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The cost of noncompliance among patients with MI?
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Medication compliance results in improved clinical outcomes and reduced overall medical expenditures, according to a 2008 study published in the Journal of Managed Care Pharmacy. Cardiology Today asked four experts to offer their thoughts on the origins and implications of noncompliance in the MI patient population.
Cardiology Today: What are the most common forms of patient noncompliance with preventive and post-event treatments for MI?
Udho Thadani, MD, professor of medicine, University of Oklahoma: It depends on the condition one is treating. In my experience, noncompliance is greater in patients with high BP who have no symptoms from their high BP to start with. These patients often have to take multiple medications to control the elevated BP, and most of these medications are not devoid of side effects. With regards to patients with an MI and angina pectoris, compliance with medications is often high, as the patients fear having a heart attack. The major noncompliance issue in these patients is because of adverse effects from medications.
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Other noncompliance issues are not making appropriate lifestyle changes, such as smoking cessation, due to the lack of availability of time health care workers have for the prolonged sessions needed to discuss these issues with their patients. It is easier to advise the patients to eat fruits and vegetables, but many patients can’t afford these.
Peter F. Cohn, MD, chief of cardiology and professor of medicine, State University of New York at Stony Brook : The No. 1 problem is failure to stop smoking. This is a bit paradoxical because by being in a nonsmoking setting such as a hospital, patients have had to go “cold turkey” for several days at least. Thus, one would think that the physiological aspects of nicotine addiction would have been eliminated by the time of discharge. Yet, it is the “mental” rather than the physiological aspect of the craving for cigarettes that drives so many patients back to this noxious habit.
Whether or not patients stop their meds because of uncomfortable side effects or simply because they do not have an organized system for taking drugs is not clear. In my experience, less educated patients in lower socioeconomic groups are more likely to experience the latter and more educated ones the former.
Problems in paying for drugs also plague the system. Finally, once there are side effects, the better educated patient is more likely to call the doctor to change them, rather than simply not take them any longer. The latter patient is also more likely to follow a healthy diet and have access to fresh produce, etc., while the lower socioeconomic groups have less access and are also used to fast-food products. The importance of the fast-food culture cannot be overestimated in these patients, despite all public health messages to the contrary.
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Paul L. Douglass, MD, cardiologist, Metropolitan Atlanta Cardiology Consultants: Unaffordable medications and inadequate prescription benefits create the greatest barriers for compliance in my patient population. Also, a lack of access to healthy environments, which includes grocery stores with fresh fruits and vegetables, crime-free neighborhoods and recreational facilities, constitute additional reasons for noncompliance.
Nanette K. Wenger, MD, professor of medicine, Emory University: I think the other noncompliance issue is that the health care providers don’t emphasize the importance of [compliance], and don’t often offer patients the help they need to stay compliant. What happens with an intervention or an MI — very often these people were well beforehand, and they really don’t understand that, given the array of medicine they’re supposed to take, they are not supposed to pick and choose. For them to understand better, health care providers need to be more proactive in explaining to the patient what the various medications are for. For example, a beta-blocker will increase their chances of survival. Statins will reduce blood cholesterol, a risk factor. And that these medicines don’t interact. Beta-blockers and ACE inhibitors — these are “two-fers;” you get BP [benefit] and benefit for your heart. Those are really the basics. Remember some of these patients have bad hypertension or diabetes, and these get superimposed.
This needs to be explained very clearly to them, but the problem is that it’s done as the patient is walking out the door. Also, the discharge papers should describe what the medication is for — electronic medical records make that easier for patients to understand. Non-adherence causes readmissions, so we should make a priority out of this. Physicians telling patients more about what they can and can’t do now that they’ve had an MI is helpful. Go through all of the medications and tell them what they’re for, and tell them not to wait several weeks until the next appointment if they have questions. Doctors need to train patients how to be patients.
The other major issue is whether the patient can afford the medication. Someone has to be in charge enough to know whether or not they can afford it. This is a population where they often have vision and hearing problems; the health care provider has to know if the person is able to understand the directions.
Depression and denial is another reason patients don’t comply. They say to themselves, ‘I’ve had my stent or bypass, I don’t need to do anything.’ This is not going to stop — the doctors have to address this. Sometimes, this is real and might require a temporary treatment. Another problem is substance abuse in response to depression.
CT: Which form of noncompliance leads to the most economic cost, and for whom?
Dr. Thadani:Noncompliance has the most serious consequences for the patient, as it may result in serious nonreversible, adverse outcomes such as a stroke or a heart attack and unnecessary hospitalizations and emergency room visits. It also has economic costs for the health care system and the tax payers who often have to bear the cost of the care provided to these patients. The only time it does not cost the health care system or the tax payers is if the patient dies at home before visiting the emergency room.
