The importance of medication adherence in healthcare and how it impacts society. Written by Helena Rönnqvist, Chief Science Officer at Pilloxa.
The “western” world is a knowledge-based world. We have let go of religion, instead championing data and science as the correct and single source of truth. We believe in the individual and health as central concepts in our lives. We all attempt to be healthy. We walk 30 minutes a day, because someone at some point said that this improves health. We eat fruits and greens, because apparently that will help us too. Staying in good health is something that truly occupies our minds and time.
Yet, science showcases that there is no way to neglect the most evident fact of them all: we will all die. It’s a morbid truth. And it will happen rather soon when compared to the entire existence of the earth.
In a knowledge-based world, we are not sure if there is a second chance at life in heavenly paradise or a raging hell, and who knows what could happen with the potential of cloning research. To ensure that we live for a bit longer, or in our mindset, do not die, we spend a lot of time trying to avoid the unavoidable. We do many things to ensure a long life. We start working out, we eat healthy, and try to sleep well – since everyone knows that with less than 7 hours of sleep every night the risk of dying from cardiovascular disease doubles. If we feel a lump somewhere, we go to check it so that, if it turns out to be cancer, we can get treatment to avoid a worst case scenario. Despite our efforts, we all age and many of us reach a point where medicine becomes a part of our daily diet. We take pills to lower this risk and in essence prolong our lives and/or increase our livelihoods.
Society firmly believes in this. We believe it so much that society actually considers it a human right to receive medical treatment (as we should). In 2017, countries in Europe spent on average 9,6% of GDP on health care, corresponding to an average spending of €2773 per person. Sweden was one of the biggest spenders, spending €4019 per person. On average, medicines accounted for 17% of total health expenditure (excluding medicines used in hospitals). These massive spendings are often justified by cost/benefit calculations referred to as health technology assessments, known as HTA for short.[1]
“Do you take every pill as you are prescribed to? I know I don’t.”
All taken together, taking medicine seems to be a subject of very high interest both on an individual as well as collective level.
When I worked within the emergency ward at Karolinska Hospital in Sweden, it became clear to me that even though many of us have decided to start a treatment, it is not at all certain that we will properly follow or complete it. In many cases, that was the main reason as to why many of my patients were spending their day in the emergency bed in front of my eyes. Some studies suggest that up to 30% of people who seek emergency care is due to medical related problems [2] and an often cited number is that 10% of hospital enrollments are directly due to poor medication adherence [3].
At a first glance, this may seem very strange and paradoxical but when scratching the surface it becomes clear that taking medicine as prescribed is not at all a simple task.
Do you take every pill as you are prescribed to? I know I don’t. And you and I are not alone. Adherence to therapies is 50% [4] on average. Even where therapies directly save lives, for example after transplantation, poor adherence is reported among 20-50% of patients [5, 6]. Furthermore, contrary to common belief, the younger population appears to have the hardest time following their prescriptions [7, 8, 9].
Why is that? A very low percentage of the younger population suffers from cognitive impairment and most of them can at least theoretically understand why medicine is important to take. They have even put in the effort to visit a physician and undergone the discomfort of examination and testing to get that prescription.
Is it because thinking of how to improve health has finally become too much? Or do the pills in some way remind us of this inevitable thing called death? Maybe we just don’t like the touch or taste of the pills? Maybe it’s a mix of all of those reasons and more. Maybe none of them.
“There are so many reasons for why that pill is not taken out of its box, placed on the tongue, and swallowed.”
But above all of this, there’s this wonderful thing called life. And life can get in the way. One thing that ill people often witness is that when becoming ill it is not death but life that becomes more present. Maybe the rituals performed to prolong life lose some of their meaning and instead living the rest of life as fully as we can becomes more important to us.
And living a full life involves a lot of activities. There’s a lot of things to do: dinners with loved ones; concerts and cinemas to attend; trips and adventures to be experienced; kids needing to be played with; and there’s friends and family to see. Somewhere between all of this “life stuff” we have to squeeze in taking medicine. It can be such a mundane task to do. There are so many reasons for why that pill is not taken out of its box, placed on the tongue, and swallowed.
But the truth is not a hard pill to swallow in this case.
