible 00:04:04] in 2017, looked at what factors impact patients adherence with medical advice. And they note that other positive factors include accessible and comprehensible form of communicating the medical information. So a real understanding for the patient of what their needs are and how to adhere with the program, continuity of care, the patient's satisfaction with their experience of care, and then shorter intervals between appointments and shorter waiting time. So really in better experience and more continuity in engaging with their provider. So, Marty, let's talk a little bit more about the doctor-patient relationship. Trust would seem to be pretty paramount here, but that isn't always easy to establish. What in your experience has been important in influencing that trust in a doctor-patient relationship?

Marty Lustick:

It's either one of two foundational concepts that underlie building trust with patients, and that's caring and competence. I was fortunate when I first started in practice to have a surgeon who was a Vietnam veteran who sat me down, and first thing he said was, patients don't care what you know until they know that you care. And coming from a surgeon, that was a really powerful statement to me. And it's not that competence isn't critically important, but really patients knowing that you respect and care about them. And what stems from that is being a good listener and meeting them where they are, not where you want them to be, and being responsive to their questions, I think.

Marty Lustick:

What flows from being caring and competent, will build trust. And the other important component of this is time. We hope in primary care, as a pediatrician, we typically do have the opportunity to build trust over relatively minor issues over time, so that when, and if, the more critical issues occur that can have greater consequences for patients, if there's already a trusted relationship there that really helps you work through those most difficult decisions that you need to make with your patients.

Graham Brown:

You know, I'd be interested to learn from each of you. In your own experience as practicing providers, what are the impacts when you have a patient that may be actually quite complex or quite ill, and they're not adhering to a plan, how have you seen those type of situations unfold? Betty?

Betty Rabinowitz:

I think it's much more common than we have even commented about here. From time to time, I would ask patients to come in with a shopping bag to collect every single medication that they have in the home. And patients would come in with plastic bags full of unopened pill bottles, pill bottles that were prescribed way long ago that still had the full complement of medications in them, where obviously they weren't taking the medications.

Betty Rabinowitz:

One of the things I learned to do as I became more experienced that, when my patients were admitted to the hospital and the admitting physician translated the outpatient medication list, I would tell them to be very cautious about the doses and the amounts that they were going to give to patients, because many a time we would crash patient's sugars or crash their blood pressure, because I kept escalating the dose of the blood pressure medication because they weren't supposedly responding. But the reality was they never were taking it in the first place. So it's interesting to see how people with total integrity, honest, upstanding citizens of the world would not acknowledge or not feel comfortable to admit that they were not taking their medications. And the truth was completely exposed when they would crash when you gave them their home doses, actually the nurse hand it to them and watch them take the medication.

Marty Lustick:

I think it's a really important point because I think traditionally, a lot of patients, they want to have a positive relationship with their doctor. So it's not unusual for them to give the answer that they think the doctor wants to hear, rather than just saying, I hate to admit it, but I really haven't been taking that medicine. They know it's important to the doctor somehow, that they have take it. So they say they're taking it. And it is a maturing issue as a practitioner to learn how to filter through those issues.

Marty Lustick:

I give also, just for myself as a pediatrician, a simple example that's very relevant today, is I've had I had a couple of patients in my practice who refused the initial vaccinations for their baby and the baby ended up getting whooping cough, pertussis, which, the whole reason for vaccinating newborns and two month olds for pertussis is because it's such a dangerous illness at that age. And they ended up with pertussis in the intensive care unit in the hospital. Fortunately, the couple that I had in my practice, over time both survived it, but it's a really dangerous illness. And it's just a simple example of people make a choice, and sometimes it has pretty substantial implications.

Graham Brown:

So lets kind of segue way into that, because I think it's a really important matter and very much something that's happening in the current context. At the patient level, there's obviously a lot of factors at play. There's much discussion and debate in the United States right now about physicians making recommendations to their patients to get vaccinated against COVID. Yet there's a very significant cohort of individuals, some 80 million adults in the United States, who weren't heeding this advice for one reason or another. And so what else is at play here from your perspective? I'd be interested to hear, Marty?

Marty Lustick:

I'd start with, you mentioned at the beginning, the cost of non-adherence to the system. If you look at this non adherence to medication specifically, pharmaceutical companies are obviously very interested in this issue because if people aren't filling their prescriptions, then they're not meeting their sales objectives for those medications. So the pharmaceutical industry has invested a lot in trying to understand what drives patient adherence, particularly for medications. And consistently the surveys that they've done have shown three foundational issues that get in the way.

