Medication adherence is one of the more consequential and intractable obstacles facing health care. Not only does it drive up costs by reducing the efficacy of treatment, it can also cause substantial harm through misuse, overuse, or underuse.
We’ve known about problems with medication adherence—once referred to as compliance—for decades. Yet despite countless interventions, improvement has been slow. Today, more than a third of patients prescribed angiotensin receptor blockers for hypertension will have simply stopped taking them a year from now. Nearly three-quarters of those prescribed ß-blockers and thiazide diuretics will have done the same.
These treatment failures can have countless causes: patients not understanding instructions, incomplete instructions, lack of access to pharmacies, lack of money, or fear of side effects. Yet many promising interventions that address such hurdles have fallen flat. Even when their medications are fully covered by insurance, for instance, over 40 percent of patients are non-adherent.
So how do we improve medication adherence? Let's start with a simple truth: the decision to take a medication rests with the patient. Full stop. No matter what we think as health care providers, it is the patient who ultimately decides in the privacy of his or her home. In that vein, and with the help of several colleagues from Kaiser Permanente, we have begun focusing our attention on the less commonly studied factor of patient motivation. Our quest has led us to interview people in and outside of health care, and one example—Weight Watchers—struck us as particularly salient.
At Weight Watchers, a national weight loss program, one of the first things new clients do is participate in an interview to assess their motivations for losing weight. Do they want to lose weight for their daughter’s wedding? Do they want to look better when summer rolls around? Did they recently have a heart attack? Weight Watchers has found eliciting such motivations early on to be a critical step in fostering healthy behavior. As with taking medication such as anti-hypertensives, the rewards of weight loss behaviors come far in the future. In both cases, strongly linking action and motivation is key.
The lessons for medicine are clear. We should determine what motivates our patients. Do they plan to see their grandchildren grow up? Do they hope to be active into their later years? Or do they want to be around for a wedding in the future? Understanding and tapping into this motivation is, I believe, one of the more effective strategies to improve medication adherence. Taking medications for a chronic disease is a lifestyle change driven by the patient’s motivation.
Of course, the other barriers are important too. We should absolutely ask patients if they expect any problems in acquiring or taking the medication. And, yes, all of the reminders and pill boxes are helpful. But we must not forget that the decision to adhere rests in the hands of our patients. Medication adherence will only improve so far if patients perceive the act of adhering as a chore disconnected from their hopes and dreams. A pill box cannot overcome apathy. But if we as health care providers take this page from the Weight Watchers playbook, perhaps we can.