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The quietest problem in healthcare is a palindrome

The effects of non-compliance

Problems aren’t usually defined as ‘quiet’ or ‘loud’. But in this scenario, it may be apropos. The tenor of our discussion in healthcare tends to focus on drug prices, doctors’ salaries, insurance companies, pharmacy benefits managers, adverse events, regulatory issues, patent laws and special vouchers for breakthrough designation. These problems ‘feel’ loud. Like loud in the sense that everyone talks about them all the time and this constant chattering creates a crescendo of noise that is, well, loud.  

figure 1Rarely do we spend any time taking about non-compliance, which we define as “the lack of congruence between a patient’s behaviour (in terms of taking medication, following a diet or executing lifestyle changes) and a healthcare provider’s recommendations for health and medical advice”. It seems like a ‘quiet’ problem. Tucked away over there in the corner, just minding its own business. Some statistics suggest that up to half of all prescriptions are not filled and/or completed as required (see figure 1). The downstream effects of non-compliance are massive: sicker patients, disease complications, more provision of services, more drugs needed and higher costs. And this list is, for the sake of brevity, very rudimentary.

table 1But why are patients non-compliant in the first place? The behaviour behind the problem is intriguing. Broadly speaking, non-compliance falls into three major categories (see Table 1). There are other categories of non-compliance that are patient-centred and therapy-centred, but we can agree, I’m sure, that these three reasons represent 85-90% of all non-compliance. The irony is that when you talk to patients and doctors separately, they both recognise and acknowledge that compliance can be improved. And before you read any further, I’ll cut to the chase: there is no magic bullet. This ‘quiet’ problem has been around as long as medicine itself.

Perhaps we can implement strategies and public health campaigns to ensure that patients don’t discontinue medications just because they feel better. Remind patients that even though they may not feel that a medicine is working, it doesn’t mean it isn’t. But other than that, it’s hard to address non-compliance in a meaningful way. It’s hard to compete with ‘I don’t have the money to buy my medicine’ and ‘the side effects of my medicine are worse than my illness’. Scores and scores of studies in the policy and public health world have looked at the issue of non-compliance. Many have postulated interesting ideas and shed light in dark corners and revived ideas that were once forgotten. But to what avail? As discussed earlier, it’s really hard to move the needle.

But what if we could? What if we could ‘flip’ this problem such that we have significantly better (or perfect) compliance? Would this be better? All patients taking every prescription exactly as they are supposed to according to each product’s labelling and/or their physicians’ instructions. Now imagine the total tab for drug spending in your country. This scenario represents a palindromic problem: the same essential problem frontwards as it is backwards but with different outcomes. Too much non-compliance is a problem. And too much compliance is also a problem. This is the perfect paradox. Palindromic problems present unique challenges for policymakers and public health wonks. They force us to admit that problems are multi-directional. In an industry where uni-directionality is the norm, this can be disconcerting. The prices of drugs are a uni-directional problem: always too expensive. We never say they are ‘too cheap’. The efficacy of therapies is a uni-directional problem: medicines don’t work well enough. We never say they work ‘too well’. Access to the provision of services is a uni-directional problem. Access is always too little. We never say that people have ‘too much access’. And the list of uni-directional healthcare problems goes on.

And so, in the end, when we toss aside all the labels and categories of ‘palindrome’, ‘multi-directional’ or ‘uni-directional’, we must ask ourselves if we want all patients taking all their prescriptions exactly as required, knowing that increased costs and potentially increased adverse events and complications may be the sequelae of this behaviour. Or do we want essentially what we’ve got, which is somewhere less than half of people taking their medications as prescribed and a population of sub-optimally controlled patients. We are left with the unique challenge that I alluded to earlier: having to choose. And in healthcare, choice is not something we’re used to having.

Article by
Rohit Khanna

3rd August 2017

From: Healthcare

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