bs_bs_banner
doi: 10.1111/1753-0407.12306
Journal of Diabetes 7 (2015) 777–778
C O M M E N TA R Y
Poor medication adherence in diabetes: What’s the problem?
The exact numbers remain a point of some controversy (because the many different ways in which medication adherence is estimated often lead to widely varying results), but there is broad agreement that poor medication adherence (PMA) is a common occurrence among patients with diabetes.1 It has been well established that PMA is associated with poor clinical outcomes, including higher healthcare costs, more long-term complications, more hospitalizations, and elevated mortality rates.2 Indeed, although poor adherence to any of the recommended diabetes self-care behaviors may contribute to difficulties in achieving good outcomes, PMA may be the key reason why so many patients have not achieved the recommended metabolic goals.3 When we consider the reasons for PMA, it is tempting to presume that the critical contributor is the patient’s lack of knowledge or education, or that the patient is “in denial” of some sort, or that the patient is merely “noncompliant” (a vague and inexact tautological notion that explains nothing). But recent evidence points to more precise and understandable reasons for PMA, helping us to realize that our patients are responding rationally to the obstacles they face. In this issue of the Journal, for example, three articles highlight a number of these factors. In a large cross-sectional study of adults with type 2 diabetes (T2D) across four cities in China (n = 2538), Zhang et al.4 found that poor medication adherence (self-reported) was associated with “probable depression”, defined as Patient Health Questionnaire-9 (PHQ9) scores >10. Similar associations have been found in subject samples from many other countries around the world,5 although it may be that elevated scores on a common depression questionnaire like the PHQ9 are more likely to represent diabetes-related distress than clinical depression.6 Larkin et al.7 reported on 807 respondents to an Internet survey (90% with T2D) and found that commonly reported reasons for PMA were forgetfulness, concerns about side effects or that the medication could be harmful, and cost. Further data analysis suggested that being less engaged with one’s physician or other healthcare professionals was associated with PMA as well. This parallels several recent findings that medication adherence is better when patients report a sense of trust in their physician.8,9 Unfortunately, no validated measures were used in the Larkin
et al.7 study and the actual questions are not included, so one must be careful in generalizing from these results. Finally, Miller et al.10 examined poorly adherent nonelderly adults with diabetes in the Medical Expenditure Panel Survey and calculated the increased out-of-pocket cost that would be necessary for these patients to have sufficient medications. In this simulation, the authors concluded that 39.6% of the uninsured would need to spend ≥10% of their income on drugs. Probable depression, medication costs, patient beliefs. As we consider these and other key contributors to PMA in diabetes that have been identified over the past decade, I would suggest that there is one single underlying factor that unites and explains almost all of these: perceived worthwhileness. Patients are willing and able to follow prescribed medication regimens when they come to the conclusion, be it conscious or unconscious, that it is worth doing, when the perceived benefits outweigh the perceived negatives. It is, in other words, how they really think and feel about their medications that matter.11 And, unfortunately, in the realm of diabetes care, the perceived negatives of prescribed medications are typically more apparent, tangible and/or immediate (e.g. outof-pocket costs, inconvenience, perceived side effects) than the perceived benefits (e.g. the reduction in risk of long-term complications over an extended period of time). In addition, the mere act of taking medications can be perceived as negative: it may represent the “sick role” for many patients and be associated with shame and blame, especially when associated with a disease like T2D where there is already considerable blame, be it stated or unstated, that the disease is considered to be the patient’s fault due to “bad behavior”. Therefore, when the patient decides to reduce or quit a prescribed medication, this may actually be an effort to be, or be seen, as healthier. Finally, depression or high levels of diabetes distress may color the patient’s perception of diabetes and of their own future, causing them to conclude that efforts to actively manage their health (e.g. medication adherence) will be ultimately futile. In total, this suggests that PMA can be understood as a rational response to what the patient perceives his choices and circumstances to be. When patients are unconvinced that their medications will be helpful or are suspicious that they may be harmful, they are making the smartest choice they can
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
777
Commentary
make, given what they believe to be true. This means that patients who are not adhering to prescribed medication regimens are, in most cases, trying to make the healthiest choice they can. And this is very good news, because it means that we and our patients are, at a fundamental level, on the same side. Good news? This is good news because it opens up new avenues for intervention. To date, a wide range of interventions to address PMA have been tested, but recent meta-analyses indicate that results have been decidedly modest.12 New intervention approaches are needed. If we are in agreement with our patients that living a long and healthy life would be a good outcome, perhaps we can desist from arguing with them; instead, we could take the opportunity to ask questions and to understand and appreciate their perspective regarding the diabetes medications that have been prescribed. When we can have two-way conversations with our patients, sharing new facts about their medications, challenging old and incorrect beliefs, providing more convenient and less costly options when possible, addressing their worries and suspicions about what has been prescribed, clarifying the benefits, and providing an overall sense of trust and caring, perhaps the issues of PMA can be better understood and resolved.13 As Larkin et al.7 have argued, the physician can play a critical mediating role in reframing for patients how pluses and minuses of their prescribed medications can be better understood. Could it be worth a try? William H. Polonsky Behavioral Diabetes Institute, University of California, San Diego, California, USA Email: [email protected] References 1. Krass I, Schieback P, Dhippayom T. Adherence to diabetes medication: A systematic review. Diabet Med. 2014; 32: 725–37. doi:10.1111/dme.12651.
