The challenge of patient adherence

Leslie R Martin, Summer L Williams, Kelly B Haskard, and M Robin DiMatteo
Ther Clin Risk Manag. 2005 September; 1(3): 189–199. Published online 2005 September

• "The risk of nonadherence is reduced when patients know their doctors well."
• "Patients' trust in their physicians is essential to their emotional disclosure and is therefore a crucial component to the patient-physician relationship."
• "Trusting relationships between physicians and patients can greatly affect patient outcomes."
• "Adherence rates have been found to be nearly 3 times higher in primary care relationships characterized by very high levels of trust."
• "Non-adherence carries a huge economic burden. $300B in medical costs, annual US deaths 125,000. 50-70% of patients are non-adherent."
• "Patients’ trust in their physician has been found to far exceed many other variables when it comes to promoting patients’ satisfaction with their care."

The Role of Patient-Physician Trust in Moderating Medication Nonadherence Due to Cost Pressures

John D. Piette, PhD; Michele Heisler, MD, MPA; Sarah Krein, PhD, RN; Eve A. Kerr, MD, MPH
Arch Intern Med. Vol 165, Aug 2005 American Medical Association

• "A trusting physician relationship may moderate the impact of cost pressures on patients’ medication adherence."
• "Patients' level of trust in their physician may be especially important in shaping their medication adherence decisions in the face of high out of pocket medication costs."
• "Physician trust has been found to be even more important than treatment satisfaction in predicting subsequent adherence to recommendations and overall satisfaction with care."
• "Physician trust also correlates positively with acceptance of new medications, intentions to follow physicians’ advice, perceived effectiveness of care and improvements in self-reported health status"
• "When trust levels are low there is a significantly increased rate of cost-related underuse of medication."
• "Physicians' efforts to enhance patients’ trust may contribute to decreased rates of cost-related medication underuse even when patients’ prescription drug benefits or medication regimens cannot be changed"
• "Physicians' efforts to enhance patients’ trust may contribute to decreased rates of cost-related medication underuse even when patients’ prescription drug benefits or medication regimens cannot be changed"
• "11% of patients with high levels of physician trust underused their expensive medications vs. 29.6% of patients with low levels of physician trust. "

Strong Healthcare Provider-Patient Relationship Improves Patient Adherence and Lowers Healthcare Costs: A Meta-Analysis.

Kevin Cheung, PharmD, Jacob Hicks, PharmD Brian McEwen, and Gregory Cianfarani, RPh 2012

• "Strengthening the patient-provider relationship may result in improved adherence, which can ultimately reduce healthcare dollar spending."
• "Patients who express greater trust tend to enjoy a stronger relationship with their healthcare providers. Consequently, patients are more likely to be adherent to medication regimens and medical advice."
• "Medication adherence, in turn, leads to elevated prescription drug costs, but the lower non-drug healthcare expenditure yields a net savings in terms of dollars spent on healthcare."

The importance of the patient-clinician relationship in adherence to antiretroviral medication

2007 International Journal of Nursing Practice

• "The notion that better patient-clinician relationship results to higher adherence rates with recommended medication is widely accepted."
• "A trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect."
• "Our findings support this definition, as key broad themes behind adherence were trust, respect and communication"
• "The level of trust placed in the nurse was a key predictor of the patient adherence behaviour"
• "Trust and respect in the patient-clinician relationship might be the vehicle for enhancing communication and facilitating the development of that relationship"

Patient trust in physicians and adoption of lifestyle behaviors to control high blood pressure

Patient Education and Counseling 2012 Johns Hopkins University

• "Trust in one's physician predicts attempts to lost weight among patients with hypertension and may contribute attempts to reduce salt and increase exercise"
• "Strengthening patient-physician relationships through efforts to enhance trust may be a promising strategy to enhance patients' engagement in healthy lifestyle behaviors for hypertension"
• "Trust is at the core of building an effective patient-pysician relationship."
• "Within the last decade trust has been used as a way to assess patient-physician relationships"
• "Trust in one's physician has been linked to improvements in many factors, including patient-physician communication, satisfaction with healthcare, adherence to medical treatments, utilization of health services, continuity of care, self-rated health and blood pressure control."
• "The finding that patients' trust in the their physicians was significantly associated with attempts to lose weight has not previously been reported."
• "The results of this study newly identify the importance of patient trust in physicians as a predictor of adherence to recommended lifestyle modifications for hypertension control; they also substantiate the results of previous work that demonstrates the important role of trust in enhancing patient outcomes."

The patient-physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation

Journal of Behavioral Medicine 2011

• "Patient-physician relationship (satisfaction with care, trust in physician, patient participation) have a significant association with outcomes."
• "Results show that the patient-physician relationship is significantly associated with the outcome."

Linking primary care performance to outcomes of care.

Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR.
J Fam Pract. 1998 Sep;47(3):213-20.

