TAKEAWAY The importance of patient adherence, part 1

Listen to the discussionAdherence to medication is probably the primary factor that impacts treatment success. The benefits are most measurable in health maintenance, disease response and in cost savings. In a series of columns, Dermatology Times editorial adviser Elaine Siegfried, M.D., discusses a number of issues surrounding patient adherence with Dr. Steven Feldman. He is a professor of dermatology at the Wake Forest University School of Medicine, Winston-Salem, N.C., and a pioneer with regard to adherence. In part 1, the two discuss the important role adherence plays in patient management.

Part 2: Using patient surveys to influence adherence

Part 3: Incentives to encourage adherence

Dr. Siegfried: In a recent issue of The Dermatologist, you wrote in your editor’s message about giving your cell phone number to patients to encourage adherence.1, 2  Can you talk more about that? Do you take calls on evenings and weekends?

Steven Feldman, M.D.Dr. Feldman: Yes, I do give out my cell phone (number), and yes, I do encourage patients to call me anytime, but I don’t think they’ve ever called me late at night. Giving people my cell phone number is one of my most powerful tools to encourage patients to use medications. Consider scalp psoriasis: I used to think scalp psoriasis was the most difficult disease to treat. Nothing ever seemed to work. Then, I found that if I told patients to use their medicine twice a day and come back to the office in three days, they would clear up. So it turns out scalp psoriasis is incredibly sensitive to treatment if you get people to adhere to treatment.

RELATED: Quality time with patients improves adherence to medications 

Then, instead of making them come back in three days, I started having them call me - often on Sundays as I have clinic on Thursdays - to report their progress. The idea was that this would force patients to get the medicine and start using it right away. On top of that, patients would trust me because I gave them my cell phone number. When they call on Sunday, I often do not answer the phone, usually because I’m busy with family, or I don’t hear it ring. The messages are almost invariably the same: “Dr. Feldman, I am so glad you didn’t pick up the phone, because I really didn’t want to bother you on a Sunday, but you said I had to call. I just want to let you know it worked like a miracle! My scalp is 90 percent better already.” So you don’t need to take the call to improve adherence, and in fact, the patient might even prefer if you don’t answer the phone when they call.

I find that people are extraordinarily respectful. I’ve talked to other dermatologists who are in the habit of giving surgical patients their cell phone numbers to call if there’s a problem, and what they tell me is that those phone numbers tend to be underutilized - patients may have problems and they don’t call.

Now there are probably a few who will call more often than others, and if I were getting a lot of calls from somebody I might have to establish limits; I haven’t had to do that yet.

NEXT: Does this technique work with the anxious parents of pediatric patients?

More to come in this series on medication adherence

Part 2: The power of empathy and patient satisfaction measurements

Part 3: Interventions, patient accountability, and whole health system incentives for research

Elaine Siegfried, M.D.Dr. Siegfried: In my office I have two nurses that are on the phone almost full-time. It’s well-studied that pediatricians spend more time on the phone than any other specialty, primarily to reassure anxious parents. So have you done this for pediatric patients, or do you think the technique differs in terms with respect to parents of pediatric patients as opposed to adult patients?

Dr. Feldman: Yes, parents are more anxious about their children. That’s an enormous issue. I do use the cell phone technique regularly for parents, too. I used to think that atopic dermatitis was hard to control. When I was a resident I would see patients with atopic dermatitis who had failed every single outpatient therapy: the standard topical steroid, the more potent topical steroid, cyclosporine, methotrexate. But when those patients were admitted to the hospital on Friday night with lichenified dermatitis from head to toe, they would be ready to go back to school on Monday.

When you admit kids to the hospital they’re putting the triamcinolone on, and they get better. Presumably you should be able to clear up any child of atopic dermatitis with triamcinolone - if you can get the parents to follow the treatment at home; but parents are terrified of topical steroids. When I give them my cell phone number it reassures them. They can trust me. If there’s a problem, they can call me. 

