AlignMap

Sources:

Screening: Older Women May Be Skipping Mammograms
By Eric Nagourney; NY Times June 20, 2006

Older Women Have Far Fewer Mammograms Than They Report
By Joel R. Cooper, Health Behavior News Service June 20, 2006
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Both of these articles report on a study to be published in the August issue of The American Journal of Preventive Medicine¹ that compared Medicare data for mammograms received by 146,669 women ages 65 and older with patient self-reports collected by the Behavioral Risk Factor Surveillance System and the National Health Interview Study for the period between 1991 and 2001.

The trend demonstrated by the results in general can be seen in isolated finding that 70 to 80 percent of women ages 65 to 69 self-reported compliance with receiving a mammogram every two years, but only 61 percent were actually screened.

African-American, Asian-American and Hispanic women in this age group received mammogram screening at even lower rates

The study did not address the causes of this disparity.

Commentary

None of this should be surprising, but it is worthwhile to note another bit of supporting evidence for the prevailing trends in patient compliance:

1. Significant noncompliance exists regardless of age or treatment/screening.
2. Noncompliance is typically (but not always) more pronounced among lower socio-economic and minority groups.²
3. As a instrument for measuring patient compliance, self-report is almost universally unreliable

1. Kagay CR, Quale C, Smith-Bindman R. Screening mammography in the American elderly. Am J Prev Med 31(2), 2006.↩
2. This is not equivalent to noncompliance being limited to these groups↩

Fees For HIV Treatment Increase Risk Of Death In Developing Countries

That impoverished HIV patients in developing countries are more likely to die than those who receive free treatment is hardly a suprise. Still, seeing that truth starkly reported is impressive and provocative.

The data, from the ART-LINC collaboration, is derived from 18 treatment centers in South America, Africa and Asia, 12 of which provided free treatment.

Patients who did not pay for treatment had a 75% lower risk of death in the first year than patients who paid.

The report also points out that many programs report providing free treatment, they actually involve substantial costs. Patients at a South African clinic, for example, incurred costs (e.g., clinic fees, transport, food and lost wages) of US$75 a year.

Commentary

Once again, it appears obvious that all factors, including fiscal issues, must be aligned for compliance to improve.

This Reuters News story summarizes the most recent annual healthcare survey conducted by the U.S. Department of Health and Human Services. For those working with addictions, these findings contain no surprises; they do, however, provide yet more evidence of noncompliance persisting in the face of severe consequences, including death, even when the smokers know the risks.

The results, from survey data collected in 2003, include the following:

• 43% of subjects with emphysema reported that they continued to smoke
• 22% of those with asthma reported that they continued to smoke
• 21 percent of stroke victims reported that they continued to smoke
• 20 percent of those with cardiovascular problems reported that they continued to smoke
• Almost 50% of those who smoked in 2003 had a routine medical check-up within the previous year (compared with 61% of nonsmokers). Of the smokes who had a check-up, 63% were advised to stop smoking.

A brief but insightful take on culture-specific noncompliance comes from an excerpt of an article from the Salt Lake Tribune, “Work at clinic a labor of love for midwife” By Kirsten Stewart (Last updated 05/10/2006)

Background: Ms Montiel is a midwife who runs Centro de Salud Familia, a women’s clinic adjacent in Salt Lake that treats that primarily treats impoverished Latino families. She points out that just speaking Spanish is insufficient. She speaks to research that correlates poor healthcare among Latinos to noncompliance:

“If they [Latinos] miss an appointment, it’s because they’re working. And if they lie about it, which they often do, it’s because in the Hispanic culture, it’s better to fib then offend someone,” said Montiel. “And if a patient is late, it’s probably because she was making a platter of food. She’s two weeks post-partum and she’s making us lunch.”

Two forum entries by patients in the multiple sclerosis section of the BrainTalk Communities Online Patient Support Groups for Neurology indicate that mistrust of a company that produces medications for the treatment of multiple sclerosis can “significantly affect drug adherence.”

The thread begins with a forum member’s posting of what appears to be the Biogen Idec press release describing the Global Adherence Project, a large-scale, international study of patient compliance with multiple sclerosis treatments. The press release included this quotation from the study’s lead investigator, Elliot Frohman, MD, PhD:
“Our analysis of adherence patterns thus far tells us that certain drug-related issues can significantly affect adherence in MS, including frequency of drug administration, medication side effects, as well as how effective the patient perceives their treatment to be.”

