Sound Body

Take as directed

Millions of patients skip drug doses or never get prescriptions filled in the first place. Fixing the problem will require solutions as varied as the reasons that cause it.

By Stephen Smith
May 10, 2010

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The doctor was baffled.

He had a patient, an older man, with high blood pressure that ricocheted wildly despite prescriptions for pills that tame hypertension in millions of Americans.

“I just could not figure out why I could not get this guy’s blood pressure under control,’’ lamented Dr. Lars Osterberg, of the VA Medical Center in Palo Alto, Calif.

So he scheduled an appointment with the man, determined to pry from him why the medicine wasn’t working. And that’s when the patient confessed: He was using a dowsing rod — traditionally the province of prospectors of water, gold, or gems — to determine whether he would take his blood pressure medication. If the rod went up, the pill was taken. If it trembled in the opposite direction, the cap on the pill bottle remained firmly attached.

“I had to show him up-and-down blood pressures were not good for his health,’’ said Osterberg, also an associate medical professor at Stanford University.

It is a common conundrum in doctor’s offices, clinics, and hospitals across the nation: patients who do not take their medication as directed. It’s true for people with high cholesterol, low calcium, diabetes, and asthma. It’s even true for patients with the AIDS virus and those who have received life-saving replacement organs.

Last month, in the New England Journal of Medicine, a Harvard health economist and the New England Healthcare Institute’s president sketched in stark detail the consequences of patients failing to take their drugs. The behavior spawns hospital stays costing $100 billion a year — stays that could have been averted. And 89,000 deaths from high blood pressure could be prevented annually if hypertension drug regimens were followed.

There are no easy-to-blame villains, neither patients nor doctors nor pharmacists. Instead, a thicket of medical, financial, and social forces can snag the best of intentions, causing prescriptions to go unfilled or unused, or be taken incorrectly.

“It is an issue that will be central to our efforts to reform the health care system,’’ said Dr. William Shrank of Brigham and Women’s Hospital. “There are many different reasons for it, and that’s what makes it such a hard nut to crack.’’

One major reason: the sheer complexity of what patients with chronic illnesses are expected to take. Consider someone diagnosed with congestive heart failure, a common ailment among the aged. There are drugs specifically for that diagnosis: ACE inhibitors, beta blockers, and pills that reduce water weight.

But that’s usually not all. There’s a good chance the congestive heart failure was presaged by other cardiovascular diseases. So the same patient might also take pills for high blood pressure and pills for elevated cholesterol. And physicians acknowledge they often don’t do enough to explain the importance of hewing to instructions on prescriptions bottles.

“If you’re faced with trying to take 10 different types of medicines at various times of the day, if you’re going to get it right, it’s going to take an awful lot of organization and support,’’ said Dr. Thad Schilling, an internist at Harvard Vanguard Medical Associates.

And for some of the most common conditions, the benefits of medication may not be readily evident to patients.

It’s one thing if you have asthma and the drug you inhale each morning and night prevents the gasping and wheezing that are the disease’s calling cards. It’s something else entirely if your condition exists largely as numbers scrawled on a piece of paper, such as with high blood pressure or high cholesterol. The effects of the disease and the benefits of the drugs are equally opaque — until disaster strikes in the form of a heart attack or stroke.

“If I don’t have any symptoms and my doctor says, Please take this drug to keep your blood pressure lower, and the drug itself makes me feel tired or not myself, then I have a little internal battle going on,’’ said Wendy Everett, president of New England Healthcare Institute, a think tank underwritten by foundations and corporations. “I’m saying, Hmm, why do I want to take a pill that’s going to make me feel ill to control a disease for which I have no symptoms?’’

Even when there can be a dire, swift outcome from failing to take a drug, there’s no guarantee patients will follow directions.

Dr. Michael Somers, a Children’s Hospital Boston kidney specialist, has encountered that with adolescent transplant patients. Their failure to consistently use medications to prevent rejection of donated kidneys represents a leading cause of transplant failures in teens.

Sometimes, it’s an act of adolescent rebellion. Sometimes, it’s a reflection of side effects — weight gain, puffy facial features — related to steroids in drugs.

“I’ll have patients who say, Well, I skipped my medication for a day or two, and nothing happened so it’s OK for me to skip my medication, where, in fact, they may be very lucky nothing bad happened,’’ he said.

Economics also figure prominently into patients’ actions.

A study last year showed that a $5 increase in copayments for cholesterol-controlling statin drugs significantly reduced the likelihood prescriptions would be filled by veterans in Philadelphia. Still, that same study discovered that even when veterans were exempt from copayments, there was far from universal use of prescribed drugs.

An author of the study, Dr. Kevin Volpp, said that’s proof lowering copays isn’t enough.

Volpp experimented with using a lottery to enhance compliance. Patients prescribed a blood-thinner were given a monitoring device tethered to a phone line. When they opened pill compartments on the right schedule, they had a chance to win $3 to $100. The results were impressive: The usual rate of missed doses was 22 percent at the clinic the patients attended; that plummeted to 2 percent among those in the study.

At Geisinger Health System in Pennsylvania, patients who check out of the hospital with complicated drug regimes get visits from nurses who act like medical Sherpas, guiding them through rugged terrain.

And by this summer, Geisinger patients treated for serious heart conditions will leave the hospital with their prescriptions for drugs such as the blood-thinner Plavix already filled. A study last month showed that one in six patients whose gummed up arteries are surgically unclogged fail to get Plavix prescriptions filled expeditiously, doubling their risk of a heart attack or death.

“The health consequences are so enormous and the expenses are so enormous that we’re trying some of these innovative methods on clinical conditions with the greatest return of investment,’’ said Dr. Peter Berger, director of the Geisinger Center for Clinical Studies.

When Carole Connolley went to Geisinger for a ruptured appendix, doctors discovered she had type 2 diabetes. She was put on insulin as well as medications to tackle conditions that can exacerbate diabetes.

The effects of the drugs and the importance of taking them were explained in detail before she left the hospital. A nurse came to her home, three times a week at first. Now, Connolley, 71, takes four prescription or over-the-counter pills in the morning, four at night, and insulin. “They made me understand how important it was for me to behave myself,’’ she said.

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