Armstrong AW. Practice Gaps—Failure to Maximize Patient Adherence Strategies in Clinical Practice. Arch Dermatol. 2010;146(12):1430-1431. doi:10.1001/archdermatol.2010.348
Patient adherence to topical medications averages only 25% to 35%. Sagransky et al found that an additional office visit 1 week after the initial consultation was associated with higher medication adherence in patients with atopic dermatitis. While this difference did not reach statistical significance, and trials with larger sample sizes are necessary to examine the precise impact of this intervention, the pilot study presents an opportunity to deliberate on the failure to maximize adherence strategies in clinical practice and the role of dermatologists and their medical staff in implementing these strategies.
Although increasing evidence suggests that nonadherence is a major contributor to perceived treatment failure, few studies have evaluated whether dermatologists are using methods to increase adherence in real-world practice.1 Interventions by dermatologists to improve patient adherence can be categorized into nonpharmacologic and pharmacologic approaches. Nonpharmacologic approaches include patient education, reminders, frequent follow-ups, and encouragement of self-monitoring. Pharmacologic interventions include simplification of medication regimens and consideration of patient preferences in choosing formulations for more individualized therapy.
Patient education has been the primary nonpharmacologic approach studied to increase adherence. Patient education will be more effective if it begins with identification of patients' perceptions and misperceptions regarding medications. This type of tailored counseling may help patients overcome misconceptions that contribute to nonadherence. While most dermatologists would agree that good clinical practice includes giving patients clear and detailed instructions on the proper use of medications and their associated adverse effects, short encounter times in most practices make such face-to-face counseling challenging. Therefore, innovative methods for disseminating patient educational materials need to be considered. For example, educational materials for commonly recommended topical agents may be posted on a practice's Web site as either static text-based Web pages or instructional videos. The nonvideo online materials could also be printed and handed to patients during the visit. As a systems solution, electronic medical record systems may be configured to create automated and customizable patient educational materials that are linked to prescription orders and delivered to patients with their prescription. For practices that are primarily paper based, hard-copy handouts are still a time-honored means of conveying educational information, which should be written at an appropriate literacy level to ensure maximum comprehension.
Other nonpharmacologic adherence strategies include empowering support staff to provide face-to-face patient counseling, which will likely lead to increased adherence and save physicians' time. Another strategy is encouraging patients to self-monitor medication adherence. Asking patients to keep a medication diary and bring back medication tubes at each visit may also promote greater adherence.
Strong evidence exists in adherence literature that a complicated medication regimen is associated with lower adherence. To increase adherence, dermatologists need to consider designing regimens with the fewest possible number of medications and the lowest dosing frequency.2 While medications with combined formulations are often more costly, this increased cost may be justified for selected patients if it significantly improves adherence and prevents unnecessary office visits resulting from nonadherence.
To close this practice gap, dermatologists need to address the issue of medication adherence explicitly with their patients, their medical staff, and themselves. While changes in existing practices may be difficult to implement, increasing patient adherence is a worthwhile effort at the heart of effective therapeutics.
Correspondence: Dr Armstrong, Dermatology Clinical Research Unit, Teledermatology Program, Department of Dermatology, University of California Davis Health System, 3301 C St, Ste 1400, Sacramento, CA 95816 (firstname.lastname@example.org) (email@example.com).
Financial Disclosure: None reported.