Why don't some patients take their medicines?

August 08, 2005

ANN ARBOR, Mich. -- Patients who trust their doctors are more likely to stick to their prescription medicines, even if they face high out-of-pocket costs, a new study finds. But patients who have lower levels of trust in their physicians, or who have depression-like symptoms, are much more likely to skip doses or refills when costs become a problem for them.

Those findings, from a new study of 912 patients with diabetes, provide evidence that the quality of the doctor-patient relationship can greatly affect patients' medication use when drug costs become a burden. The study reinforces the importance of the doctor-patient relationship in helping patients adhere to medicines, and has implications for how doctors talk with patients -- not only about what a medicine will do for them, but also about their ability to pay for it and the availability of lower-cost options.

The research, from a team at the VA Ann Arbor Healthcare Center and the University of Michigan, will be published in the August 8/22 issue of the Archives of Internal Medicine. The data are from a larger VA-funded study of diabetes care at five health care systems around the nation.

Most of the patients in the study were men, half of them were over the age of 65, and the majority had household incomes under $25,000 a year. All patients were enrolled in the VA's relatively generous prescription drug program, but a significant number reported cost-related problems in adhering to their medications.

The authors say the results provide insights into how cost, trust, mental health and income interact to influence patient behaviors toward prescription medications.

In all, nearly 30 percent of people who reported low levels of trust in their doctors and had monthly drug costs over $100 said they skipped medicines due to cost, compared with 11 percent of those who had a more trusting relationship with their doctor and the same level of cost. Among people with incomes under $10,000, cost affected adherence to drugs only among those with low physician trust.

Patients who reported experiencing symptoms of depression on a standardized scale were twice as likely to skip medicines due to cost as patients without depression. And patients who reported problems taking medications for other reasons were much more likely to report that they had cut back on medicine use due to cost.

"Our findings suggest that a trusting patient-physician relationship can significantly influence whether a person sticks to prescriptions when that patient faces pressures from their medication costs," says lead author John Piette, Ph.D.

Piette is a member of the VA Ann Arbor Center for Practice Management and Outcomes Research and associate professor in the general medicine division of the U-M Medical School.

Research has shown that skipping medications due to cost can seriously affect a person's health. That's especially true for people with chronic diseases, Piette says. The patients in the current study had diabetes, and 41 percent of them used insulin. People with diabetes who fail to take their medication as prescribed may have poor blood sugar control and a higher risk of heart attacks, strokes, blindness, kidney failure and amputation.

Piette notes that many patients who cut back on medication use due to cost do not tell their doctors. Last September, the VA/U-M team published findings in Archives of Internal Medicine showing that two-thirds of a nationwide sample of chronically ill patients who had cut back on their prescription drugs because of cost didn't tell their doctors before they did it. And even after they had started skimping, 35 percent never told.

Despite the important role of medication costs in influencing patients' adherence, Piette and colleagues note that most patients continue taking their medication as prescribed despite financial pressures, suggesting that there may be other influences at work for patients who respond to these costs with medication under-use.

"We need to understand better how chronically ill patients cope with their drug costs," he says. "We know that cost alone makes a big difference to people, but it's not the only factor. The quality of patients' relationships with their physician also appears to be key. The influence of depression is also important, as is a range of non-cost-related barriers to adherence."

Depression especially may lead people to feel fatalistic about their disease, overwhelmed by medication costs, and more likely to cut back on drug use as a result, Piette says.

In the VA study, depressive symptoms were common: nearly half of the low-trust group had depressive symptoms, compared with 35 percent of those reporting more physician trust. Even after controlling for other factors such as patients' income and actual drug payments, depressed patients had twice the risk of cutting back on their pharmacotherapy due to cost. Identifying these patients and treating their depression may be an important component of an overall plan to support their medication use despite the burden of drug costs.

Piette says the message of this research for doctors is for them to recognize the multiple benefits from actively reaching out to establish trust with their patients, striving to form a strong therapeutic bond, and asking patients directly how drug costs are affecting them.

For patients, he says, "It's important to be open and honest with your doctor regarding worries about how you're going to pay for your medicines, as well as other things such as side effects and lifestyle issues that might keep you from taking your medications, and any depression-like symptoms such as prolonged sadness or sleep and appetite changes."

There may be opportunities for patients to lower their drug costs if they get their doctor involved, he explains, and patients may not appreciate the negative consequences of cutting back on drug use unless they discuss this with their doctors.
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In addition to Piette, the new paper's authors are senior author, VA research scientist and U-M associate professor of internal medicine Eve Kerr, M.D., M.P.H., VA research scientist and U-M assistant professor of internal medicine Michele Heisler, M.D., M.P.A., and Sarah Krein, Ph.D., RN, internal medicine research investigator.

Reference: Archives of Internal Medicine, Vol 165, Aug. 8/22, 2005

University of Michigan Health System

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