Most reasons to not take medication are not deliberate. It is more of a mishmash of reasons like forgetting to take the medicine, forgetting if you already took it, forgetting to collect it from the pharmacy, lacking routine, forgetting to renew the prescription, or maybe even the information of how or when to take your medication is uncertain. If, in the beginning, taking medicine might seem like a great idea in most cases there is no instant reward of doing so, and with time motivation declines. There might even be side effects that you need to struggle with, possibly making it even easier to let it fall into oblivion.
This of course leads to a lot of sad and avoidable health effects. For the individual, this might have fatal consequences. For example, it might result in losing a transplanted organ or leading to stroke. In Europe, poor adherence is estimated to cause 200,000 premature deaths yearly and results in a cost of EUR 125 billion in avoidable hospitalisations, emergency care, and adult outpatient visits [1].
Even though this problem has been known for decades, finding the right solution has been hard. It has been proposed that to overcome this massive problem one has to work with a multifaceted approach built around the individual rather than a population [10].
“Even though it seems like a hard nut to crack, the most promising thing about this problem is that there are no losers if the problem gets solved – only winners.”
Whose responsibility is it to solve this enormous problem? The individual who we so strongly believed in? Society that has put up a rigid structure of how to provide these potent drugs and also pays for much of the use or pharmaceutical companies that claim to sell medicine that improve health? Today, initiatives are being made from the state, clinics, patient organisations and industry. However, the outcome of these initiatives are rarely connected to direct reimbursement and the direct monetary incentives seem to be lacking even though the bill for non-adherence is in the end ultimately paid by taxpayers. Maybe if pay for performance models for medicine become more common we will see larger efforts, but that’s another topic to dive into.
Even though it seems like a hard nut to crack, the most promising thing about this problem is that there are no losers if the problem gets solved – only winners. And with emerging technologies, there is more hope than ever that multifaceted solutions directed to the individual really can make a change.
So to answer the question: does medicine really work? Only if you take them. As Haynes and colleagues well put it back in 2001: “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments” [11]. Therefore, it’s time to fit your medication seamlessly into your life so that you can focus on enjoying it.
And then, maybe we can trick death a little while longer…
Helena Rönnqvist, Chief Science Officer at Pilloxa
References
[1] OECD/EU (2018), Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris. https://doi.org/10.1787/health_glance_eur-2018-en.
[2] Fryckstedt J. et al. Läkemedelsrelaterade problem vanliga på medicinakuten, LÄKARTIDNINGEN, 2008-03-18 nummer 12.
[3] Iuga, A. O., & McGuire, M. J. (2014). Adherence and health care costs. Risk management and healthcare policy, 7, 35–44. https://doi.org/10.2147/RMHP.S19801.
[4] Osterberg L et al. Adherence to medication. N Engl J Med 2005;353:487-97.
[5] Lennerling, A. & Forsberg, A. Self-reported non-adherence and beliefs about medication in a Swedish kidney transplant population. Open Nurs. J. 6, 41–6 (2012).
[6] Denhaerynck, K. et al. Prevalence, consequences, and determinants of nonadherence in adult renal transplant patients: A literature review. Transpl. Int. 18, 1121–1133 (2005.
[7] Age-related medication adherence in patients with chronic heart failure: A systematic literature review., Kreuger et al., Int J Cardiol. 2015 Apr 1;184:728-35. doi: 10.1016/j.ijcard.2015.03.042. Epub 2015 Mar 4.
[8] The impact of age and gender on adherence to antidepressants: a 4-year population-based cohort study, Amir Krivoy et al., Psychopharmacology (Berl). 2015 Sep;232(18):3385-90. doi: 10.1007/s00213-015-3988-9. Epub 2015 Jun 21.
[9] Medication adherence in HIV-infected adults: effect of patient age, cognitive status, and substance abuse, Charles H. Hinkin et al., AIDS. 2004 Jan 1; 18(Suppl 1): S19–S25.
[10] WHO, ADHERENCE TO LONG-TERM THERAPIES: EVIDENCE FOR ACTION, 2003.
[11] Haynes RB. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2001, Issue 1, 2001.
Credit for picture to https://www.kratomiq.com/