Marty Lustick:

The first one is a lack of the full understanding of why they need to do it. The second one is fear of side effects, and the third one is financial or access issues. It's either too expensive or too difficult to get the prescriptions filled. And I think those underlying issues apply to the situation we're in today, and have just been further complicated by the politicization of this issue, and the confusing messages that have come out publicly that make it very difficult for people to navigate these two big issues of, why should I do it? And what are the possible side effects of it?

Betty Rabinowitz:

Interestingly, I think that the way we referred earlier to the emotional context, the relationship in which the recommendation is being provided, as a key driver of adherence or lack thereof. This recommendation was made as a public health recommendation, and by definition, in the absence of an individual personal relationship. And I had this interesting conversation just yesterday with a group of folks, and one of them commented that in the context of the COVID pandemic, we have seen our primary care physicians less, and that many of us haven't even had an opportunity to hear their opinions about the vaccination.

Betty Rabinowitz:

So there has been an absence of a trusting relationship ,and add to that that many elements, many of the folks who are resistant or hesitant to take the vaccine have had prior experiences with the healthcare system, individual providers, the broader system, that have been traumatic or not positive. And that has created kind of a foundation of lack of trust. So that context becomes that's again a deterrent. Thankfully there have not been a lot of barriers for access that Marty referred to, but there still are some in some rural areas. Initially, when the vaccine was rolled out, there was a scarcity, there was difficulty making the appointments and people got... I think some people are struggled with getting in, to get the vaccines at that time.

Graham Brown:

So on this topic of encouraging individuals to get vaccinated, what do you think can be done? Are there lessons from the research around medication and treatment adherence that point us in the right direction or might be applicable here?

Marty Lustick:

I think Betty touched on a couple of the important issues already. That one, you talk to somebody, talk to a professional who you trust. So I think there's some obligation or responsibility among primary care practices to be reaching out to their patients. Hopefully they have the infrastructure to identify who has and hasn't been vaccinated, and to really proactively be having those conversations to try identify what are their barriers? Is it that they don't understand why? Is it that they are worried about side effects? What are we worried about? What's their experience? Then it goes back to the trust thing. We meet them where they are, and you try to help them get to the best decision for themselves, and meeting them where they are is also about making sure it's convenient, I think. I still think there's a subset of people where taking off time from work, transportation issues, getting to where the vaccines have been delivered are also still barriers.

Betty Rabinowitz:

Yeah. I agree with Marty, and just breaking news from this morning in Israel, they just recommended a third shot to their population over 60. So as of Sunday all individuals over the age of 60 in Israel are going to get a third shot. So here we are with the kind of logistic challenge of getting 330 million citizens vaccinated twice, or once for Johnson & Johnson. We're probably sooner rather than later going to be facing another challenge there. But I think one of the important aspects of the public and individual conversation about vaccines is to be non-judgemental about people's reservations and concerns. You have to be willing to listen with no judgment to what has led people to make their decision.

Betty Rabinowitz:

And at the same time, be transparent about the things we don't know, and the risks that we need to acknowledge. There are unknowns about this vaccine. It is a new technology. We do not have patients who've had a messenger RNA vaccine five years ago. We are learning as we go. The recommendations have shifted and changed. It's very unnerving to people to say, which is it? I think my experience has been that if you are honest with patients about your concerns, or the reasons why you had worries about it, but overcame them and what the rationale for that was, patients appreciate that. And behavior has changed.

Graham Brown:

You know, it's a little anecdotal, but I consistently have seen on the news interviews with folks recovering from COVID in the ICU, they've just come off intubation and they're recovering, and they have a conversation with their doctor around, well, should I get vaccinated now? And one of the things that often comes up is, patients really didn't have an understanding of how severe the illness was going to be.

Graham Brown:

And many physicians that have been working in hospitals and serving COVID patients are expressing that it's so important for individuals to really understand the potential side effects of the inoculation are nowhere near the potential side effects of having the disease itself, let alone the longterm implications of COVID and these long haulers, which we're just starting to understand. So there's really clearly a lot at play here in making these decisions for folks and hope that we brought some different topics to the floor for folks to consider. Thank you, Dr. Marty Lustick and Betty Rabinowitz for joining me today, and our listeners also for tuning in. If you'd like to listen to more episodes of the NextGen advisors podcast, hit the subscribe button. This is Graham Brown with NextGen healthcare. Thanks for joining us and have a great day.