Discordance Between Drug Adherence as Reported by Patients and Drug Importance as Assessed by Physicians

The purpose of this discussion is to analyze the study discussed in the paper titled: Discordance Between Drug adherence as Reported by Patients and Drug Importance by Stephanie Sidorkiewicz, MD; Viet-Thi Tran, MD, PhD; Cecile Cousyn, MD; Elodie Perrodeau MSc; Philippe Ravand, MD, PhD. The study compares patient and physician assessment of drug adherence and of drug importance; and it compares drug adherence reported by patients with drug importance as assessed by their physician. The overall goal of this study was to see if the viewpoint of physicians matches the viewpoint of their patients.

This study recruited 128 patients from 6 different sites who were receiving at least one prescription drug that was taken on a scheduled basis for at least 30 days from both hospital and clinic settings in France. Patients with cognitive impairment or language barriers, and patients who were receiving medication from a nurse or home care provider were excluded from this study. Patients were asked to assess their drug adherence through a self-report adherence instrument that was based off of 2 random questions obtained from a validated questionnaire. Patient perceived importance of their medications was assessed using the Adherence Estimator. The Adherence Estimator predicts nonadherance associated with beliefs about medicine. Finally patients were asked open ended questions about the reasons why they do not adhere to their medication regime. Each participant's physician was contacted and given an 11-step rating scale to assess their patient's adherence to their prescribed medications. Secondly, physicians were asked to rate the importance of each drug to their patient's health on a scale of 0 (not important) to 10 (very important).

For quantitative data, authors used interquartile ranges in order to exclude outliers from overall data. To analyze the qualitative data obtained from the response from the open-ended questions, nonadherance was defined as "a person's behavior fails to coincide with medical advice". The authors then subdivide nonadherance into two broad categories: "intentional nonadherance" or "unintentional nonadherance". "Intentional nonadherance" is defined as the patient willingly choosing not to take their prescribed medication whether it was because the patient did not think the medication was helping them or the patient did not like the side effects of the medication. "Unintentional nonadherance" is defined as patients accidentally forgetting to take their medication, or if the patient runs out of their medication. Unfortunately, the definition for adherence seems quite vague and the authors fail to consider other reasons why patients chose not to take their medication like financial reasons, and whether or not this would be defined as "intentional" or "unintentional".

Results show that the median age of patients studied was 59.8 years, 63% of participants were female, 90% of participants were in the outpatient setting, and on average patients were taking 3 medications. In this study, the average age of the physician recruited was 57.4 years, 75% were female, and 56% were general practioners. It is unclear if the authors tried to match the physician's results with their patients results or if the data is just a sum of all patients and all doctors that could be recruited.

Initial analysis takes a closer look at whether there is a correlation of patient and physician assessment of drug importance. There was a very weak correlation between patient and physician evaluation of drug importance. This weak correlation shows that what the patient thinks is important is not what the physician thinks is important and vice versa. Therefore it can be concluded that there is lack of patient-centered communication, and this discrepancy can be improved if discussion was encouraged between patient and physician. In addition, these results show that physicians or other healthcare professionals may need to take more time to educate patients about their health conditions in order to positively affect the overall health of their patients. Other results find that physicians rated 13% of the medication that patients were taking as less important for the patient's health although these drugs were prescribed. Many of these drugs labeled, as "less important" were medications used for psychiatry, which shows that many physicians in this study neglect to see the importance of mental health issues. In addition, a key limitation in this study is that the authors do not define what "important" means and leave the meaning up for interpretation. For instance, does important refer to the benefit the medication does to a patient's physical health or to their quality of life? For example, is it more important for a 90 year old patient to take 20 medications to decrease their mortality risk or should the patient be on less medications and enjoy their quality of life. These are important conversations doctors always need to have with their patients, and doctors always need to assess what matters most to the patient. Finally the other drugs that are listed as "not important" raises the issue of polypharmacy and if doctors are prescribing medications just to prescribe medications for a "quick fix".

In addition, the study examined both patient and physician assessment of drug adherence, and the correlation between these assessments was also weak. Many things can impact how a physician perceives their patients adhere to their medications. Unfortunately the article fails to analyze any of these factors.

Finally, the study compares patient reported drug adherence to physician assessed drug importance. Unfortunately, 20% of the medications that patient report poor adherence were assessed as important by their physician. This poor adherence included antihypertensive medications, platelet aggregation inhibitors, and other cardiac agents, oral blood glucose lowering drugs and insulin. These results show that patients do not understand the importance of their chronic disease, and how their chronic disease can impact their body. For instance, patients may not understand that their high blood pressure is consistently affecting their kidneys and peripheral vessels every second because they do feel the side effects until several years have passed. In addition, these patients may not realize that these antihypertensive medications are protecting their peripheral vessels and kidney from damage because they do not feel or sense or see the impact it is having on their body. These misunderstanding need to be addressed by healthcare professionals, and points to the importance of patient education.

Overall, this study shows that there is no correlation between patient and physician assessment of drug importance and drug adherence, and no correlation between patients reported drug adherence and physician assessed drug importance. This study shows that there is a lack of communication between the patient and doctor, and this issue needs to be addressed. To address this issue some barriers need to be discussed. The most important barrier is: time. Physicians are pushed to see patients in 15-minute appointments. Physicians already struggle to obtain a patient's history, perform a physical exam, and diagnose in fifteen minutes. Since it is unlikely for physicians to have more time with their patients due to their heavy patient load, this poses the importance of using midlevel providers to help in the process of educating patients about their diagnosis and the importance of their medications.

There are several limitations to this study. First of all the sample size was only limited to 128 patients and the physician response rate was only 33.5%. In addition, the patients in this study were not wholly representative of those on long-term drug therapy because they were recruited in only 6 different centers in France. The authors assume that 2 random parts of a whole validated questionnaire makes their 2-question instrument valid, but this is not the case. In addition, most data that is obtained through self-report has the potential to be biased. The study does not point out the differences in the sites or how much education the patients were receiving at each specific site. Though the average time the physician spent with their patients was given to the reader, there is no breakdown of how this time was spent with the patient. Finally 40% of the physicians in this study were trained before 1985, and this study does not account for any generational value differences.

In the end, the only way to lessen this discordance between patient adherence to medications and physician perceived importance is to use a multidisciplinary team to provide patient centered care. This patient centered care should focus on making the patient feel comfortable through positive body language and support from their doctor and midlevel providers, and it should allow patients to ask questions about their conditions and medications, and provide patients with the education they need to take control of their health.

Competing interests: None declared