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The Incidence and Determinants of Primary Nonadherence With Prescribed Medication in Primary Care: A Cohort StudyPrimary Nonadherence With Prescribed Medication in Primary Care

Robyn Tamblyn, PhD; Tewodros Eguale, MD, PhD; Allen Huang, MD; Nancy Winslade, PharmD; and Pamela Doran, MSc
[+] Article, Author, and Disclosure Information

From the Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, and University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada.

Acknowledgment: The authors thank Dr. Jim Hanley for his thoughtful suggestions about the statistical analysis and its interpretation and Sherry Shi for her assistance in data analysis.

Grant Support: Dr. Eguale was supported by the Canadian Institutes of Health Research Fellowship.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1705.

Reproducible Research Statement: Study protocol and data set: Available from Dr. Tamblyn (e-mail, robyn.tamblyn@mcgill.ca). Statistical code: Not available.

Requests for Single Reprints: Robyn Tamblyn, PhD, McGill University, Morrice House, 1140 Pine Avenue West, Montreal, Quebec H3A 1A3, Canada; e-mail, robyn.tamblyn@mcgill.ca.

Current Author Addresses: Drs. Tamblyn, Eguale, and Huang; Ms. Winslade; and Ms. Doran: McGill University, Morrice House, 1140 Pine Avenue West, Montreal, Quebec H3A 1A3, Canada.

Author Contributions: Conception and design: R. Tamblyn, T. Eguale, A. Huang, N. Winslade.

Analysis and interpretation of the data: R. Tamblyn, T. Eguale, N. Winslade.

Drafting of the article: R. Tamblyn, T. Eguale, P. Doran.

Critical revision of the article for important intellectual content: R. Tamblyn, T. Eguale, A. Huang, P. Doran.

Final approval of the article: R. Tamblyn, T. Eguale, A. Huang, N. Winslade, P. Doran.

Provision of study materials or patients: R. Tamblyn.

Statistical expertise: R. Tamblyn, T. Eguale.

Obtaining of funding: R. Tamblyn.

Administrative, technical, or logistic support: R. Tamblyn, P. Doran.

Collection and assembly of data: R. Tamblyn, T. Eguale, A. Huang.

Ann Intern Med. 2014;160(7):441-450. doi:10.7326/M13-1705
Text Size: A A A

Background: Primary nonadherence is probably an important contributor to suboptimal disease management, but methodological challenges have limited investigation of it.

Objective: To estimate the incidence of primary nonadherence in primary care and the drug, patient, and physician characteristics that are associated with nonadherence.

Design: A prospective cohort of patients and all their incident prescriptions from primary care electronic health records between 2006 and 2009 linked to provincial drug insurer data on all drugs dispensed from community-based pharmacies were assembled.

Setting: Quebec, Canada.

Patients: 15 961 patients in a primary care network of 131 physicians.

Measurements: Primary nonadherence was defined as not filling an incident prescription within 9 months. Multivariate alternating logistic regression was used to estimate predictors of nonadherence and account for patient and physician clustering.

Results: Overall, 31.3% of the 37 506 incident prescriptions written for the 15 961 patients were not filled. Drugs in the upper quartile of cost were least likely to be filled (odds ratio [OR], 1.11 [95% CI, 1.07 to 1.17]), as were skin agents, gastrointestinal drugs, and autonomic drugs, compared with anti-infectives. Reduced odds of nonadherence were associated with increasing patient age (OR per 10 years, 0.89 [CI, 0.85 to 0.92]), elimination of prescription copayments for low-income groups (OR, 0.37 [CI, 0.32 to 0.41]), and a greater proportion of all physician visits with the prescribing physician (OR per 0.5 increase, 0.77 [CI, 0.70 to 0.85]).

Limitation: Patients' rationale for choosing not to fill their prescriptions could not be measured.

Conclusion: Primary nonadherence is common and may be reduced by lower drug costs and copayments, as well as increased follow-up care with prescribing physicians for patients with chronic conditions.

Primary Funding Source: Canadian Institutes of Health Research.





