Treating nonadherence as a medical condition

Medication nonadherence remains a pesky impediment to quality care. In a viewpoint in the May 22 issue of the Journal of the American Medical Association, researchers encouraged physicians to approach nonadherence not as a problem but rather as a medical condition that they can diagnose and treat.

Zachary A. Marcum, PharmD, Mary Ann Sevick, ScD, and Steven M. Handler, MD, PhD, all of the University of Pittsburgh School of Medicine, plotted out the methodical steps a physician would take when treating a medical condition and applied them to medication nonadherence.

First, screen. Marcum et al acknowledge that most physicians are not trained to screen, diagnose and treat medication nonadherence. Screening starts by asking the patient if he or she has any problems taking the medication—and not stopping there. “When no further questions are asked, potentially addressable medication issues are left unattended.”

Next identify the underlying behaviors for nonadherence. They list six:

  • The patient doesn’t understand the relevance and health consequences;
  • The patient believes the costs outweigh the benefits;
  • The patient can’t comprehend;
  • The patient is not vigilant;
  • There is a conflict with the patient’s belief systems; and
  • The patient doesn’t perceive the medication to be therapeutic.

Each of these will require an appropriate diagnostic tool and treatment. “[W]ithout a correct diagnosis made for the specific medication nonadherence phenotype, no significant benefit will be achieved; even worse, patient harm can occur and resources can be unnecessarily wasted,” they cautioned.

They offered several instruments and methods for measuring internal barriers, such as an adherence estimator and questionnaires. They proposed that measures of medication adherence should be implemented in EHRs and accessible for physicians and insurers to share, use to study trends over time and establish quality improvement benchmarks.

The measures should include information in keeping with a patient-centered approach to healthcare, with the goal of aligning barriers with proven treatments such as educational or targeted interventions.

They pointed to the Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System as an incentive for adding medication adherence to measures. To attain a five-star rank, health plans will need to have more than 75 percent of covered beneficiaries at least 80 percent adherent on prescribed statin, hypoglycemic and hypertensive medications.

“This represents another critical reason to better understand how to best identify medication nonadherence and intervene appropriately in order to address these increasingly important health policy issues,” they argued.