• "Physicians' comprehensive ("whole person") knowledge of patients and patients' trust in their physician were the variables most strongly associated with adherence, and trust was the variable most strongly associated with patients' satisfaction with their physician."
• "Patients' trust in their physician and physicians' knowledge of patients are leading correlates of three important outcomes of care."

American Medical News, October 2012

Jake Harwood, professor in the Dept. of Communication at the University of Arizona in Tucson

• "A patient emerging with full information and with a sense of trust in their physician could make the difference between life or death."

Stephen Covey, Communication & Leadership Guru

• "When trust is low it places a hidden tax on every transaction: every communication, every interaction, every strategy, every decision is taxed, bringing speed down and sending costs up."

C. Everett Koop, MD

• "Drugs don't work in patients who don't take them"

Cost of Medication Nonadherence Associated With Diabetes, Hypertension, and Dyslipidemia

Kamyar Nasseh, PhD; Sharon Glave Frazee, PhD, MPH; Jay Visaria, PhD, MPH; Anna Vlahiotis, MA; and Yuhong Tian, PhD
American Journal of Pharmacy Benefits 2012 Vol. 4,No. 2

• "The direct national cost of nonadherence for adults diagnosed with diabetes, hypertension, or dyslipidemia was $105.8 billion or an average of $453 per adult in 2010"
• "There are additional indirect costs associated with lost days at work and diminished productivity as a result of nonadherence."

Oral Antihyperglycemic Medication Nonadherence and Subsequent Hospitalization Among Individuals With Type 2 Diabetes

Lau DT, Nau DP
Diabetes Care 2004 Sep;27(9):2149-53.

• "Patients with type 2who do not obtain at least 80% of their oral antihyperglycemic medications across 1 year are at a higher risk of hospitalization in the following year."
• "For each 10% increase in adherence to oral diabetes medications, HBA1C droppend by 0.16%"
• "A significant relationship was found between antihyperglycemic medication nonadherence and subsequent hospitalization."

The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review

N Muszbek, D Brixner, A Benedict, A Keskinaslan, and Z M Khan
International Journal of Clinical Practice 2008 February 1; 62(2): 338–351.

• "Increased compliance/persistence leads to increased drug costs, but these are offset by reduced non-drug costs, leading to overall cost savings."
• "Noncompliance appears to have a significant effect on the costs of treatment. High compliance and persistence lead to an increase in drug costs while low compliance/persistence is associated with increased medical events and hence more physician visits and hospital admissions, and longer hospital stays."

Does medication adherence lower Medicare spending among beneficiaries with diabetes?

Health Serv Res. 2011 Aug;46(4):1180-99. doi: 10.1111/j.1475-6773.2011.01250.x. Epub 2011 Mar 17. Stuart B, Davidoff A, Lopert R, Shaffer T, Samantha Shoemaker J, Lloyd J.
Epidemiology and Public Health, School of Medicine, University of Maryland-Baltimore and Baltimore County, 660 W. Redwood St., Baltimore, MD 21201, USA.

• "A 10 percentage point increase in MPR for RAAS-Is was associated with U.S.$285 lower Medicare costs(SE=114; p<.05)."
• "Higher adherence with RAAS-Is and statins by Medicare beneficiaries with diabetes results in lower cumulative Medicare spending over 3 years."

Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost

Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS.
Department of Medical Affairs, Medco Health Solutions, Inc., Franklin Lakes, New Jersey 07417, USA.
Medical Care 2005 Jun;43(6):521-30.

• "For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs."
• "Patients who maintained 80% to 100% medication adherence were significantly less likely to be hospitalized compared with patients with lower levels of adherence."
• "For diabetes and hypercholesterolemia, high levels of medication adherence are generally associated with a net economic benefit in disease-related costs."
• "Medication adherence is associated with net savings in all-cause healthcare costs for diabetes, hypertension, and hpyercholesterolemia."

Diabetes: Healthcare Costs at Varying Levels of Medication Adherence:

Adherence %	N	Medical Cost	Drug Cost	Total Cost	Hosp Risk
1-19	182	8812	55	8867	30%
20-39	259	6959	165	7124	26%
40-59	419	6237	285	6522	25%
60-79	599	5887	404	6291	20%
80-100	1801	3808	763	4570	13%

GMS Psycho-Social-Medicine 2012, Vol. 9

• "A lack of trust can have negative consequences on the physician-patient interaction and on the further treatment and outcome of the patient, resulting in low adherence to treatment or low patient reported outcomes."

JABFM Oct 2006 Vol. 19

• "Adherence may be improved by remedying patient dissatisfaction and lack of confidence in their physicians."
• "Trust and confidence in one’s physician improves medication adherence"
• "Confidence in one’s physician was found to be associated with adherence, consistent with recent work on trust, patient-physician agreement, and medication adherence"