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The
New Health Care

People
Don’t Take Their Pills. Only One Thing Seems to Help.

High-tech
approaches and “reminder” packaging don’t work well. Reducing prices does.

By Austin
Frakt

Dec. 11,
2017

For
all that Americans spend on prescription drugs — $425 billion last year —
you’d think we’d actually take our medicine.

But
one of the frustrating truths about American health care is that half or more of
prescribed medication is never taken.

It’s
called medication nonadherence, and it’s a well-documented and longstanding problem, particularly
for patients with chronic conditions. The drugs they’re prescribed are intended
to prevent costly complications, reduce
hospitalization, even keep them alive. But even when the stakes are high,
many patients don’t take their meds.

Image

When
drugs cost less, patients are more likely to fill prescriptions and less likely
to skip doses and split pills.CreditPhoto
Illustration by Joe Raedle/Getty Images

This
seems like a problem we ought to be able to solve. It motivates high tech
approaches, like digital pills that can
automatically communicate to doctors that they’ve been taken.

Maybe
people forget to take their meds — about 60 percent of people say as
much — so we just need to remind them. Maybe people don’t understand the value
of what they’re prescribed, so we just need to educate them. Maybe drug regimens
are too complex, so we just need to simplify dosing.

All
these methods have been tried. It’s not so clear any of them work very well.

Only
one approach has repeatedly been shown to be
effective: reducing the cost of medications.

First,
let’s look at the research on the other methods. So-called reminder packaging
— pill packaging or containers that organize drugs by single dose or day of the
week — is a relatively simple idea intended to help people remember to take
their prescribed dose.

A systematic review by the
Cochrane Collaboration found that it was helpful in doing so, but only
modestly. Surveying 12 randomized controlled trials, the authors concluded that
reminder packaging increased the number of pills taken by patients by 11
percentage points. But they also found that most of the studies had significant
methodological flaws, casting doubt on the findings. Other systematic reviews of reminder packaging
studies also found problems with the research, like
small sample sizes and short follow-up periods.

Perhaps
reminder packaging is too passive, and patients need something like an alarm to
alert them when they’ve missed a dose. Electronic pill monitors can do that.
Some just remind patients to take their medication. More sophisticated ones
alert doctors when they don’t. In 2014, a team of researchers from the Brigham
and Women’s Hospital and Harvard
Medical School published
a systematic review of such devices in the Journal of the American Medical
Association. Here, too, the results are disappointing. Most studies of such
devices do not detect improvement in adherence.

A recent randomized trial not
included in these systematic reviews tested three dose reminder approaches for
people with a chronic health condition or depression: a
pill bottle with toggles for each day of the week that can be changed after
each daily dose; a pill bottle cap with a digital
timer displaying the time elapsed since the medication was last taken; and
a pill
organizer with a compartment for every day of the week. Over 50,000 subjects
were assigned randomly to one of these approaches or to none, as a control.

None
of the devices performed better than the control in getting patients to take
their medications. One possible explanation is that forgetfulness
may not be why patients don’t take their medications as prescribed. Drug
costs, a wish to avoid side effects, and a desire to be less reliant on drugs
are some of the other reasons patients don’t take them.

“It
is also possible that for reminder devices to be effective, they need to be
coupled with other adherence-improvement strategies,” said Niteesh Choudhry,
lead author of the study and a physician with Brigham and Women’s Hospital and
Harvard Medical School.

That’s
why augmenting electronic monitoring with other information or assistance
delivered to patients may be more successful, if more expensive. For example, one study found that the adherence
of hypertensive patients increased when
digital display containers were combined
with a blood pressure cuff and a card for recording blood pressure. This
suggests that when patients receive
feedback that signals how well they are controlling their
condition, they may be more willing to take their medication.

Still,
it isn’t hard to find studies that show that even with considerable support,
getting patients to take medications can be challenging. A Cochrane review examined
randomized controlled trials
of interventions — across many
dimensions — to increase medication adherence. Reminder packaging and alarms
were just some of the methods assessed, with approaches including patient and
family education about the value of medication, and mail or telephone
follow-up.

Of
the 182 randomized trials reviewed, four stood out as the most methodologically
sound. Among those, two increased adherence but two did not. Over all, the
authors concluded that there was a lack of convincing evidence that even complex
and costly interventions significantly increased patients’ compliance with drug
regimens.

“A
cure for nonadherence is nowhere to be seen,” they wrote. A more recent study not included
in the Cochrane review found that not even providing patients with
financial incentives and social support, along with pill bottles that signal
when a dose should be taken, was enough to boost adherence among heart attack
survivors.

So
why is price so important?

When
drugs cost them less, patients are more likely to fill prescriptions. Even if
people have already purchased drugs, they may skip doses — or split the pills —
because of concerns that they won’t be able to afford future refills. Free drugs
don’t get everyone to take them,
but many more do so than if they have to pay for them.

For
those with certain chronic conditions, extra
help in affording medications can reduce adverse events and
hospitalizations — a big increase in quality of life, as well as a potential
benefit to the wider health care system and the economy.

Lowering
prescription drug costs has been a longstanding pursuit for many politicians,
and Medicare Part D and the Affordable Care Act helped (although most Americans
still say costs are too high).
President Trump said drug companies “have been getting away with murder,” but
lower drug costs have not yet been a top priority of this White House.

Austin Frakt is director of the Partnered Evidence-Based Policy Resource
Center at the V.A. Boston Healthcare System; associate professor with Boston
University’s School of Public Health; and adjunct associate professor with the
Harvard T.H. Chan School of Public Health. He blogs at The
Incidental Economist, and you can follow him on Twitter. @afrakt

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