I have some other tricks for getting patients with atopic dermatitis to use the recommended medicine:

• First, don’t use the word steroid in front of them. It’s a very misleading word.

• Next, tell the parent to put the triamcinolone on the child for three or five days and then call you or your nurse to report the progress. The anticipated call nearly forces patients to get and use the triamcinolone. They don’t have to worry about long-term side effects because they’re going to call you in three days and you’re going to talk about the results. 

Now, if you have patients calling your nurses eight hours a day, it suggests that the patients aren’t getting the full information they need up-front, in a way that is reassuring to them. We did a study on the callbacks to our office.3 Our nurses documented every call, and we found that most of the calls were anxious parents with concerns about isotretinoin. As a result, we prepared a handout of frequently asked questions.

NEXT: Do socioeconomic factors come into play?

Dr. Siegfried: Do you think that socioeconomic factors impact adherence? And if so, do you have mechanisms to address that? 

Dr. Feldman: I think there are socioeconomic factors that impact adherence, but I don’t know that we can count on anybody to be adherent to treatment. It’s the oddball that actually uses the medicine truly religiously. I think we have to assume that people of all socioeconomic statuses are not using their medicine. I like to teach my residents to never label somebody a noncompliant patient … because it’s redundant. That said, prescribing unaffordable treatments is almost certainly going to reduce patients’ adherence to treatment.

Dr. Siegfried: Can you clarify your feelings about the word compliant or noncompliant versus adherent or nonadherent?

Dr. Feldman:  I use the words “compliance” and “adherence” interchangeably.

Dr. Siegfried: Do you use any measures of adherence and do you document adherence in any way in your EMR? 

Dr. Feldman: For the most part, no, I just assume that adherence is a problem. But I sometimes ask patients about adherence. If you ask the patient if he’s taking his medicine, he may say, “Of course!” But there are ways of telling. For example, you would think that a patient with psoriasis so bad he needs a biologic, would take it regularly. They don’t. You can tell by asking the patient, “Are you keeping the extra syringes you’ve accumulated refrigerated like you’re supposed to?” If he says, “Yes and I’ve got about six or eight of them in the drawer,” then you know he is not using it regularly because he wouldn’t have accumulated any extras. 

When it comes to topical medications, one of the problems we have is that it’s very hard to quantify how much you should go through in a given period of time. If the patient comes back for a return appointment three years later with some of a 30-gram tube remaining, you may want to think about the possibility that there could have been poor adherence.

In Denmark they have a single national pharmacy system. Andreas Storm, M.D., and colleagues looked at how long it took patients to fill prescriptions.4 They gave patients with psoriasis, eczema and acne their prescriptions and then they went to the pharmacy database to see how long it took the prescriptions to get filled. They found that 90 percent of acne prescriptions were filled within one month, which is pretty good except that means 10 percent of them did not get filled. One-third of the prescriptions for atopic dermatitis were not filled within a month. Half of the prescriptions for psoriasis were not filled within a month. I look forward to the day when we have one giant health system and the pharmacy records are right there in the chart for us to see. 

References:

1. Feldman SR. The dermatologist. 2014; 22(4):7

2. Feldman SR. Clin Dermatol. 2014;32(3):444-447

3. Barnes LE, Al-Dabagh A, Huang WW, Feldman SR. Dermatol Online J. 2014;20(5):22609

4. Storm A, Andersen SE, Benfeldt E, Serup J. J Am Acad Dermatol. 2008;59(1):27-33

More in this series on medication adherence

Part 2: The power of empathy and patient satisfaction measurements

Part 3: Incentives to encourage adherence

Read or listen to past Takeaway expert interviews:

Dr. Robert Kirsner on strategies for managing leg ulcers

Dr. Alan Menter on recent developments in the treatment of psoriasis

Dr. John Zone on whether gluten drives skin disease