“Drugs don’t work in patients who don’t take them.”
–C. Everett Koop, M.D.
While it would be hard to imagine accountable care organizations being able to get the data they need to manage care without electronic health records, and EHRs are critical as payment has evolved to emphasize the outcomes of treatment, one area remains the holy grail of disease management: how to get patients to take the medications that are prescribed.
Poor adherence to medications is a critical issue in the management of chronic disease. The causes for suboptimal adherence are numerous, including the cost of medications, patient-physician communication, patient education, motivation, and simple forgetfulness.
Approximately 1.5 billion prescriptions, at a cost of more than $250 billion, are dispensed each year in the United States. A large body of evidence supports the use of these medications. For patients with diabetes, for instance, correct medication use can lower blood sugar, blood pressure, and cholesterol, and by so doing, decrease morbidity and mortality from both microvascular and macrovascular disease.
The act of taking medications is influenced by many factors, and all of these factors come together at a point in time when patients are not directly engaged with the health care system. It is at that moment that patients remember and decide whether to take their medications.
Numerous studies show that individuals often do not take their medicines as prescribed. Adherence rates for medications for chronic disease show that patients on average take only about 50% of prescribed doses. For patients with diabetes, the average adherence rate is about 70%, with rates ranging in different studies from 31% to 87%.
When patients do not take their medications correctly, there can be severe consequences. Poor medication adherence can lead to poorer clinical outcomes, including increased hospitalizations. One large dataset of more than 56,000 individuals with type 2 diabetes covered by employer-sponsored health insurance showed that increased adherence to medications significantly reduced hospitalizations and emergency department visits. When adherence rates increased, the hospitalization rate fell 23%, and the rate of emergency department visits decreased 46%, resulting in significant cost savings for the health system.1
In response to this issue, many strategies have emerged. We now regularly get correspondence from insurance companies alerting us to nonadherence of individual patients. This information tends to be of little benefit, because the information is received long after the decision to take or not take the medication is made. Our response in the office to our patients is generally to remind them to take their medications, which is not much different from the discussion we have with them without that information.
Recently, a new set of apps for smartphones and tablets has emerged to help patients organize their approach to taking medications. Examples of some of these apps include Care4Today, Dosecast, Medisafe, MedSimple, MyMedREc, MyMeds, and OnTimeRx. Most of these apps allow a patient to put in their medication schedule and are organized to provide reminders when it is time to take medications.
The problem with reminders, of course, is that they don’t always happen at a time when it is convenient for a person to take their medications. For example, if your app reminds you to take your medicines at 9 p.m. each night, and you are at the movies on a Saturday night, you may extinguish the reminder and not remember to take the medications when you get home.
Many of the apps also track adherence rates so that patients can see how well they are doing in taking their medications. The results are often startling to patients, and it is hoped that such information would encourage more effort in taking medications.
One problem with many of the apps currently available is that they essentially function as sophisticated alarm clocks. They do not get at some of the fundamental reasons that people do not take their medications, which would require more behavioral input.
In fact, a recent article in the American Journal of Preventive Medicine looked at 166 medication adherence apps and concluded that current apps contained little in the way of evidence-based behavioral change techniques that have been shown to help change behavior. In fact, only about one-third of apps contained any feedback on behavior at all.2
While adherence apps still have a way to go, they can be helpful, and many contain interesting, novel features. Some allow the patient to input the name of a medication by scanning the name from the medication’s pill bottle. Some have the ability not only to remind a patient to take a medication, but also to text that patient’s caregiver (or parent, in the case of a teenager) if the medication is not taken.