Dr. Cohn: The economic cost of noncompliance is felt by the taxpayer because it results in more hospitalizations, especially for people who require public assistance. Since many of these people are seniors, Medicare costs also rise.
Dr. Douglass: All of the consequences of noncompliance place a heavy burden on our health care system. The result of noncompliance is poor health status of many patient populations, which leads to loss of productivity for our society and an increased cost burden that everyone in our society has to pay. There are no winners in this situation, only losers.
Dr. Wenger: Pretty soon, hospitals are going to be penalized for readmissions within 30 days, particularly with HF patients. There really needs to be some kind of format for transition of care — the most dangerous part, especially for seniors, is transition of care. It varies by facility. Often things get so hectic at flu season, for example, that a lot of discharges happen where the patients leave without medication.
CT: If patients are complying with medical treatment advice, the pharmacological costs probably increase; how is this offset by the savings of nonmedical therapies that become unnecessary when the patients are in compliance?
Dr. Thadani: For the compliant patient, pharmacologic costs may increase, but these are offset by reduced hospital emergency room visits and unnecessary hospitalizations. Non-drug treatments such as lifestyle modifications also should not be ignored and must remain relevant, even in compliant patients.
Dr. Cohn: Drug costs are offset by less hospitalization. Compliance pays.
Dr. Douglass: Disease prevention has not been scientifically proven to reduce cost; however, intuitively, a healthier population with a lower disease burden should result in significant cost savings financially and improvement in the quality of life.
Dr. Wenger: Controlling a disease is a cost-saving prevention. It might take months to years to realize these cost-savings because these medications are expensive, but the majority of these medications are generic.
CT: Does the prevalence of noncompliance affect the way physicians practice and prescribe? Does this potentially create an emotional or Hippocratic Oath crisis for the physician?
Dr. Thadani: Most physicians will document noncompliance in their notes but continue to prescribe the medications with the hope that the patient may become compliant. However, most physicians don’t spend a lot of time addressing this issue. Nurses and dieticians do a better job, as they spend more time with the patients. I do not believe that physicians often feel guilty for the noncompliance, unless their patients can’t afford the medications.
Dr. Cohn: We do tend to prescribe less expensive drugs to avoid compliance problems, and we do realize the limitations of “drastic” diet changes in less educated patients. I do not think it is an ethical crisis. For example, clopidogrel (Plavix, Sanofi-Aventis) is a very expensive drug, but it only need be prescribed for up to a year. Yet, many doctors prescribe it longer if they know their patients can afford it or have a drug plan that can.
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Dr. Douglass: Irrespective of the potential for compliance, I feel that most physicians give patients the very best advice that will improve clinical outcomes, including medication compliance and necessary lifestyle changes.
Dr. Wenger: It depends on your population. I see an enormously different population in an indigent care setting. If they have insurance, it’s limited. For many of them, it’s a choice of food and medicine. It’s different for people who have access to everything. The crisis will be among the seniors, where they have vision problems, or they have problems with cognition.
CT: Are there any programs that show promise for reversing noncompliance trends?
Dr. Thadani: Group sessions for smoking cessation are often useful, and the cost of the medication is not an issue in countries such as the United Kingdom and Canada, which provide universal health care. The use of generic-approved drugs can reduce the cost substantially. The cost of medications remains a major concern in the US and needs to be addressed.
Dr. Cohn: There was a study that UCLA did in the 1990s showing that intensive inpatient educational programs prior to discharge after an MI, followed up by nurses calling doctors and their patients afterward, yielded much better compliance statistics than was found in a control group just receiving standard discharge instructions.
Dr. Douglass: The current health reform efforts that we are debating have the potential for alleviating many of the barriers that contribute to poor compliance.
Dr. Wenger: We have a patient education program in our Atlanta public hospital, where I have been for over 40 years. We’re now using mostly computer-based learning specific to each patient. We do education programs in our waiting room, and then we have the nurses work with patients privately. We tailor the program to the patient. What you need to do is corral everyone and make it a team effort. Every facility has someone who can do a select amount of teaching and interviewing of the patient for information.
Many systems have people fill out questionnaires on the front end, but they don’t have that on the way out. We should all ask our patients questions, like ‘Do you think you’d have any problems with this?’ and then we should call and check on them. Or perhaps we should have a dedicated telephone line for them to call with their questions. They’re things that have to be done, but once a system is in place for doing it, each time it’s done, it takes relatively little effort.
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Mahoney J. J Manag Care Pharm. 2008;14 (6 Suppl B):3-8.
Disclosures: Drs. Alpert and Wenger report having received consulting fees/honoraria from Sanofi Aventis. Dr. Thadani reports having served on the speaker’s bureau for Eli Lilly and Daiichi Sankyo. Drs. Cohn and Douglass report no relevant financial discloures.
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