[Thorpe] Welcome to Beyond the Data.
I'm Dr. Phoebe Thorpe, and here
with me today is Dr. Larry Garber
from Reliant Medical Group.
Thank you so much for joining us.
[Garber] Thank you for having me.
[Thorpe] The session today is
about medication adherence for chronic diseases.
Why is this a problem: thinking having patients not being able
to take the medication when they are prescribed it?
[Garber] It's actually...I have been a physician for 30 years,
and it actually came as a surprise to me.
For many years, I just assumed
that patients were taking their medications
and would just wonder why some people's blood pressure wouldn't
improve or their cholesterol wouldn't improve
with the medicines until I started to you know learn
and understand that for patients on chronic medications half
of them are not taking the medications as prescribed.
You know they're not adhering to their regimen,
and so, it's a huge problem.
And there are many reasons, but the implications are phenomenal
that you know it impacts the health of our patients
that they're more likely to progress to problems
and disability related to their diseases or even to death.
And besides being obviously bad for our patients,
it's also bad for society.
It costs hundreds of billions of dollars every year
that are wasted on hospitalizations or support
for the disabled patients who have suffered diseases
because they haven't been adhering to their medications.
[Thorpe] And you said there were lots of reasons
that patients don't take her medications.
What are some of them?
[Garber] So, I guess the way I have looked at it is
to say they fall into two categories: the categories
of patients intentionally not taking their medications
and sometimes unintentionally.
So for intentional reasons often more and more, it's becoming
to the cost of medications.
They're very expensive, and if they can't afford them,
they decide do I eat or do I take my medicines they choose
to eat.
So cost is a reason, and also, a lot of times,
they don't like the side effects
that they are getting from the medications.
So they'll choose not to take them because of that,
and a lot of times, they also don't believe that they ought
to be taking the medications.
They don't believe the medications will work for them,
or someone's told them "Oh, you shouldn't be
on that medication", or maybe there are cultural reasons
that they believe the medication's not good for them
and so, they don't take it.
And then there are a lot
of unintentional reasons why patients don't take
their medications.
Sometimes they forget.
We're all human, we forget.
You know I have trouble remembering to take medicines
when I'm on them as well, but, also sometimes,
it's just that they don't realize
that they were actually supposed to take
that pill every single day or to continue to take it
when that bottle was done and they had us get a refill.
And there are other also unintentional reasons.
If their medication regimen is complex
and you know they are supposed
to be taking pills multiple times a day
and different pill combinations,
they may accidentally not take the medications.
And sometimes due to other illnesses that they also have.
You know, maybe they have problems with dementia.
They're confused, so they may not be able to remember or know
that they're supposed to take their medications.
Or maybe they have visual problems.
They may not be able to see how much insulin they're pulling
into their syringe to be able
to properly give the administration.
Or maybe they have arthritis in their hands,
so they can't open their bottles.
Or they can't split the pills, so there are lots
of different reasons and typically not just one.
It's usually a combination of reasons that reach to the point
where a patient just won't follow their medication regimen.
[Thorpe] And in the session today your group has done a lot
of interesting things.
Some are very practical but some are high-tech.
Helping clinicians do a better job of making sure
that their patients take the medicine.
What can you tell us about some of those?
[Garber] Sure.
The way I look at it, and the way we've looked at this problem
at Reliant Medical Group is that,
if you want to change someone's behavior and if you want them
to do something, you really have
to satisfy what I call three pillars of success.
And these apply to whether you're trying to get someone
to take their medications, whether you are trying
to get a physician to use an electronic health record,
whether you're trying to get your spouse
to take out the garbage.
It's the exact same three things as you have
to pay attention to it.
So first is, you have to make sure that there is value.
Patients have to recognize the value
in taking their medications, so you have to educate them
to understand why you know not taking the medication
and letting their disease progress is a bad thing
and that taking the medication you know has the benefits
of controlling the disease, reducing the progression,
reducing the chance
of developing problems related to the disease.
And so, the values important.
In fact even myself as a physician.
I need to find value in that relationship.
I have to recognize it's important for me
to encourage my patients to adhere to their medications,
so everybody has to see value in this.
The second thing is that it has to be convenient.
So really it has to be convenient for the patients
to take their medications.
So that's, you know as I talked about,
making sure they can afford it,
but also that the regimen is simple.
You know they should take once a day medications,
so that it's a simple regimen that they can do.
People are, patients are people too, and they have busy lives
and it has to fit into it.
So, you want to give them pillboxes
that have the medications laid out for the week.
So that it's easy for them to remember "Did I take the pills"
and have them located in a place that's convenient
for them to remember.
When they're brushing their teeth,
"Oh I need to take my pills.
There's the pillbox".
So, you really need to get it to fit into their lifestyle,
and we've done those kinds of things.
Also, you want patients to be able to monitor the effect
of their medicines to show that they actually do work,
so one of things we've done
at Reliant is we've given patient's home blood
pressure monitors.
So for hypertensive patients, they can take readings,
and just plugging it in the monitor into a computer,
it uploads the readings into our electronic medical records,
so they don't have to get on the phone and call
and get the same results.
And they don't have to come to a visit
to give us their blood pressure readings.
They can just do it simply by plugging it in,
so it's convenient for them.
So, that's the second thing, and,
then the third thing, is trust.
You really need to develop a trusting relationship
with patients.
