In the United States, a staggering 3.8 billion prescriptions are written every year, yet over 50% of them are taken incorrectly or not at all. (Medscape) This magnitude of noncompliance is creating detrimental health outcomes for patients. In fact, when compared with patients who adhere to their doctor’s instructions, patients who fail to take their medications as intended have an increased risk for hospitalization, rehospitalization, and premature death. (Medscape) Additionally, when patients do not comply with their prescribed treatment, the disease state or condition typically worsens, thus leading to increased economic burden on the medical community. Noncompliance across all areas of medicine has reached epidemic proportions, but dermatology patients seem to be the worst. Noncompliance could explain why many dermatology patients fail to improve even though efficacious medications and treatments exist for all of the major dermatologic conditions. (Davis, 2016) This article will examine possible reasonings why noncompliance is particularly high with dermatology patients.
95% of Dermatology Patients Underdose
A study of 17 first-time patients with dermatologic conditions found that only one patient used the expected dosage of the prescribed topical corticosteroid. Conclusions from this study suggest that clinicians should always consider nonadherence when topical therapies fail. (JAAD, 2008) A drawback of this study, however, was that it failed to address the reason behind the underdose. Were the patients aware of the correct amount of corticosteroid to use? If the patients knew the correct dosage to apply, did they try to apply less to make the medication last longer? Was cost an issue for the non-adherence? While this study did not consider these questions, other studies have found cost to be a major factor behind noncompliance.
Medication Costs as a Reason for Noncompliance
A nationwide survey assessed 660 adults with chronic illness who reported underusing medication in the prior year because of costs. Participants were asked whether they had discussed cost-related medication underuse with clinicians, reasons that some patients did not talk with clinicians about this problem, how clinicians responded when this issue was raised, and how helpful patients perceived clinicians to be. (JAMA, 2004) The survey results revealed that two thirds of respondents did not report to a clinician in advance that they planned to underuse a medication because of cost. Findings such as this suggest that physicians could improve patient compliance by actively discussing costs before prescribing a medication.
Challenges in the Dermatology Field
One of the major reasons that dermatology patients are notoriously noncompliant is due to society’s association between a tanned appearance with youth and beauty. Many people aim to achieve such an image even though doing so has detrimental consequences to the health of their skin. Moreover, certain types of UV-related skin damage can take many years to develop, which often leads people to choose the short term benefits of a tanned appearance despite the potential long term negative outcomes.
Factors that Affect Proper Application of Topical Treatments
Treating dermatologic conditions with topical preparations is ideal since the active ingredients can be applied directly to the affected skin area with minimal systemic exposure. However, accurate dosing and application can be a challenge due to factors such as forgetfulness, neglect, stress, psychological dysfunction, and physical deficits such as impaired vision or joint problems. In a survey distributed to 53 psoriasis patients in an outpatient clinic, medication nonadherence was 40%. The main reasons given when patients deviated from usage instructions were frustration with medication efficacy, inconvenience, and fear of side effects. (JAAD, 2006)
Optimizing the Physician-Patient Relationship
Optimizing the relationship the physician has with his or her patient is said to be the most fundamental piece of the adherence challenge. Communication, reliability, trust, and empathy are key characteristics that build the physician-patient relationship thus leading to better patient adherence. One suggestion for optimizing the physician-patient relationship is giving the patient ‘perceived control’. This method is especially helpful in psoriasis patients who often feel a sense of loss of ‘control’ due to their disease state. In regards to how optimizing the physician-patient relationship can improve compliance, there is literature that suggests first replacing the term ‘compliance’ with more collaborative terms, such as ‘adherence’ or ‘self-management.’ Dr. Mary-Margaret Chren, MD, writes in her article Doctor’s Orders – Rethinking Compliance in Dermatology about the term compliance by saying, “The word connotes a stigmatizing image of rule, enforcement, control, dominance and submission.”
In Summary
Dermatology patients are notoriously noncompliant due to a variety of factors. Patients often underdose their topical treatments or do not even fill their prescriptions at all due to high costs, forgetfulness, neglect, frustration with medication efficacy, inconvenience, and fear of side effects. Physicians can help to improve treatment adherence by discussing costs with their patients before prescribing, thoroughly explaining usage instructions, and optimizing their relationship with the patient by giving the patient a more active, self-managing role.
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