The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow


January 16, 2014

In This Article

Medication Regimens Can Be Too Complicated

It's easy to lose sight of the fact, especially when dashing off prescriptions every 15 minutes, that the drug regimens being prescribed, even though they may be evidence-based, may not be easy for patients to follow even if they wanted to.

In a 2012 paper, Kaiser Permanente's John Steiner calculated how many behaviors per year are required of a hypothetical 67-year-old patient with well-controlled hypertension, diabetes, and hyperlipidemia. It came to more than 3000 behaviors.[36] "And that's a conservative estimate," he says.

Writing in the New York Times, internist Danielle Ofri, MD, Associate Professor of Medicine at New York University School of Medicine, told of a small experiment that she conducted with a group of medical students.[37] They wrote up prescriptions for several common medications: metformin, furosemide, albuterol, lisinopril, and rantidine. Each student received 2 prescriptions and 2 boxes of Tic Tacs® and was instructed to take the "medicines" for a week.

"When we met for our next session, I asked them how they did, and they all had abashed expressions on their faces," Ofri writes.[37] "Not one was able to take every single pill as directed for 7 days."

Compliance, it turns out, is inversely proportional to the number of times a patient must take medication each day.[10] For medication taken only once daily, the average compliance rate is nearly 80%; for medication that must be taken 4 times a day, the average rate drops to about 50%.[10]

One study found that the average patient who takes a statin for dyslipidemia currently takes a total of 11 medications, makes 5 pharmacy visits over a 3-month period, and synchronizes -- that is, picks up multiple prescriptions at the same time -- half of his or her refills.[38] However, 10% of statin users take 23 or more medications, make 11 or more pharmacy visits to 2 or more pharmacies over 90 days, have 4 or more prescribers, and only synchronize 10% of their refills.

Picture a Medicare patient whose memory may not be what it once was, and who may lack social support to get to the pharmacy regularly, trying to adhere to all of this.

"We're asking patients to adopt obsessive-compulsive behavior," admits internist Edmund Pezalla, MD, MPH, National Medical Director of Pharmacy Policy & Strategy for the health insurer Aetna. "Taking medication every day is hard to do. We're asking people to deal with the same boring situation over and over again. We're not programmed to do that. Machines do that. Humans don't do it very well."


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