Rush Primary Care at Oak Park, located just outside Chicago, IL, is a three-physician primary care practice affiliated with Rush University Medical Center. The practice has a strong focus on preventing complications from chronic illnesses like diabetes and hypertension. Dr. Marie Brown, a physician with the group, has a particular interest in improving medication adherence among patients with chronic conditions. She has found the following three strategies to be especially effective.
First, Dr. Brown has found it is helpful to recognize the prevalence of nonadherence among her patients with type 2 diabetes, which may be as high as 50 percent. “Many of our patients with diabetes, or other chronic conditions such as hypertension, obesity, hyperlipidemia, and depression, are not taking their medications as prescribed. As physicians, we often incorrectly assume that patients adhere to all medication prescriptions and when their conditions are not improving, we add more medications.” She now routinely asks her patients multiple times—in a respectful and tactful manner—about their medication-taking behavior. “It takes several visits to establish a trusting relationship, so the patient knows I'm not going to blame or admonish him or her. Only when patients feel comfortable and respected, will they tell me how they're actually taking—or not taking—the drug.”
Next, recognizing that people are motivated more by immediate rewards than those in the distant future, Dr. Brown helps her patients identify the short-term benefits of taking medications as prescribed. “In the past, I would speak with my diabetic patients about preventing foot amputation or kidney dysfunction but those complications are too far away to motivate change.” Now Dr. Brown tells her patients with type 2 diabetes that if they take their medications as directed, they will potentially avoid such complications in the future but are also likely to experience more immediate benefits, such as:
Urinating less frequently
Having fewer sleep interruptions (due to fewer visits to the bathroom)
Having less fatigue from hyperglycemia
Losing weight (if insulin or sulfonylureas can be avoided)
Avoiding daily finger sticks to check blood glucose, if they are able to transition from insulin or a sulfonylurea to an agent that does not cause hypoglycemia (e.g., metformin)
Avoiding the weight gain and leg swelling associated with insulin, if they are able to take an oral agent consistently
Needing eyeglass prescriptions less frequently (visual acuity is more likely to remain stable)
Saving money (if they can use first-line drugs, which are less expensive)
Dr. Brown engages in these types of conversations with her patients using a two-step approach (see Box): providing information and providing specific instructions. First, she explains the purpose of the drug and the relationship between dosage and side effects. She stresses that the GI symptoms usually resolve within a week if the patient continues taking the medication as prescribed. Then Dr. Brown provides a specific plan for titrating the drug.
Step 1: Provide information:
Metformin can help you lose weight and lower your blood sugar. Metformin is derived from the French lilac bush and is very safe. One of the good things about metformin is that it will not make your sugar go too low. It is very inexpensive as well.
Some patients experience a mild upset stomach and diarrhea when they begin taking metformin. These symptoms usually go away within a few days as your body gets used to the medication. The stomach upset and diarrhea may return every time you increase the dose. These symptoms will go away within a few days if you keep taking the medication.
Step two: Provides specific instructions:
Take 1/2 of [the usual starting dose] once a day. Taking the pill with food can help reduce stomach symptoms and diarrhea.
After you have had no stomach symptoms or diarrhea for one week, start taking [the usual starting dose] once a day.
If you do miss doses, start again at the lower dose (Step 1) and wait until the stomach symptoms go away before increasing the dose (Step 2).
Dr. Brown reports that it can take three to six months for some patients to reach the full metformin dose, but with slow titration, many are able to tolerate the drug.
Encouraging and educating patients takes more time initially, but saves time in the long run because patients meet their treatment goals more easily and require escalating therapy less often. By supporting medication adherence in these ways, Dr. Brown and her colleagues have seen many positive outcomes among their patients.
Specifically, among patients with type 2 diabetes who are able to switch from second-line drugs to metformin, within six months they often experience:
Weight stabilization or weight loss
Fewer required medications
Improved well-being
Improved control of blood glucose levels
Fewer costs in terms of copays or out-of-pocket cost of medications
Having such conversations with patients also benefits the practice's clinicians and staff by reducing the time spent obtaining preauthorization for second-line drugs.
To learn more about medication adherence and how to implement it in your practice, view the STEPS forward module on this topic entitled Medication Adherence.