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Physicians Can Help Patients With Cost-Related Medication Nonadherence
Posted on April 8, 2014
Christopher Moriates MD, Neel Shah MD MPP, Vineet Arora MD MAPP
University of California San Francisco and Costs of Care Inc., Harvard Medical School and Costs of Care Inc., University of Chicago and Costs of Care Inc.
Conflict of Interest: All three authors are members of the non-profit organization Costs of Care Inc, and have received grant funding for the Teaching Value Project from the ABIM Foundation.
As recently highlighted by Tamblyn et al.,(1) the out-of-pocket costs of medications have led many patients to forgo recommended treatments. Nearly one out of every three new prescriptions are not filled by patients, providing further evidence to support the expansive scope of this problem.(1) The authors appropriately call for policy initiatives, such as copayment waivers for medications needed for chronic conditions. While these strategies are important, clinicians must not wait for these policies to be put in place prior to helping patients navigate cost-related non-adherence.

Teaching clinicians to address patients concerns about their out-of-pocket-drug costs is vital to improving their health and wellbeing. Although the majority of patients report a desire to talk to their providers about out-of-pocket drug costs, only 15% of patients say they have ever done so, and only 16% believe that their physician was aware of the magnitude of their out-of-pocket costs.(2) Moreover, patients who are not asked by their providers about the problem of medication costs have a more global, negative perception regarding their clinicians’ overall interest and potential ability to assist them.(3) Lastly, physician discussion of drug costs with patients is strongly associated with switching to a medication that costs less.(4)

If clinicians strive to provide truly “patient-centered care,” then they must no longer ignore a problem that is central to patient experience and their health. In our teaching, we recommend three specific questions to ask patients while taking a medication history to detect cost-related non-adherence: 1) Do your medications cost too much? 2) Have you ever cut back on medications because of cost? 3) Have you ever cut back on other things (e.g. food, leisure) due to high drug costs?(5) By taking a proactive approach to identify patients who will have problems paying for their medications, clinicians can initiate a conversation with patients about strategies to reduce out-of-pocket costs, including potential alternatives such as generic drugs or therapeutic alternatives.

Making such screening routine, much like is done with preferences for advanced directives, could help alleviate the patient or physician discomfort with this topic. The American College of Physicians’ High-Value Care curriculum (available at www.highvaluecarecurriculum.org) and the Costs of Care Teaching Value Project (available at www.teachingvalue.org) offer free teaching modules for clinicians to provide strategies for addressing patients’ medication costs. It is time that we at least start talking about medication costs with our patients.

1. Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. The Incidence and Determinants of Primary Nonadherence With Prescribed Medication in Primary CareA Cohort StudyPrimary Nonadherence With Prescribed Medication in Primary Care. Ann Intern Med. 2014;160(7):441-450.
2. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA. 2003;290(7):953-958.
3. Piette JD HM. Cost-related medication underuse: Do patients with chronic illnesses tell their doctors? Arch Intern Med. 2004;164(16):1749-1755.
4. Wilson IB, Schoen C, Neuman P, et al. Physician-Patient Communication About Prescription Medication Nonadherence: A 50-state Study of America’s Seniors. J Gen Intern Med. 2007;22(1):6-12.
5. Arora V, Kumar R, Levy A, Saathoff M, Farnan J, Shah N. GOT MeDS: Designing and Piloting an Interactive Module for Trainees on Reducing Drug Costs. J Gen Intern Med. 2013;28 Suppl 1:S464-465.
Physician-Patient Alliance
Posted on April 30, 2014
David M. Mitchell, MD, PhD
Akron General Medical Center, Akron, OH
Conflict of Interest: None Declared
The authors have appropriately noted the significant limitations of the study, particularly the inability to define the patient-specific and physician-specific factors involved in primary non-adherence. As noted, these factors are much more difficult to study. In that sense, the study is "looking where the light is" and potentially missing major factors involved in primary non-adherence.

In my opinion, the data presented indirectly highlights one thing: the prevalence of an ineffective physician-patient alliance (i.e. lack of two-way communication, adequate patient education, "primary" resolution of concerns, etc.). Assuming that care decisions (such as a new medication) are made with respect to the principle of patient autonomy (thus, a shared decision), the rate of primary non-adherence strongly suggests that patients, at the time of prescribing, are either not aware of their concerns (cost, side effects, etc.), or are simply not able to raise these concerns directly to their physician, due to fear or time constraints of a clinic visit.
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