Encouraging adherence to long-term medication with Prof Tim Usherwood

I think it's important we understand that as prescribers our job doesn't finish with writing the prescription.

Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed and free.

I'm Dr Janine Rowse your host for this episode, and it's a pleasure to be speaking to Tim Usherwood today about adherence to long-term medication. Prof Usherwood welcome to the program.

Thank you Janine.

This article that you've written about adherence to long-term medication has been a real eye-opener for me as a GP and will help me to rethink how I interact with my patients. Can you tell us about the rates of non-adherence in developed countries?

Yes, I must say the figures startled me when I was writing this article. So we know from a WHO review of the literature that in developed countries approximately 50% of patients living with chronic disease do not adhere to treatment recommendations.

And I'm not surprised that as clinicians we are historically poor at detecting non-adherence. What are your practical recommendations for better identification in the primary care setting?

I think it's important to start by being aware that many patients don't adhere to their prescribed medication but it's important for all of us as prescribers, and in fact also for pharmacists and others to check whether patients are able to adhere and are in fact adhering to their medications. So there’ve been a number of studies looking at this issue and a small number of studies have examined different styles of questioning by prescribers to detect non-adherence. And effective strategies have been shown to include using a collaborative style, working with the patient, using the patient's own expressions and responding to them, and normalising non-adherence in some way. And in the article I give an example of a possible conversation between a prescribing doctor and a patient using some of those techniques. But it's important to note that in one study, questions that asked directly about missed doses were almost four times more likely to elicit disclosure and non-adherence than other question types so direct questions at every consultation is the key.

That's really important to remember and I also suppose normalising non-adherence will help get honest answers as opposed to patients wanting to please the doctor by saying oh yes yes I took all of those pills.

I think that's really important and it’s possible to say something like ‘many people forget to take their pills occasionally’. That's not blaming, that's just acknowledging a fact of life.

A label that often gets thrown around which I really object to, is the label of a poorly compliant patient. That label tends to follow patients around. What are your thoughts on this label being given to patients and should we alternatively see the poorly compliant patient as an opportunity for trying new strategies?

I don't think there's such a thing as a non-compliant patient. I think there are people who don't adhere to prescribed medications for a whole range of reasons. There are two broad reasons. One is the patient for some reason decides not to adhere to their prescribed medications. That might be because they have concerns about side effects or they're not sure about the efficacy and those are issues that are largely open to education by the prescriber. Then there are reasons why people don't adhere which are non-intentional. That might be for personal reasons, for example, misunderstanding or forgetfulness, cognitive impairment, regime complexity. Then there might be further practical difficulties such as costs, such as difficulty getting to the pharmacy or the dispenser, difficulties opening medicine bottles or using inhalers, and again it's really up to us as prescribers and dispensers and other health professionals to identify what these things are and to work with the patient.

Some of the consequences of non-adherence can be clinically very important and indeed risk significant harm. Could you tell us about some of these consequences?

Obviously medications don't work if they're not administered. A chronic disease may be undertreated or that patients may not obtain full benefit from prescribed medication for preventive purposes. But the other risk - this has been shown in a number of observational studies - is that doctors may not realise that the patient is not adhering, for example their blood pressure is not adequately controlled, and then escalate treatment, and that's potentially very dangerous because then if the patient then does start to take all their prescribed medicines they risk in fact overdosing on the prescription.

And I'm sure I've found myself doing that at times, increasing blood pressure medication for example without questioning appropriate adherence.

I think we probably all have.

Can you tell us about some of the evidence-based technological interventions for improving adherence?

Yes. Well I think very exciting recent research has shown that electronic reminders of various kinds are highly effective for increasing adherence. The study that I was involved with, colleagues at the Woolcock Institute led by Professor Reddel, we did a study where we actually had reminder devices attached to people's inhalers and showed that over six months adherence was 50% higher in patients whose inhaler bleeped when they hadn't used it on time.

That's phenomenal.

Yeah, so that was a significant increase in adherence. More broadly a recent meta-analysis evaluating use of text messaging in adults with chronic disease found that they doubled the odds of adherence across 16 randomised controlled trials. One could even suggest to a patient quite simply that they set an alarm on their mobile phone to go off at the times when they need to take their medication.

Wonderful ideas. Tim, that's really fascinating. I suppose it just reminds me as a GP but not only for GPs, for any healthcare providers at any checkpoint within the health system, how important it is to have this conversation with patients. What would be your take-home message about encouraging adherence?

I think two. First of all, as you’re first working with a patient, decide on what's appropriate treatment for them, work with them and think about their own goals, any concerns they may have, provide education about the benefits and effects of the medication, think about possible barriers or difficulties that the patient may face, whether it's cognitive impairments, pill complexity, costs or other barriers, and then every time you see the patients ask directly about adherence.

I'll certainly be making these changes to my practice in future. That's unfortunately all we've got time for this episode. Thanks so much for joining us today, Tim.

Thank you Janine.

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Tim's full article is available online at nps.org.au/australian-prescriber and like our whole journal it's free. Subscribe to get the latest Australian Prescriber delivered straight to your email inbox and follow us on Twitter @AustPrescriber to get the latest updates. The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Janine Rowse and thanks for joining us on the Australian Prescriber Podcast.