The Last Mile Problem in Health

We have a critical last-mile problem in the healthcare industry: getting from a doctor's prescription to a patient regularly taking her medication. The "last-mile problem" usually refers to the challenge of laying the final stretch of wire or cable to each individual home when providing telephone or internet service. Healthcare has its own last-mile problem that is approximately the distance from the medicine cabinet to the patient's mouth. And the fundamental cause is inadequate patient-physician communication.

This doesn't seem like a complex problem, but the numbers are astounding: about 50% of medications are taken as prescribed. That's right: the simple, sad math is that about half of patients don't succeed in taking their medications as prescribed. Given that medications are generally key treatments for our deadliest conditions such as diabetes, heart disease, and asthma; and given that half the time the medication is not making it from the prescription pad to the patient's mouth, you would expect that we would be working very hard to solve this problem. To suggest otherwise would imply an unconscionable amount of waste, missed opportunity, and needless lives lost.

It turns out that in 2008, there were more studies published just about acid reflux disease (GERD) than there were about medication compliance. Why such a disconnect? Let's reflect on my medical training. In my seven years of medical school and residency -- that's about 20,000 hours of training -- I spent approximately one hour learning about medication compliance, and about 45 minutes of that was talking about all the complications caused by those non-compliant, non-adherent, patients who failed to follow through on doctors' orders. This is not a failure on the part of the patient, it is a failure of patient-physician communication.

We doctors need to accept our share of responsibility for successfully taken medicines. The fatal flaw is thinking that our responsibility as health care providers ends when we hand the correct prescription to the patient. A corollary is that the vast majority of our research investment is targeted only at getting drugs from discovery to the point of prescription. Here are just a few points downstream from there where we can fail:
- the patient doesn't understand why he should take the medicine, so he doesn't
- she is experiencing a side effect, or is afraid of experiencing one
- he can't afford the medicine, and is embarrassed to tell the physician
- she doesn't think the medication is helping, so she stops taking it

To be sure, there are other points of failure, but the ones above are common and they have something in common: they all result from inadequate patient-physician communication. Especially among the tens of millions in the U.S. taking multiple medications, many don't even know why they are taking a given medication. Personally, I think I have failed if one of my patients doesn't know the purpose of each of her medications. In fact, I try to include the reason for taking the medication as part of the prescription, e.g., "Atenolol 50 mg tablets, take one by mouth every day for high blood pressure." But the explanation "for high blood pressure" is rarely included in a prescription. In my experience, over 99% of prescriptions handed to patients and printed on the medication bottle fail to include this basic guidance on what the medication is supposed to treat. Why? Because we think our job is done when we figure out what drug to prescribe. Because we are too busy or too lazy. Because the reason for taking the drug is not a required part of the prescription! Now that seems like low-hanging fruit in health care reform.

And let's not forget to talk to each other. At every doctor visit, the patient and doctor should review the patients' current medication list (this actually is explicitly recommended by the leading hospital certification organization). Doctors: let's make sure this discussion includes the patients' understanding of what each medicine is for, and an invitation to share any questions, doubts, or concerns. It's amazing what we learn if we simply ask. Patients: this is YOUR health. Don't leave the doctors' office until your questions are answered and you understand the plan. Lawmakers: we should require prescriptions to include the reason for taking the medicine, and we should give doctors financial incentives not just when they prescribe the right medicines, but when their patients actually take them. And finally, innovators: as we create novel treatments, let's not forget the millions of lives and billions of dollars we can save by innovating on the process of getting those prescriptions taken as prescribed.

** Disclaimer: The views expressed here are mine alone and not those of my employer. **

Comments

[henrywei]

Hi Roni, great article:
1) A study at Cornell showed that *PHYSICIAN* compliance is just a big an issue as patient adherence. (AMIA Annu Symp Proc. 2008 Nov 6:1171) The authors identified several gaps in care and tried to figure out where the chain had broken down -- doctors not prescribing? Or patients not taking meds? Counter to conventional wisdom, DOCTORS were the main barrier vs. patients (about 80/20 split!). i.e. Patients can't even be non-compliant if we doctors don't write the prescription in the first place!

2) How about financial incentives for patients themselves? Today, a plan will charge an employee a co-pay of $20 for a critical medication -- almost a disincentive to take it -- but still subsidize the adverse event & hospitalization if they don't take it! Enter "Value Based Insurance Design" (VBID). Done in its most basic forms (e.g. Pitney Bowes), it basically relieves the co-pay for critical preventive medications, e.g. asthma inhalers. Done in more sophisticated forms we can zoom into the exact non-compliant patients, pinpoint which meds they ought to be taking (but aren't), and then reduce or eliminate co-pays. The technology is a little intense -- it requires a lot of data, a decision support engine and some cool algorithms (...CareEngine *cough self-promotion cough*). But we do it today, for real, and so far, it seems to work.

** Disclaimer: The views expressed here are mine alone and not those of my employer. **

[itsjon]

I think an interesting challenge here is the information available to the patient _not_ through their doctor. For instance, when I was recently taking a medication, I searched online to find more information (and find out if what I was feeling was normal). The first 10 results were all various drug databases (and the wikipedia page), which essentially all contain the same information - a list of uses and scary side effects with very little context. It's incredibly difficult (as a patient) to get relevant information that actually informs your usage. I imagine it's equally complex to provide such information (as a service, online or offline). There's certainly a gap there...

Thanks for bringing this up. A very interesting problem, and one that really requires a closer look...

-Jon

[myriamgst]

Roni, thank you for writing about this issue - the information is illuminating - the low percentage of those who actually follow through with their doctors' prescriptions is shocking! I suspect many factors contribute to that, but by bringing them to light, you are helping us all. Thank you so much.
-Myriam

[DrRC]

Roni -

Thanks for your thoughtful article, and I enthusiastically agree with your ideas. One group I would add to the list of participants you'd like to see activated to this cause is community pharmacists. As you know there's been interesting recent work in the redesign of pill bottles and labels in retail pharmacies , including improving the prominence and accessibility of the reason the drug should be taken. Pharmacies should take this further, providing visual summaries of a patient's medications, the dosing schedule, and the reasons for each. For now this would be predicated on a patient receiving all their medications from a single source, which is common but not universal. If the recently legislated incentives for interoperability of health IT systems and electronic prescribing are successful, there may be more opportunity to provide that service even to patients who may access more than one pharmacy over time.

Dr RC

[ganitsky]

Roni:

Thanks so much for sharing.... and congratulations. I liked it very much. In my mother's case, I have noticed how right you are. She is always suspicious of taking the medicines and wants to know what they are intended for but it is always a struggle 'cause there is no explanation in the bottle, and specially since she takes so many medicines. There was only one instance where we were happy that she did not know what it was for: an antidepressant and we didn't want her to be self conscious.

On the other hand, I think that part of the problem is the limited time that physicians can devote to a patient which is the cause of so many additional problems in the current medical environment.

Anyway, congrats again and I am sure it will be very useful to the community and also for you: "Mi col melamdai, iscalti"

Your fan, Enrique