WBB's Thought Leadership

Nonadherence to Prescribed Medication an Out-of-Control Epidemic in the US

April 25

Lack of adherence is estimated to cause approximately 125,000 deaths and 10 percent of hospitalizations, and to cost American health care between $100 billion and $289 billion a year.


Excerpt: “20 percent to 30 percent of medication prescriptions are never filled, and approximately 50 percent of medications for chronic disease are not taken as prescribed,” according to a review in Annals of Internal Medicine. People who do take prescription medication — whether it’s for a simple infection or a life-threatening condition — typically take only about half the prescribed doses.”

“This partly explains why new drugs that perform spectacularly well in studies, when patients are monitored to be sure they follow doctors’ orders, fail to measure up once the drug hits the commercial market.”

Studies have shown that a third of kidney transplant patients don’t take their anti-rejection medications, 41 percent of heart attack patients don’t take their blood pressure medications, and half of children with asthma either don’t use their inhalers at all or use them inconsistently.”

“‘When people don’t take the medications prescribed for them, emergency department visits and hospitalizations increase and more people die,’ said Bruce Bender, co-director of the Center for Health Promotion at National Jewish Health in Denver. ‘Nonadherence is a huge problem, and there’s no one solution because there are many different reasons why it happens.”

“…’ the prescription may be too complicated, they get confused, they don’t have symptoms, they don’t like the side effects, they can’t pay for the drug, or they believe it’s a sign of weakness to need medication,” Dr. [William] Shrank [chief medical officer at the University of Pittsburgh Health Plan] said.”

“Cost is a major deterrent. ‘When the co-pay for a drug hits $50 or more, adherence really drops,” Dr. Bender said. Or when a drug is very expensive, like the biologics used to treat rheumatoid arthritis that cost $4,000 a month, patients are less likely to take them or they take less than the prescribed dosage, which renders them less effective.”

“Dr. Shrank said that when Aetna offered free medications to patients who survived a heart attack, adherence improved by 6 percent and there were 11 percent fewer heart attacks and strokes, compared with patients who paid for their medications and had an adherence rate of slightly better than 50 percent.”

Source: NY Times

WBB Take: A fundamental problem with the measurement of value in healthcare is that very often the metrics used are process measures rather than outcomes measures. Clinical workflows very seldom measure what is happening from point of view of the process customer, i.e. the patient. We may measure the number of encounters scheduled and completed, the number of procedures conducted, the number of prescriptions written, etc. We seldom measure the number of times a patient’s goals were achieved, the number of healthy days gained, the duration of illness, etc.

This fundamental problem can be seen in the lack of feedback loops from the patient back to the provider. Often from the provider point of view, a treatment plan recorded is a treatment plan executed, a prescription signed is a medication taken, and advice given is advice taken. Providers are well aware that there is a big gap between doctor’s orders and patients’ compliance, and providers generally lack a feedback loop that might alert them to deviation, or measurement that would show incomplete execution of a treatment plan.

While no complete solution currently exists, a significant improvement can be achieved by adopting health systems engineering approaches, and building verification and balancing checks into the clinical workflow. For example, having a care-coordinator or case manager follow up to check on patients and ask if the medication is being used and is performing as expected will not solve nonadherence, but it may reduce it significantly. Measuring adherence as a quality metric will not make a patient take their medications as prescribed, but it will highlight cases where there is nonadherence, and could help uncover the root causes. Allowing the patient to self-report adherence, barriers, and issues on the patient portal will not solve them, but it may allow timely corrective action that improves patient outcomes.

Kathy Kramer

Kathy Kramer



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