Take as Directed (or Why Not?)

William Vinacco had high blood pressure. His doctor wrote him a prescription for a drug to bring his numbers down. But the 57-year-old environmental manager from Cranston, Rhode Island, never picked up the pills.

Vinacco is not alone. Nearly one-third of patients don’t fill a new prescription. That can be a big problem, particularly for those with high blood pressure or other serious conditions. Numerous factors play a role in a patient’s decision, and researchers are looking for ways to engage patients and their doctors in a collaborative process that takes into account a patient’s preferences and health goals.

Assigning blame isn’t the point; improving the process is, says Jennifer Polinski, ScD, MPH, MS, an epidemiologist at Brigham and Women’s Hospital in Boston.* “Failing to fill a new prescription reflects poor communication among the patient, prescriber, and pharmacist about their shared goals for the patient’s health, their plan for achieving those goals, and whether drug treatment is acceptable to the patient,” she notes.

Straight Talk about Medication Concerns

With support from the Patient-Centered Outcomes Research Institute (PCORI), Polinski is working to get patients and clinicians to discuss concerns about medications routinely. For example, Vinacco says his physician had told him there were no side effects of the newly prescribed medication, but he reports learning online and from his pharmacist and wife that the drug could harm his kidneys and liver. So he did not fill the prescription: “I thought the right thing to do is to eat right and work out.”

“Some people can reduce their blood pressure with lifestyle modifications like diet and exercise, but most people will need an antihypertensive medication to do so,” Polinski says. “Having a conversation with one’s doctor about what approach is best makes the most sense.” She notes that the consequences of not controlling blood pressure over the long term could be dire, including increased risk of a stroke or premature death.

Patients may be more likely to fill an initial prescription when it is part of shared medical decision making. In that process, a patient and a provider consider the available scientific evidence, as well as the patient’s values and preferences, and decide together what options to pursue.

Tracking which or how many patients do not fill an initial prescription was difficult in the era of paper-based medical records. “But with health information technology and e-prescribing,” Polinski says, “we can much more easily study this phenomenon.”

Identifying the Issues

Polinski has held focus groups with Vinacco and other patients who had just received their first prescription for blood pressure medicine. She hosted other focus groups with either physicians and other prescribers or pharmacists. Each discussed why patients might not fill a new prescription.

“Patients may face cost barriers or lack social support. Or they may not believe in the need for drug therapy. Or they may worry about side effects or toxicity,” notes Polinski. Some patients said that they were unconvinced or angry about their diagnosis of hypertension. Others thought that they should be able to take only one medication, although their doctor prescribed more.

With those findings, Polinski developed an easy-to-read brochure and a poster to help patients ask questions of their doctors or pharmacists about newly prescribed hypertension medicine. Next, she plans to find out whether the brochure and poster increase shared decision making and patient satisfaction with decisions about their treatment. She will also measure whether the materials boost the rate at which patients fill new prescriptions.

PCORI funded this two-year project in 2012 as one of 50 pilot projects that address a broad range of questions about methods for engaging patients in health research and information dissemination.

"So Far, So Good"

Polinski was inspired to do her study after overhearing a man at her local drug store explain to the pharmacist that he had received five new prescriptions from his doctor. He asked, “I have $50, which ones can I get?”

Too often, patients don’t bring up such personal issues with their physicians—nor do doctors encourage such conversations—even though solutions to practical problems might be available.

“There are so many missed opportunities for doctors and patients to discuss, even briefly, issues that may sway a reluctant patient to fill a new medicine,” Polinski says.

As for Vinacco, he boosted his exercise program, improved his diet, and took natural supplements. When he went back to see his doctor, she noted that his blood pressure was lower. They talked about his decision, and she agreed he was on the right track. “So far, so good,” Vinacco says.

Posted: December 19, 2013; Updated: March 25, 2015

^{*Jennifer M. Polinski is now Director of Foundational Research at CVS Caremark Corporation. Michael Fischer Brigham is currently the Principal Investigator of this PCORI-funded project at Brigham and Women’s Hospital.}