Nonadherent patients with diabetes face severely increased risks of hospitalization and death.
During “The Realities of the Problem—Prevalence and Common Barriers,” part of the “Improving Compliance and Outcomes in the Era of Complex Therapeutic Regimens—What Really Works?” symposium at the ADA 71st Annual Meeting in San Diego, John R. White Jr., PharmD, provided an overview of non-adherence challenges in patients with type 2 diabetes and discussed the scope, predictors, and some solutions for improving adherence.
White said that many providers tend to think, “your patients may not be adherent, but mine are.” The fact is, most providers think their patients are adherent, when many are not. Worldwide, 50% of all patients take medication as prescribed. In the US, one-third to one-half are not taking medications as directed. Non-adherence causes 69% of medication-related hospitalizations versus 33% in those who are adherent. The annual cost of non-adherence-related problems is $290 billion. Specific to diabetes, mortality increases to 12.1% from 6.7%, the risk of hospitalization goes up to 30% from 13%, and the average annual cost nearly doubles, to $16,498 from $8,886 (non-adherent versus adherent, respectively). Quoting C. Everett Koop, White reminded the audience that the basic problem is that “Drugs don’t work in patients that don’t take them.”
Factors contributing most to non-adherence include complexity of the regimen, side effects (actual or perceived), poor provider-patient relationship, the patient’s lack of belief in the benefit of treatment, and cost or insurance reimbursement. In a study conducted in 2005, researchers found that as frequency of medication increases, adherence decreases. Another study found 38% adherence with tid
dosing versus 79% adherence with qd
dosing. White also cited a study of 37,431 Medicaid type 2 diabetes patients which found 15% adherence for monotherapy versus less than 5% with combination therapy.
Interestingly, and unfortunately, many of the predictors of non-adherence are commonly seen in diabetic patients. Presence of psychological problems such as depression, inadequate follow-up or discharge planning, side effects, patients’ lack of belief in the benefit of treatment, patients’ lack of insight into illness, complexity of treatment, cost, and missed appointments can all contribute to non-adherence in the general patient population, but also in diabetics. “Part of the problem in diabetes is that it is a complex metabolic disease that exists often in the presence of other conditions,” said White. So providers will find many patients taking multiple medications (eg, statins, antihypertensives). And patients have life stressors in addition to medical problems. He said that providers “have to be cognizant of all these other factors that may contribute to adherence problems.”
Putting some of the responsibility on our health care system, White examined whether providers are adherent to practice guidelines. After reviewing the literature, he found few providers who escalated treatment regimens for patients whose A1C was not under control. So clearly it is not just patients who are non-adherent.
Aside from adhering to practice guidelines themselves, providers can help improve patient adherence by implementing various strategies. First and foremost, said White, is to identify patients with poor adherence. Emphasize the value of the treatment regimen, elicit patients’ feelings, listen to patients, reinforce desirable behavior, and incorporate other communication methods for improving the provider-patient relationship. In addition, White suggests providing simple, clear instructions to patients, simplifying the regimen when possible (eg, qd
), and considering more “forgiving” medications (eg, those with better side effect profiles). Finally, providers should seek help from family members or friends.
Although he painted a rather grim picture in terms of adherence, White reminded the audience that “As providers, we should do all we can to improve adherence. Even if we go through all the appropriate steps and patients don’t take their medications, we’re failing.”