Enhancing Patients’ Treatment Adherence
Within the world of dermatology, I specialize in the treatment of psoriasis. For many years, the most difficult, the most resistant, the most frustrating type of psoriasis to manage was scalp psoriasis. I tried prescribing every treatment known for psoriasis with little to no improvement. I attended dermatology meetings, seeking out sessions that covered the management of scalp psoriasis. I learned many little tricks, often combination drug treatments, that didn’t help one iota in my psoriasis patient population. I began to doubt my worth as a dermatologist.
None of the conventional tricks worked. Scalp psoriasis was supposed to be resistant because the thick scales block penetration of topical treatments. But adding descaling agents to the treatment or prescribing oily, moisturizing vehicles didn’t seem to help at all. Scalp psoriasis was supposed to be resistant to treatment because patients would scratch their scalp, irritating and exacerbating the disease. But adding anti-itch medications didn’t seem to help at all, either.
Then it dawned on me that the reason scalp psoriasis wasn’t improving wasn’t because of any of the reasons I had been taught, it was simply that patients were putting the medications on their heads. We know patients are taking their pills. Applying messy creams and ointments to spots on the body is even worse. But the mother of all compliance problems is a prescription for topical treatment of the scalp, as getting medication past the hair is difficult and time consuming, not to mention quite messy with some of the oily products I used to recommend.
It turns out that scalp psoriasis is one of the easiest forms of psoriasis to control. Prescribing a potent topical steroid for just 3 days will clear the disease. But the key is prescribing it for ONLY 3 days. If I prescribe the medication for 8 weeks, it doesn’t work. If the patient is given a prescription to use the medication for 3 days along with a return appointment in 3 days, the disease clears up—in the words of many of my patients—like a miracle!
Why is this? Consider what happens when dentists recommend to their patients to floss every day. The only patients who comply are truly obsessive-compulsive (I floss daily, but then, the field of medicine probably selects for people with obsessive-compulsive traits). But if the dentist put his or her hand on the patient’s should and said, “I’m worried about your gums. I want you to floss twice a day. I will see you back here in the office in 3 days,” patients would floss really well those 3 days.
The return visit does all sorts of things to improve adherence to treatment. Foremost, an early return visit reduces the apparent burden of treatment. The prospect of taking medication over the long run may seem daunting; taking it for just 3 days seems easier. If the return visit is scheduled for 8-12 weeks, patients may not feel any urgency in filling the medication in the first place; they may not even try to fill it until after they lost prescription. With an early return visit, there is an urgency to fill and start on the medication right away. Finally, that early return visit communicates that the doctor cares about the patient (see last month’s post if you don’t know how important caring is); when patients realizes how much the doctor cares about them, patients are more trusting of the medication and feel the need to take the medication as recommended as not to disappoint their doctor.
The return visit may be the most powerful motivating factor in the adherence universe. If you are caring for patients with hypertension, diabetes or any chronic illness, you can get rapid initial control of their condition, you can make medications work much better, just by seeing the patient back shortly after starting treatment.1, 2
References
- Turchin A, Goldberg SI, Shubina M, Einbinder JS, Conlin PR. Encounter frequency and blood pressure in hypertensive patients with diabetes mellitus. Hypertension. 2010 Jul;56(1):68-74.
- Brixner DI, McAdam-Marx C, Ye X, Lau H, Munger MA. Assessment of time to follow-up visits in newly-treated hypertensive patients using an electronic medical record database. Curr Med Res Opin. 2010 Aug;26(8):1881-91.
Author Bio
Dr. Steven Feldman is a professor of dermatology and public health sciences at Wake Forest Baptist Medical Center in Winston-Salem, NC, where he studies patients’ adherence to treatment. He is also Chief Science Officer of Causa Reseach, an adherence solutions company (www.causaresearch.com), founder of www.DrScore.com and author of “Compartments” (www.compartmentsbook.com). Contact him at sfeldman@wakehealth.edu.