They need to believe everything you say.
That it's important, and trust is interesting
because you know the Gallup poll has done studies every
single year.
They do surveys to find out who do people trust, and,
it turns out, people trust nurses more
than they do trust doctors and pharmacists.
Year after year nurses top the list of people that you trust.
So you really need to leverage that and actually get nurses
to be part of the team to continue to reinforce
that message about how it's important
to take these medications to adhere to the regimen
that they're supposed to be taking them.
So that's really important.
I call these the three U's: it has to be useful, usable,
and you have to develop trust.
[Thorpe] Oh yeah.
So some of what you've talked about is more
on an outpatient side.
What about inpatient
and hospital-based physicians and care teams?
What can they do?
[Garber] Well, that's so important because these days,
you know, when I started practicing medicine I was the
outpatient doctor, and I was the inpatient doctor.
I took care of all my patients in the hospital.
But now, most of the time, it's a different team of physicians
and staff that are caring for the patient in the hospital
than the team that will see them in follow-up.
And so, what can happen is there's this tendency
to just hand off the patient.
You know, to that follow-up team the primary care physician
or referring physician,
and think that's their responsibility to, you know,
to take care of patient after that.
Whereas what as you heard today,
is that if you actually have the inpatient team focus
on making sure that the handoff is successful
and that it's not fumbled, they can make sure that the education
to the patient takes place completely and thoroughly
at the time of discharge, and then contact the patient
after discharge to make sure that they got the pills
that they were supposed to be taking,
and that they know what they are
for that they're taking them correctly.
That proper handoff and the follow-through can really make a
difference in medication adherence,
and reducing adverse events, reducing rehospitalizations.
Things like that.
[Thorpe] Yeah, that was a very interesting point
from today's session for me about how
that follow-up really did make a difference.
The other thing that I wondered about or I just, hit the bottom
of it all, it really seems like it's the kind
of the patient's responsibility in the end to take these.
They're the decision-maker.
What would you suggest patients and people do
about taking medications?
What's their role in it?
[Garber] Well, it's both the patient's role as well
as the physician and provider team's role to work together.
You know, I may have made it sound
like it's the doctor decreeing
"You're going to take these pills."
You know, "Here you go."
You know, "Good luck with it."
But it's actually a needs to be a discussion.
It needs to be a two-way negotiation to understand,
you know, what are the best treatments
for a particular problem, and if it is medications,
what are the most appropriate medications?
You know, we really need
to understand what are the actual personal situations
that the patient is in.
Do they have financial issues?
Do they work the night shift,
so that the timing is not in the morning?
It's when they wake up, which is different.
Do they have problems with opening pills or transportation,
or these social issues really need to be conveyed
and discussed between the patient and the physician?
So, if the physician doesn't ask, patients need to speak up
and really convey that information.
There has to be a discussion about, you know,
are there certain side effects
that the patients more concerned about?
You know, with hypertensive medications and, you know,
there are issues about such sexual dysfunction,
and is that something that the patients are worried about.
Or, do they have cultural reasons?
Do they believe that their hot medicines or cold medicines
that shouldn't be taken together with certain diseases?
That needs to be conveyed to the physician if they're not asking,
so it's really patients need to speak up.
[Thorpe] And then the last group that I think has some role
in this is public health.
How has public health been contributing
to improving medication adherence?
[Garber] Well, public health has a huge role, because they span
across communities and states in the whole country.
And so, they have the ability to reach far beyond, you know,
what I could do as an individual physician,
so they have the ability to identify, you know,
gaps in care, issues or inequities in care
across a population,
and actually do large-scale interventions.
We look at the Million Hearts Program.
It's a fantastic program, and they made it very simple.
You know they're trying to save lives, reduce heart attacks,
and other deaths due to cardiovascular diseases,
and they came up with very simple ABC's.
You know we want to make sure people are taking aspirin
appropriately, that you're controlling their blood
pressure, their cholesterol, and stop smoking.
And you know, and just the communication
that they do is very valuable to education
that they do on a broad scale.
And they also do incentives.
So you know at Reliant Medical Group, we saw that energy
or blood pressure control wasn't as good as it could be.
We're only at about 68% blood pressure control,
as we saw today, and through the incentives of...
Gee, and wouldn't it be wonderful if we could, you know,
be recognized by Million Hearts.
We brought our blood pressure control up to 80%.
Which is, you know, very in the tops in the nation.
And you know we were able to get national recognition for that,
which is what really felt good, but it also felt good
that we're getting better care to our patients.
Because they pointed out to us, they made us think
about the fact that, you know, we could be better
than we currently are.
And I'd like to see you know public health go even further.
A lot of the care that I give is based on, you know,
making sure that I understand what's going
on with our patients wherever they happen to go,
and I want to try to incorporate more
of the social determinants of health.
That impacts why they do or don't take their medications,
and also, the care that they get.
So, you know, I love to be able to reach out and understand more
about what's happening to my patients, you know, in schools,
in the workplace, in other parts of society.
And it's possible that, you know,
public health could help us get those connections, you know,
to go places and get more information
than that we're currently capable of doing today.
[Thorpe] Well thank you so much for joining us.
Lovely. [Garber] Thank you it's my pleasure.
This is great.
[Thorpe] Thank you so much for joining us.
We'll see you next time on Beyond The Data.