Although the issue of patient adherence to treatment in underserved communities and especially with those of color has always been an issue which is based in my opinion on systemic racism in the medical field, the mistrust of the medical professional which stems from The Tuskegee Study of Untreated Syphilis in the Negro Male conducted between 1932 and 1972, which my uncle (my father brother) Leroy Hendrix was a part of. Based on the misrepresentation by the medical professionals during this time along with the lack of education and the lack of education of the participants who participated in this study the participants believed what was being told them and trusted those (medical professionals) and participated. (2)
We now live in a time where many of us can research information that is being provided ask questions to make sound medical decisions regarding our health care. But there are those who remain unknowledgeable regarding his/her health care issues based on the fact that he/she lack the skills to understand the medical terminology that is used by his/her doctors. They are afraid of that white coat and too afraid to ask questions. Physicians must understand that they must earn adherence from his/her patients. Meet the patient on his/her level, take the time by using layman's terms when speaking with patients. Don't just write a prescription and say, "I want to see you back in two weeks."
Patient adherence is essential for treatment efficacy and can be broadly understood as a patient's behavioral response to the health care provider's treatment recommendations and medication prescriptions. While patient adherence is most commonly assessed regarding medication, it also applies to healthcare providers’ recommendations regarding behavioral characteristics such as self-care, diet, exercise, lifestyle changes, etc. Patient nonadherence poses a significant economic burden both to the patient and to the health care system since a condition can progress and result in increased morbidity and mortality. Therefore, improving patients’ general adherence to health providers’ recommendations and medication regimens could prevent future adverse health outcomes and increased economic burden. (3)
General adherence is defined as patients’ tendency to adhere to clinical recommendations and treatment, and it can be driven by many elements, including a patient's socioeconomic status, chronic conditions, provider-patients discordance, and healthcare access. (3)
Poverty plays an important role in nonadherence. Low socioeconomic status patients adhere less well to treatment and medication, on average, increasing their risk of morbidity and mortality. The prevalence of medication nonadherence is also higher among underserved populations. For example, lack of insurance and low income are directly related to a patient's medication nonadherence because patients may have difficulty paying for prescribed medicine.
In chronic conditions, poor general adherence may lead to adverse events. For example, when diabetic patients are not adherent to their medication regimen, causing their blood sugar level to be poorly controlled, they are predisposed to an increased risk of hyperglycemic episodes. Thus, the consequence of nonadherence often results in disease progression, more hospitalization, and ultimately, lower quality of life.
Medical Economics (213) asserts "Faced with these difficulties, how can primary care doctors best help patients adhere to a plan for managing their chronic disease or condition? Those experienced in treating such patients say it begins with ensuring the patient understands the disease and how and why it needs to be managed."
“The most essential first step is making sure the patient understands the rationale and importance of the treatment plan,” including the potential consequences of nonadherence, says Ryan Mire, M.D., MACP, an internist in Nashville, Tennessee, and president of the American College of Physicians. (1)
“To be able to explain to them why they’re taking these medications or on this type of diet, why they have to lose 20 pounds, it all plays a big role in getting patients to buy into their health care,” adds Daron Gersch, M.D., FAAFP, who practiced family medicine in Long Prairie, Minnesota, for 25 years. (1)
Building long-term relationships is the key
I have been saying for years that the medical professional must build long term relationships with their patients. Along with educating the patient, it is vital to establish a long-term relationship, doctors say. Doing so not only builds trust, but it also often reveals clues as to what motivates the patient — a crucial part of coping with chronic diseases.
“What I teach residents and try to follow throughout my career is first of all really getting to know the patient,” says Robert Juhasz, D.O., an internist affiliated with the Cleveland Clinic and former president of the American Osteopathic Association. “That’s why I focus on getting a good history when I meet a patient for the first time, so I can understand what’s going on with them.”
That understanding, he adds, also enables him to grasp the external obstacles the patient faces in improving their health. “You can say you’d like to see them move towards a healthier diet, but if you think they don’t have access to nutritional food, you have to ask, ‘Is that [goal] something you think you could do? If not, what would get in the way?’”
Juhasz says he lets patients set the agenda for the visit in terms of what they see as its purpose and their expectations for it. Doing so, he says, provides important insights into the patient’s daily life, such as whether and how much they smoke or drink, if they are sexually active, the type of work they do and whether it exposes them to health risks. (1)
“I think to be successful at patient (adherence) requires the skill set to act paternally with some patients, meaning you make the decisions for them, and other times to be more fraternal and make the decisions together,” he says. “The doctors who are good at patient care are able to flip those roles depending on what works best for each patient.” (1)
Meeting the cost challenge
Inability to afford prescription medications poses another adherence barrier and one doctors say they are seeing among more of their patients. Not only are the prices of many medications rising, but patients are paying more out of pocket for them. A 2020 IQVIA Institute study found that patient out-of-pocket costs for prescription medications jumped by 8.1% between 2015 and 2019, from $74 billion to $82 billion. And although 9% of all prescriptions in 2019 went unfilled, the rate was 45% for those with an out-of-pocket cost of $125 or more.
The problem is exacerbated by some patients’ unwillingness to admit they cannot afford their medications. “They feel like they’re saying, ‘I’m not successful enough in life to afford these prescriptions,’ and it’s embarrassing for them to admit that. (1)
It takes a team
A further important contributor to successful adherence, doctors say, is team-based care. “Designating roles for members of the health care team to assist in additional counseling or follow-up to check in on patients can help to make sure they are continuing their treatment plans,” Mire says. He adds that a team member who can spend time counseling patients also provides an opportunity to identify any social or cost barriers to adherence patients may be facing.
“Having motivated team members who care about patients is a fundamental part of managing chronic disease,” says Arnold, adding that some of his long-term patients have become friends with the nurses in his practice. “When they come in it’s more like a social visit and I’m kind of an afterthought. (1)
Medical Economics Journal Medical Economics April 2023Volume 100
2. McGill Office for Science and Society (2023) 40 Years of Human Experimentation in America: The Tuskegee Study. Retrieved from, https://www.mcgill.ca/
3. Panahi S, Rathi N, Hurley J, Sundrud J, Lucero M, Kamimura A. Patient Adherence to Health Care Provider Recommendations and Medication among Free Clinic Patients. J Patient Exp. 2022 Feb 9;9:23743735221077523. doi: 10.1177/23743735221077523. PMID: 35155751; PMCID: PMC8832560.