778
2. Egede LE, Gebregziabher M, Echols C, Lynch CP. Longitudinal effects of medication nonadherence on glycemic control. Ann Pharmacother. 2014; 48: 562–70. 3. Casagrande R, Fradkin JE, Saydah SH, Rust KF, Cowie C. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010. Diabetes Care. 2013; 36: 2271–9. 4. Zhang Y, Ting RZW, Yang W et al. Depression in Chinese patients with type 2 diabetes: Associations with hyperglycemia, hypoglycemia, and poor treatment adherence. J Diabetes. 2015; 7: 800–8. 5. Gonzalez JS, Peyrot M, McCarl LA et al. Depression and diabetes treatment nonadherence: A meta-analysis. Diabetes Care. 2008; 31: 2398–403. 6. Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: A call for greater clarity and precision. Diabet Med. 2014; 31: 764–72. 7. Larkin AT, Hoffman C, Stevens A, Douglas A, Bloomgarden Z. Determinants of adherence to diabetes treatment. J Diabetes. 2015; 7: 864–71. 8. Kerse N, Buetow S, Mainous AG 3rd, Young G, Coster G, Arroll B. Physician–patient relationship and medication compliance: A primary care investigation. Ann Fam Med. 2004; 2: 455–61. 9. Ratanawongsa N, Karter AJ, Parker MM et al. Communication and medication refill adherence: The Diabetes Study of Northern California. JAMA Intern Med. 2013; 173: 210–8. 10. Miller GE, Sarpong EM, Hill SC. Does increased adherence to medications change health care financial burdens for adults with diabetes? J Diabetes. 2015; 7: 872–80. 11. Horne R, Chapman SC, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherencerelated beliefs about medicines prescribed for long-term conditions: A meta-analytic review of the NecessityConcerns Framework. PLoS ONE. 2013; 8: e80633. doi:10.1371/journal.pone.0080633. 12. Sapkota S, Brien JA, Greenfield J, Aslani P. A systematic review of interventions addressing adherence to antidiabetic medications in patients with type 2 diabetes: Impact on adherence. PLoS ONE. 2015; 10: e0118296. 13. Rosenbaum L. Beyond belief: How people feel about taking medications for heart disease. N Engl J Med. 2015; 372: 183–7. doi:10.1056/NEJMms1409015.
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
doi: 10.1111/1753-0407.12306
Journal of Diabetes 7 (2015) 777–778
C O M M E N TA R Y
Poor medication adherence in diabetes: What’s the problem?
The exact numbers remain a point of some controversy (because the many different ways in which medication adherence is estimated often lead to widely varying results), but there is broad agreement that poor medication adherence (PMA) is a common occurrence among patients with diabetes.1 It has been well established that PMA is associated with poor clinical outcomes, including higher healthcare costs, more long-term complications, more hospitalizations, and elevated mortality rates.2 Indeed, although poor adherence to any of the recommended diabetes self-care behaviors may contribute to difficulties in achieving good outcomes, PMA may be the key reason why so many patients have not achieved the recommended metabolic goals.3 When we consider the reasons for PMA, it is tempting to presume that the critical contributor is the patient’s lack of knowledge or education, or that the patient is “in denial” of some sort, or that the patient is merely “noncompliant” (a vague and inexact tautological notion that explains nothing). But recent evidence points to more precise and understandable reasons for PMA, helping us to realize that our patients are responding rationally to the obstacles they face. In this issue of the Journal, for example, three articles highlight a number of these factors. In a large cross-sectional study of adults with type 2 diabetes (T2D) across four cities in China (n = 2538), Zhang et al.4 found that poor medication adherence (self-reported) was associated with “probable depression”, defined as Patient Health Questionnaire-9 (PHQ9) scores >10. Similar associations have been found in subject samples from many other countries around the world,5 although it may be that elevated scores on a common depression questionnaire like the PHQ9 are more likely to represent diabetes-related distress than clinical depression.6 Larkin et al.7 reported on 807 respondents to an Internet survey (90% with T2D) and found that commonly reported reasons for PMA were forgetfulness, concerns about side effects or that the medication could be harmful, and cost. Further data analysis suggested that being less engaged with one’s physician or other healthcare professionals was associated with PMA as well. This parallels several recent findings that medication adherence is better when patients report a sense of trust in their physician.8,9 Unfortunately, no validated measures were used in the Larkin
et al.7 study and the actual questions are not included, so one must be careful in generalizing from these results. Finally, Miller et al.10 examined poorly adherent nonelderly adults with diabetes in the Medical Expenditure Panel Survey and calculated the increased out-of-pocket cost that would be necessary for these patients to have sufficient medications. In this simulation, the authors concluded that 39.6% of the uninsured would need to spend ≥10% of their income on drugs. Probable depression, medication costs, patient beliefs. As we consider these and other key contributors to PMA in diabetes that have been identified over the past decade, I would suggest that there is one single underlying factor that unites and explains almost all of these: perceived worthwhileness. Patients are willing and able to follow prescribed medication regimens when they come to the conclusion, be it conscious