“Samantha, I have the list of our patient’s prescription medications from his wife. Quite a few, actually.”
Samantha glances at the list. “How compliant is he on these?” she asks.
I stammer for a moment, then say, “I’ll see what I can find out.” Then I begin to wonder.
Over the years we’ve asked countless patients, “What pills do you take on an everyday basis? What prescriptions do you have from a doctor? Other than marijuana or CBD oil, any street drugs?” Some patients are organized and have a list written out. Some medications will be vague, such as a blood pressure pill without a name or dosage. Some might be new to us.
Usually we take their answer at face value. But after looking into the data on patient compliance with doctors’ medication instructions, an approach of gentle questioning may be just what is needed.
Know the Why
Even those of us who know better can struggle with compliance. My chiropractor, Dr. Klein, asked me during a recent visit how I was doing with the stretching and exercises she’d assigned me. Apparently when I looked down at my feet and mumbled a vague “Fine, no problem,” she knew I was not being compliant. While I’ve had amazing results from Dr. Klein, admittedly I had not done my stretching and strength-building homework.
I asked Dr. Klein her expectations for her patients following their treatment regimen at home. “It’s different for each patient,” she says. “When a patient is compliant with one recommendation, it increases my confidence that they will continue to follow other aspects of their treatment plan. Making sure the patient knows why something is being prescribed has been the single most impactful way to increase compliance in my experience.” Pretty much on point across the medical field!
In looking at prescribed medications, we’d be wrong to assume they are all actually filled and picked up. According to the Healthcare Finance website, “Nearly half of consumers have abandoned a medication prescribed by their physician because it was too expensive.”1 Half of patients don’t take all their medications because a prescription is too costly or they simply don’t get around to picking it up!
When you get a prescription from a doctor, do you ask them what it costs? In the past the patient would need to drop the prescription off, then return to pick it up. That is changing. Many prescriptions now are sent directly to the pharmacy from the doctor’s office, so this may increase the number actually picked up.
Take cost out of the equation for a moment. Low-dose aspirin is one of the least expensive drugs for cardiovascular treatment to reduce the risk of heart attack. A small 81-mg daily pill is often directed by a doctor and is available over the counter. Aspirin is a first-line drug for EMS, yet, the compliance in taking aspirin over 6 to 12 months is only 71% according to a Harvard Medical School study.2
The same study looked at beta blockers for high blood pressure. Only 46% of patients still took those medications after 6 to 12 months. Why? The reasons are many and include cost, side effects, and lack of disease signs or symptoms in the patient. Cholesterol-lowering drugs? Just about the same, 44%. The list goes on, but for all these medications, it’s a coin flip whether the patient is taking them as they should be.
What about patients with treatable mental conditions? Getting accurate compliance data does not seem viable. The Harvard study said for bipolar disorder the rate is 34%–80%—a range so wide as to tell us very little. Schizophrenia numbers are even worse, with rates from 11%–80%.2
Nursing home patients are common for many of us. It is reasonable to assume they will be taking their medications as prescribed, since the staff dispenses and maintains them. It is acceptable to ask if there are any problems with the patient taking their medications.
Some patients may split pills to make prescriptions last longer. What’s the downside? Some medications—Tylenol, for example—have a narrow therapeutic range. If not enough of the drug is in the bloodstream, it is not as beneficial. If the concentration is just right, it is very effective. Too much, and very adverse side effects appear. Other drugs may have wider therapeutic zones. Whether splitting the pill can be effective depends on the drug, but the doctor prescribed the drug and dosage for a reason; cutting the dose in half is likely not good practice.
Understanding But Aware
What does this all mean for EMS? Be understanding but aware. It is rare indeed when we have a patient encounter and don’t ask about medications (or street drug usage). If we ask and get a very specific list of medications that includes dosages, in our opinion that patient is more likely to actually take those medications every day. A patient reluctant to answer may have privacy concerns—there are many Viagra prescriptions in the U.S., but I can’t recall once it was included in a patient’s list without requiring drilling down.
Here are some things you might ask yourself or look for in your patients:
Is their list specific? Does it include dosage?
If you are told something like “a blood pressure pill,” can they be more exact?
What pills do they take in the morning? What pills do they take at night?
Are there any pills they take only as needed?
Do they split pills to make them last longer?
Are they good about taking their pills when they should?
Are old prescription bottles still fuller than they should be?
Ask your medication question again when family members aren’t around or go over the list and ask, “What do you take that for?”
Patients are just like EMTs: Sometimes we are a little shy about admitting our faults. Be gentle and understanding to get past these barriers. Read the body language, just as Dr. Klein did with me. You can do this on your very next call.
Dick Blanchet (ret)., BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.
Samantha Greene has been a paramedic, field training officer, and operations supervisor for Abbott EMS of Illinois for the last 10 years and a lieutenant for the Madison, Ill., Fire Department for the last five.