Making Sense of Adherence
To be fair this isn't a new problem. Adherence has been a pain point for the pharmaceutical industry for decades, mostly due
to the lack of knowledge about why patients choose not to take their medicine. Industry was under the impression that most
patients didn't follow through with the their treatment because they simply couldn't remember to take it.
The US Outcomes Research Group at Merck wanted to test this theory and analyzed 79 studies pertaining to the reporting of
prescription nonfulfillment rates at the patient and prescription level.
The report, "Medication Nonfulfillment Rates and Reasons: Narrative Systematic Review," categorizes medication nonadherence
into four categories:
»Primary Nonadherence—Patient never fills the first prescription.
» Early Nonpersistence» Patient doesn't refill the medication after the first prescription.
» Secondary Nonadherence» Patient does not take his or her medication as prescribed.
» Secondary Nonpersistence» Failure to continue treatment after first prescription is filled.
After reviewing nearly 30 years of research, it was determined that 15 percent to 20 percent of patients, on average, do not
get their first prescription filled.
According to Abhijit Gadkari, senior manager, Outcomes Research at Merck, the old adage that patients just can't remember
to take their medicine proved to be a myth. Instead, the main reasons for nonadherence are:
» Concerns about the medication;
» Lack of perceived need for the treatment; and
The report states that "about one-third of chronically ill adults who underuse prescription medications because of cost do
not discuss medication affordability with their providers in advance, and may never raise this issue with their providers
However, the fears about taking a medication or the feelings that a drug isn't needed fall squarely with the physician. The
report cited a 19 percent spike in risk of nonadherence in patients that felt they didn't understand what their physician
was telling them. This is a particular headache for the physician, because he or she typically isn't reimbursed for time spent
educating patients about their treatment. Add to that the short amount of time a doctor has to see the patient and it is possible
that many patients feel overwhelmed and underserved after receiving a prescription.
Worst yet, new technology such as e-prescribing might make things worse. Merck found that in the few studies that had e-prescribing,
if the patient hadn't walked out with the physical copy of the prescription in hand, sometimes they didn't realize that the
scrip was written and might not come back to fill it. Either they forgot that the scrip was directly sent to the pharmacy,
or they might not know that it was written at all.
"If the patient doesn't come in for that first scrip—if they don't have a chance to see if the drug works for them or not—there's
really no chance that the patients can experience firsthand if the therapy is working for them," explains Gadkari. "In that
case, the pharma industry is losing these patients forever."
The situation is a giant catch-22 that won't be rectified until some kind of paradigm shift happens that makes all of the
stakeholders responsible for the success of treatment regimens.
The closest thing down the pike is pay-for-performance (PFP), a controversial initiative in which insurance companies will
compensate physicians based on the outcome of the patient. Physicians are incentivized to make sure that a patient stays on
a treatment path and follows the regimen prescribed. Pilot programs for PFP are under way, but how well they will work is
"With the focus on outcomes, we can't just look at efficacy and know that this drug lowers cholesterol," says Jonothan Tierce,
general manager, Health Economics & Outcomes Research, IMS Health. "We realize that we are all in the same situation—the payers,
the providers, the patients, and the physicians—and we all have a common interest in getting patients to take their medication
so that we can get the outcomes that we are looking for."
Research shows that if pharma companies send out reminder letters, a few more patients will take their medication more regularly,
but it's not a big proportion of patients. The goal then is to target patients based on the exact reason why they rejected
"The key is understanding why somebody doesn't come in to take medications and then implementing interventions or messages
that are tailored to patient's specific beliefs," explains Gadkari.