or unconscious, that it is worth doing, when the perceived benefits outweigh the perceived negatives. It is, in other words, how they really think and feel about their medications that matter.11 And, unfortunately, in the realm of diabetes care, the perceived negatives of prescribed medications are typically more apparent, tangible and/or immediate (e.g. outof-pocket costs, inconvenience, perceived side effects) than the perceived benefits (e.g. the reduction in risk of long-term complications over an extended period of time). In addition, the mere act of taking medications can be perceived as negative: it may represent the “sick role” for many patients and be associated with shame and blame, especially when associated with a disease like T2D where there is already considerable blame, be it stated or unstated, that the disease is considered to be the patient’s fault due to “bad behavior”. Therefore, when the patient decides to reduce or quit a prescribed medication, this may actually be an effort to be, or be seen, as healthier. Finally, depression or high levels of diabetes distress may color the patient’s perception of diabetes and of their own future, causing them to conclude that efforts to actively manage their health (e.g. medication adherence) will be ultimately futile. In total, this suggests that PMA can be understood as a rational response to what the patient perceives his choices and circumstances to be. When patients are unconvinced that their medications will be helpful or are suspicious that they may be harmful, they are making the smartest choice they can
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
777
Commentary
make, given what they believe to be true. This means that patients who are not adhering to prescribed medication regimens are, in most cases, trying to make the healthiest choice they can. And this is very good news, because it means that we and our patients are, at a fundamental level, on the same side. Good news? This is good news because it opens up new avenues for intervention. To date, a wide range of interventions to address PMA have been tested, but recent meta-analyses indicate that results have been decidedly modest.12 New intervention approaches are needed. If we are in agreement with our patients that living a long and healthy life would be a good outcome, perhaps we can desist from arguing with them; instead, we could take the opportunity to ask questions and to understand and appreciate their perspective regarding the diabetes medications that have been prescribed. When we can have two-way conversations with our patients, sharing new facts about their medications, challenging old and incorrect beliefs, providing more convenient and less costly options when possible, addressing their worries and suspicions about what has been prescribed, clarifying the benefits, and providing an overall sense of trust and caring, perhaps the issues of PMA can be better understood and resolved.13 As Larkin et al.7 have argued, the physician can play a critical mediating role in reframing for patients how pluses and minuses of their prescribed medications can be better understood. Could it be worth a try? William H. Polonsky Behavioral Diabetes Institute, University of California, San Diego, California, USA Email: [email protected] References 1. Krass I, Schieback P, Dhippayom T. Adherence to diabetes medication: A systematic review. Diabet Med. 2014; 32: 725–37. doi:10.1111/dme.12651.
778
2. Egede LE, Gebregziabher M, Echols C, Lynch CP. Longitudinal effects of medication nonadherence on glycemic control. Ann Pharmacother. 2014; 48: 562–70. 3. Casagrande R, Fradkin JE, Saydah SH, Rust KF, Cowie C. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010. Diabetes Care. 2013; 36: 2271–9. 4. Zhang Y, Ting RZW, Yang W et al. Depression in Chinese patients with type 2 diabetes: Associations with hyperglycemia, hypoglycemia, and poor treatment adherence. J Diabetes. 2015; 7: 800–8. 5. Gonzalez JS, Peyrot M, McCarl LA et al. Depression and diabetes treatment nonadherence: A meta-analysis. Diabetes Care. 2008; 31: 2398–403. 6. Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: A call for greater clarity and precision. Diabet Med. 2014; 31: 764–72. 7. Larkin AT, Hoffman C, Stevens A, Douglas A, Bloomgarden Z. Determinants of adherence to diabetes treatment. J Diabetes. 2015; 7: 864–71. 8. Kerse N, Buetow S, Mainous AG 3rd, Young G, Coster G, Arroll B. Physician–patient relationship and medication compliance: A primary care investigation. Ann Fam Med. 2004; 2: 455–61. 9. Ratanawongsa N, Karter AJ, Parker MM et al. Communication and medication refill adherence: The Diabetes Study of Northern California. JAMA Intern Med. 2013; 173: 210–8. 10. Miller GE, Sarpong EM, Hill SC. Does increased adherence to medications change health care financial burdens for adults with diabetes? J Diabetes. 2015; 7: 872–80. 11. Horne R, Chapman SC, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherencerelated beliefs about medicines prescribed for long-term conditions: A meta-analytic review of the NecessityConcerns Framework. PLoS ONE. 2013; 8: e80633. doi:10.1371/journal.pone.0080633. 12. Sapkota S, Brien JA, Greenfield J, Aslani P. A systematic review of interventions addressing adherence to antidiabetic medications in patients with type 2 diabetes: Impact on adherence. PLoS ONE. 2015; 10: e0118296. 13. Rosenbaum L. Beyond belief: How people feel about taking medications for heart disease. N Engl J Med. 2015; 372: 183–7. doi:10.1056/NEJMms1409015.
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
