Help patients (and parents) change their behavior by speaking clearly, using data, and remaining nonjudgmental.
It’s a tale as old as time: A patient receives a prescription for a chronic condition such as asthma, and at a later date, the patient reluctantly admits that they have only been taking it 25% of the time. Medication nonadherence is an issue around which many health care providers can share frustrating anecdotes.
During a session at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Heather De Keyser, MD, MS, assistant professor of pediatrics–pulmonology medicine at the University of Colorado School of Medicine and Children’s Hospital Colorado in Aurora, discussed the impact and scope of nonadherence, reasons for nonadherence, and ways to improve adherence.
Nonadherence to medication is a frustrating problem, with the worldwide average adherence for chronic diseases at approximately 50%, according to De Keyser. She noted that nonadherence is costly, citing one study of 43,156 children with asthma on Medicaid that found if adherence to inhaled steroids rose from the 33.35% seen in the participants to just 40%, $8 million per year in cost savings would result; increasing adherence to 80% would save $57 million per year.
Even in patients with serious medical issues, De Keyser said that adherence can be low, with 58% nonadherence in the 6 months following newly diagnosed epilepsy and 30% to 76% nonadherence in patients with solid organ transplant—with the poorest adherence in adolescent patients.
A variety of factors can influence medication adherence, including poor access to care, poor provider knowledge of the formulary, patient/provider relationships, social determinants of health, stigma, medical beliefs that lead to intentional nonadherence, forgetfulness, poor technique, and medication administration responsibility.
De Keyser noted that primary nonadherence—not getting the prescription filled—is only 14% to 20% and 24% to 40% for subsequent fills; secondary nonadherence, or prescription being filled but not used, is 30% to 70%. Whether due to poor device technique, true adherence with asthma medication is likely very low.
Ask a provider why patients don’t take their medications, and many will answer that patients would “if only they knew how important it was.” However, De Keyser emphasized that the reasons behind nonadherence are complex and can range from a prescription not being filled because it requires frequent refills to parents being unsure of the proper dose to the child or parent simply forgetting the dose.
She also shared a study that looked at HIV medication adherence. Barriers related to habit were far more commonly reported by children and parents than barriers tied to education. Habit is indeed a strong driver of an action, thanks to the loop of cue, routine, and reward, said De Keyser.
She explained that the habit loop was used to improve oral care when a toothpaste company, wanting to sell more product, encouraged people via an ad to run their tongue along their teeth and whether they felt a film to brush their teeth—which resulted in the reward of no more film. To improve adherence, De Keyser recommended asking all patients on chronic medications about adherence and verifying their understanding with objective data, particularly when the condition is not well controlled.
When talking with patients and parents, she advised that providers speak clearly, use data, and be nonjudgmental. Even health care providers don’t always adhere to habits related to good health, she noted, adding that mentioning your own lack of flossing, for example, can help put patients at ease and let them know they’re not alone.
This article originally appeared in Contemporary Pediatrics®.