In response, another member of the forum lists “Other drug related issues that can significantly affect drug adherence in MS,” including

• A pharmaceutical company’s surreptitious recall of “tainted lots” of medications for the treatment of multiple sclerosis
• A pharmaceutical company misleading patients, pharmacists, and physicians about the reasons for a recall of “tainted lots” of medications for the treatment of multiple sclerosis
• The production and marketing of a new version of a medication for the treatment of multiple sclerosis without thorough research and, in effect, using patients who then took the medication as test subjects to evaluate side-effects
• Executives of a pharmaceutical company selling their privately owned stock in the company just prior to publicly announcing that a new medication has caused patients’ deaths

In the next posting in the thread, another participant in the forum extends the list of possible causes of “distrust of the medical community” to include

• Pharmaceutical companies charging “unwarranted” prices for essential medications.
• The prescription of the same medication to all multiple sclerosis patients in the face of the observation that these medications do not work for every patient
• The influence a physician’s “affiliations” [apparently with pharmaceutical companies] on the choice of medications prescribed
• The failure of the medical community to endorse a trial of alternative therapies for multiple sclerosis
• The suspect motives of Biogen’s support for the Global Adherence Project.

These are not the first, nor will they be the last, criticisms leveled against pharmaceutical manufacturers and their affiliated physicians, and I have no independent data supporting or refuting the particular allegations made by these forum participants.

I am, however, struck by the direct link specified by the forum members between mistrust of a pharmaceutical manufacturer and effect on adherence to medication produced by that manufacturer. While there is, of course, a plethora of literature relating compliance to a trusting patient-physician relationship, a good deal of advertising paying homage to the notion of the public nonspecifically trusting one or another company in the abstract, and there have been several cases of public concerns about the dangers of a specific drug decreasing its use, I cannot recall or, in a hasty search, find evidence of research exploring the direct impact of a pharmaceutical manufacturer’s corporate reputation among patients on those patients’ compliance with that corporation’s medications in a non-crisis situation..

It would be easy to dismiss this as simply a case of unhappy patients using adherence as a handy soapbox on which to rage against a pharmaceutical company being blamed for a portion of his or her suffering, and I doubt that most patients prescribed a medication for an acute condition (e.g., a patient prescribed an antibiotic for a urinary tract infection) would routinely consider the identity, let alone the reputation, of the corporation that produces and markets the drug. On the other hand, it does not seem incredible that a subset of patients, those suffering from a chronic, severe disorder who assiduously seek and follow medical research and other news pertinent to that disease, are aware of and react to the perceived trustworthiness of a company responsible for a medication that could greatly improve or gravely endanger their outcomes.

In any case, it would seem both foolish and dangerous for pharmaceutical companies to casually discount the possibility that their perceived integrity among these patients directly affects how these patients use the manufacturer’s medications, and research checking for correlations between shifts in a patient’s esteem for a pharmaceutical manufacturer and the patient’s adherence with the manufacturer’s medications might prove interesting.

A New View of Compliance by Brian Robinson (Director of Pharmaceutical Marketing at RTC Relationship Marketing) & Charles Islander (President of The People’s Medical Society). (DTC Perspectives Magazine, 4/23/2002)

OK, DTC Perspectives Magazine is not usually at the top of my stack of medical literature. DTC Perspectives, according to their web site is a “company specializing in consumer marketing of pharmaceuticals.” That their point of view may differ from that of a typical clinician, however, does not automatically negate the validity of their ideas; in fact, a different different perspective can prove enlightening.

The article’s primary points, by my reading, are

1. There are multiple distinct causes leading to the final outcome of noncompliance.
2. Healthcare professionals have an inherent tendency to view any identifiable set of medical issues, such as pregnancy and, in this case, noncompliance, as a disease or medical condition.
3. A more effective way to address noncompliance would be to take “… a concordant physician-centric approach” which requires “… a physician-driven partnership with the patient.”
4. Underlying that approach is “the assumption that a consumer who is shown the value and importance of their [sic] medications and their [sic] medication regimen will use their drugs correctly and consistently.”

The authors go on to suggest specific steps a physician should take to educate the patient about how and why the medications should be taken and to follow-up, using electronic alerts that notify the doctor’s office if the patient has not picked up the prescription.

My scoring of these major points from the article is three out of four ain’t bad. The notion that a patient who knows the importance of the medication will therefore take them correctly (Point #4) is, I fear,  simplistic, overly optimistic, and unrealistic.¹ A patient’s understanding of the medication regimen is a necessary but not sufficient requirement of participative adherence.

On the other hand, their first three points are insightful and the specific steps they suggest, particularly the often overlooked need for follow-up, are helpful. Their primary concern, that the healthcare profession’s intuitive medicalization of noncompliance as a single, unified syndrome is especially telling. Of course, that this view is congruent with my own may influence my judgment on this issue.

And, of course, I agree with their closing argument, that “Helping a patient be compliant should become an integral part of the doctor-patient relationship.”

1. See Myth #3: Noncompliance Can Be Eliminated By Educating The Patient, Motivating The Patient, Eradicating Or Relieving Side-effects, Simplifying The Treatment Plan, …↩