The Problem of Medication Noncompliance
When people have chronic health problems, they may need to take medication for long periods of time. Unfortunately, many people do not take their medications as prescribed. This medication noncompliance leads to a variety of health problems and is very costly to the medical system. As described in a New York Times article, medication noncompliance leads to over 100,000 deaths per year and costs about $100 billion per year in hospital admissions.
The New York Times (NYT) article discusses how behavioral economics might be able to encourage individuals to take their medications as prescribed. Behavioral economics is the currently trendy field that examines how psychological, social, emotional, and cognitive factors impact individuals' economic decisions.
The NYT article discusses a study that tried to encourage patients to take their medication as prescribed after experiencing a heart attack. To encourage patients, the study offered patients in the control condition electronic prescription bottles that monitored the patients' use of medication. Patients who took their medication were entered into a lottery where they had a daily 20% chance of winning $5 and a 1% chance of winning $50. In addition, the patients were able to list someone who would be notified if they did not take their medication as a source of social support, had access to social work resources, and spoke with a staff engagement advisor who provided close monitoring, feedback, and reinforcement of adherence.
While this may sound like a lot of resources and support, unfortunately the researchers found that this experimental condition did not improve outcomes compared to a treatment-as-usual condition. The study discusses some of the logistical reasons why largely no effects were found, including needing to enroll patients an average of 40 days after hospital discharge and that due to the study enrollment procedures, only motivated patients enrolled and thus there might be little benefit for the additional incentives and resources provided.
These results may be discouraging, however, there are more questions than answers from reading the study. For example, the study did not clearly describe the role of the staff engagement advisor, including what their interactions with patients looked like. If the staff engagement advisor used a motivational interviewing approach, a treatment technique that is used to increased motivation amongst clients, then perhaps the intervention would have better results. In addition, how the lottery system worked is unclear. Contingency management systems such as the lottery system work best with an immediate reinforcer (i.e., the chance to win money) and it is unclear what the time gap between the behavior (taking one's medication) and the reinforcer was. Lastly, it is unclear what social work services were offered, this could be a wide variety of services and it is unclear how targeted these services were to the clients needs.
One interesting note is that the medical cost per patient did not differ per condition. Given the additional costs associated with the treatment condition, this would appear to indicate that something was working in the treatment condition. Interestingly, the authors did not spend much time discussing this finding.
Reasons for medication noncompliance are often complex and multi-faceted. It is unclear why the patients did not always take their medication including whether the patients had concerns about potential side effects of the medication, did not understand the importance of taking the medication, prefer not to take medication more generally, etc. Patients who experience heart attacks can often experience depression afterwards, as such it may be important to have a multidisciplinary staff that treats both medical and psychological problems.
In terms of lessons learned, it seems that this study is a good reminder that there are likely not going to be quick fixes to difficult, complex problems. Experiencing a heart attack can be a life changing event that requires interventions that target biological, psychological, and social problems simultaneously. Similarly, reasons why people do not take medication are complex and cannot be solved with a lottery system. Hopefully practitioners make more time to listen to patients' concerns about taking medication as prescribed and help patients problem solve ways to overcome barriers faced. Medication noncompliance is a public health concern that requires all of us to work to overcome.
Article link: https://www.nytimes.com/2017/11/06/upshot/dont-nudge-me-the-limits-of-behavioral-economics-in-medicine.html?partner=rss&emc=rss&smid=tw-nythealth&smtyp=cur
Research paper: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2633258
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