Shared Care

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We healthcare professionals seem to chase around the dream of patient compliance.

“What’s the compliance of this patient?”

“Well, that patient is not very compliant.”

“How can we improve compliance?”

“Here’s a great ‘gizmo’ to help with compliance.”

I was recently in a room with a group of physicians and pharmacists discussing this very topic.  Most of the physicians in the group assumed that as long as the medication was picked up at the pharmacy, the patient was actually taking the drug exactly as prescribed.

While the pharmacists in the room had a silent chuckle over this, we cannot forget our own illusions of patient compliance.  Pharmacists can easily believe that if we just sync up patient’s refills or put their medications into blister packs, this will improve compliance.

The bottom line is, if a patient does not want to take a medication, no tool, technology or compliance aid is going to fix this.

It is the patient who will ultimately decide whether they take the drug.

Mr. V is a great example of patient “non-compliance”.  Mr. V had a cardiovascular event 5 years ago and afterwards was put on a statin.  He had been told over and over again by his physician that it was important for him to take this drug every day.  The pharmacist put it in his blister pack and the doctor checked the fill history on the provincial electronic record which showed consistent filling of his prescriptions.  All was well, except for one major problem: Mr. V’s LDL had been climbing in the last two years.  Mr. V’s doctor, out of concern, added an additional lipid lowering agent to improve the situation.

In sitting down with Mr. V for a medication review, he disclosed to me that he was punching his statin drug out of his compliance pack.  Indeed, he had hardly been taking it for years.

After some conversation, which was mostly listening on my part, Mr.V trusted me enough to tell me how he was ACTUALLY taking his medications. From that discussion I was able to discern why he didn’t like taking them.

I presented to him the science of reducing LDL post heart attack. I looked up his cholesterol levels and give HIM the numbers on a piece of paper to compare for himself. Ultimately the decision was his. What we agreed on was to reduce the dose of his statin and test again in six months.

Had I simply said “you need to take your medication” and left it at that he would still be punching out his pills.

This is the essence of shared decision making. If we don’t involve patients in decisions about their own health (for example what medications to take, whether therapy should be intensified, or what screening or testing should be done), they will often make their own decisions, and it will be without the guidance of their health care professional.

Simple open ended questions can accomplish this by inviting the patient to share their thoughts and experience.  Asking a patient, “Do you know why you are taking this medication?” or “How do you feel this medication is working for you?” can open up a vast window of opportunity to engage a patient in their own care.

The key to compliance, or the more politically correct term “adherence”,  is the degree to which a patient understands the importance of therapy. I can make all kinds of changes to therapy from reducing the number of doses per day, reducing cost, improving timing to make things easier, etc. Ultimately if the patient does not understand the importance of the WHY, compliance will be lagging.

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