Physicians and Adherence: the Bad, and the Ugly

By | October 10, 2013

Physicians are very well placed to drive improvements in medication adherence. But are they fully engaged in the task? This is the second in a two-part post exploring this question. Part one, ‘the Good’, is here. This second part focuses on: ‘the Bad and the Ugly’.

The Story So Far

Physicians are a critical cog in the adherence machine. With the focus of healthcare moving to ‘value’, doctors have clear incentives to improve adherence. Because improving adherence helps achieve better outcomes.

In ‘the Good’, we identified five behaviors that physicians should adopt to promote better adherence among their patients. These are:

  • Prioritize the quality of their communications
  • Devote appropriate time to talking with their patients
  • Engage patients and activate them to self-manage
  • Commit to shared decision-making
  • Build trusting relationships

In this post we’ll review how doctors are currently doing in each of these areas, based on available information.

Physicians and Adherence: the Bad

Before we get into the five areas, I’ll lead off with three more general findings about doctors’ views on medication adherence.

Physicians’ have a low overall sense of responsibility for adherence

Physician views on their adherence responsibilities were reported in a 2012 paper (see here). Findings were that physicians feel responsible for assessing medication adherence and for addressing factors underlying non-adherence.

However physicians believe that patients were ultimately responsible for taking medications.

Undoubtedly, adherence is a shared, physician-patient responsibility. However to adhere better, patients need help and support. For example, physicians can provide information on the importance of adherence, guidance on tools that can assist adherence, and counseling to address misconceptions.

Placing the ultimate responsibility on patients hints at assignment of blame, something that should be avoided.

A weak sense of responsibility for adherence among physicians potentially weakens their resolve to adopt the five behavior changes described above.

Physicians are poor at actively identifying non-adherence

Physicians say they feel responsible for assessing medication adherence (see here). In the same paper however the authors found that in-depth inquiries about medication use were made in only 4.3% of patient discussions.

Physicians feel responsible for assessing adherence. But the words don't carry through to actions. Physicians ask indepth questions about adherence less than 5% of the time.

These two findings are clearly at odds. However, they say “actions speak louder than words”.

It is self-evident that if physicians don’t actively look for non-adherence, they’ll miss much of it. So that raises the question: how much non-adherence is out there, but unrecognized?

Physicians overestimate patient adherence

Hard data on a patient’s adherence may be difficult to get. In its absence, physicians tend to overestimate how well patients are adhering to their medications’ regimens. For example, in a 2010 study (see here) doctors overestimated adherence in 67% of patients.

The study compared physicians’ assessment of adherence with that found using MMAS-8. Agreement between physician perception and MMAS-8 was 95% for high adherers but only 33% for low adherers. Overall, physicians underestimated adherence in 5% of patients, while overestimation occurred in 67% of patients.

A tendency to significantly overestimate patients’ adherence levels may adversely affect doctors’ views on the importance of dealing with non-adherence. Perhaps this over-optimistic view of true adherence levels also contributes to their low sense of responsibility as well? This overestimation maybe also explain why physicians so rarely question patients about their tablet-taking habits.

That deals with the three general areas. The next few points get us back to the behavioral areas flagged earlier in ‘the Good’ post. Here goes …

Quality Communications

It seems there’s quite some room for improvement in physician-patient communications. For instance, the headline from a recent infographic (see here) caught my eye:

 “50% of patients walk out of the physician’s office not knowing what they were told or are supposed to do.”

Perhaps sounds excessive? Maybe not so much. This number is within the range from an earlier 2003 paper (see here), which noted that:

“40–80% of medical information provided by healthcare practitioners is forgotten immediately.”

Of further relevance is the advice from the infographic that:

  • Telling patients once is usually not enough to get the patient’s attention or buy-in
  • Patients filter what they hear from their doctor in a variety of ways that physicians know nothing about, ie the patient’s health beliefs, values, previous experience, and illness explanation models

This clearly remains an area for further physician improvement.

Investing time with patients to help improve their medication adherence is time well invested.Appropriate time for patients

Physicians are pressed for time. Administrative duties, management tasks, dealing with insurance queries, and many other demands all threaten the time available for patients.

A survey by AHRQ carried out in 2012 (see here) found that almost 70% of respondents felt “rushed when taking care of patients”. And a 2013 paper (see here) found that 81% of physicians perceived a lack of time as the largest barrier to practicing shared decision-making.

So time is a problem and the problem has consequences.

To address this, better time management by physicians could be one solution. Another answer might be better sharing of workload among practice staff. For instance, relationship-building could be a shared task, as could communication and patient education.

In support of this approach, a recent survey (see here) reported the nurse practitioners are taking on key adherence-related activities, such as:

  • Providing patients with adherence resources
  • Spending time on patient education
  • Referred patients to adherence tools

Patient engagement and shared decision-making

Shared decision-making (SDM) is a prime example of patient engagement. And when successfully carried out it can boost patient activation too. So how well have physicians adopted SDM?

A 2013 paper on prostate cancer screening (see here) reported only 8% implementation of full SDM. This figure is extremely close to 9% that met the criteria for informed decision making in a 1999 study (see here).

These are disappointing numbers; both because of their lowness and because it’s possible that implementation of SDM hasn’t improved a lot in nearly 14 years.

Once again, with SDM there’s massive room for improvement.

Trusting patient relationships

In a 2013 paper (see here, Table 2) patient trust in doctors was very high. To the question: “Have you felt confidence and trust in your personal physician”, 78% of respondents said “usually” or “always”.

Questions about the continuation of such high levels may depend on possible changes to future patient expectations of their doctors. If patients begin to look for better communications, for more time, or improved engagement and participation in treatment decisions, then based on the findings above trust levels could be endangered.

Physicians and adherence, it's ugly. The low levels of doctor contributions to adherence topics just does not look good.Physicians and Adherence: the Ugly

This section addresses several more qualitative impressions relating to physicians and adherence. The term “ugly” is applied because the low levels or even absence of physicians contributing to these matters just does not look good.

Adherence – Leadership

Among leading healthcare professional groups, physicians appear to be a poor third in terms of active involvement in, and leadership of, adherence activities. Pharmacists currently lead the charge, with payers second.

Adherence – Visibility and Support

Similarly in terms of the number of general articles or reports written about adherence and its importance, physicians are not among the leaders.

Adherence – Sharing

Even when it comes to groups like ACOs or PCMHs, who are most likely to support improving adherence as a major goal, little has been shared or published from their experiences (impacts, best practices, etc). Perhaps it’s early to expect this?

Physicians and Adherence: Summary

Better adherence is of major benefit to patients because it improves outcomes and health status. It’s of major benefit to society because it can reduce healthcare costs – exactly what the economy needs. And it’s of major benefit to physicians because it improves ‘value of care’ – an increasingly important performance measure for doctors. A win-win-win!

To fulfill this vision will require physician behavioral changes. The practical dimensions of these changes are covered above.

At an ethereal level, the changes needed were nicely summarized in an article earlier in 2013 (see here). Speaking about medical practice changes the author wrote:

“This will require renewed attention to the character of the clinical practitioner, to the quality of the practitioner-patient relationship, and to the source of those values that sustain humanistic medical care. Above all, it will require exploration of what it might mean to view medicine as a spiritual vocation.”