Successfully traversing the hurdles of patient adherence.
By Allison Evans, staff editor, August 01, 2012
Often, psoriasis patients visit their dermatologist attempting treatment after treatment, trying to reduce and control symptoms of a disease that can drastically affect quality of life. But while some cases appear stubbornly resistant to treatment, dermatologists should consider whether the cause is as simple as patient adherence.
A 'eureka’ moment
Steven Feldman, MD, PhD, director at the Galderma Center for Dermatology Research and professor of dermatology, pathology, and public health sciences at Wake Forest University School of Medicine, typically works with patients who are referred to him after having been to the family doctor, followed by a dermatologist — maybe even a few dermatologists — with little or no improvement in their condition.
“When I was a medical student and dermatology resident, [the topic of adherence] almost never came up,” he said. Despite the lack of conversation on the topic, the issue of why some patients did not respond to various treatments remained elusive.
“I said to myself, I have to find out what my psoriasis patients are doing,’” he said.
Eventually, Dr. Feldman’s research colleague told him about a company that produced medicine bottles with computer chips in the cap to monitor patients’ usage. After hearing about this new technology, Dr. Feldman decided to try them. [pagebreak]
While the first study he performed with the chipped medicine bottles had only about 30 patients, it transformed the way he looked at clinical practice. He discovered that a large percentage of the patients reported using their medication as directed, but in reality did not (J Am Acad Dermatol 2007;57:81-3). The study helped Dr. Feldman realize that it may not have been that the treatments themselves were failing, but rather that they weren’t being used as prescribed.
For patients with mild to moderate psoriasis, topical treatments are generally prescribed first before systemic treatments are used. “Patients who have milder psoriasis are less adherent to their therapy, especially topical therapy,” said Mark Lebwohl, MD, professor and chair of dermatology at Mount Sinai School of Medicine.
Unfortunately, topical treatments typically have poor adherence rates. The factors that hinder patient compliance include messiness, frustration with medication efficacy, time constraints, and fear of side effects, among others. However, once clinicians recognize this fact, there are options that may be implemented to help improve adherence to topical medications. [pagebreak]
Show that you care
One of the reasons some patients decide not to take (or apply) their medicine stems from a basic mistrust of physicians. Establishing a strong patient-physician relationship can help alleviate patient fears and lead to an effective treatment plan.
“You’ve got to make [patients] realize what a caring, empathetic doctor you are,” Dr. Feldman said. When he first started practicing dermatology, Dr. Feldman believed that a good’ doctor accurately diagnosed the problem and prescribed the right treatment. Yet he was encountering several instances in which patients would return to the office angry and unhappy about their skin condition. He soon discovered these same patients did not use their medicine as prescribed or maybe at all.
“Even though I am caring, I didn’t communicate that I am caring. I gave them the right diagnosis; I gave them the right treatment. And those are pillars of successful treatment. My residency training had been all about those two things — but there’s a third thing: making sure the patient uses the medicine,” Dr. Feldman said.
Simple gestures such as talking to the patient about the frustration of previous treatments and taking the time to make sure patients realize you carefully examined their lesions can help communicate both compassion and empathy as well as establish a trusting patient-physician relationship. [pagebreak]
Write it down
One simple way to increase patient adherence is to make sure dermatologists provide all patients with clear, written instructions. Patients can simply forget to take their medicine or forget their physician’s instructions, Dr. Feldman noted.
“Each patient should get every instruction in writing,” Dr. Feldman said. These instructions can prevent misunderstandings that can result in patients not following the prescribed treatment regimen. “We cannot expect that people will remember everything, or anything, we tell them,” he continued.
Dr. Feldman often uses educational materials provided by advocacy groups for patients with psoriasis, such as those published by the National Psoriasis Foundation. The American Academy of Dermatology is another excellent resource for patient education pamphlets, online information, and other materials. Dermatologists may also want to send patients to a nurse before they leave, who can reinforce important instructions and print out additional information for them to take home.
Scalp psoriasis: The ultimate example
In Dr. Feldman’s book, Practical Ways to Improve Patients’ Treatment Outcomes, he refers to scalp psoriasis as “the mother of all adherence problems.” Many treatments prescribed to treat scalp psoriasis are messy and highly inconvenient for patients, he said. [pagebreak]
“Imagine yourself in your bathroom applying the medication to your scalp. The process takes a considerable amount of time and may be quite messy. Can you envision wearing one of the more messy preparations (such as tar ointment) on your scalp, covered by a shower cap? Can you imagine then placing your head on your pillow and lying in bed next to your spouse or significant other?” Dr. Feldman wrote.
The answer for most patients is a resounding no, even though scalp psoriasis is highly sensitive to topical treatment.
“For 12 years I just could not get anybody’s scalp cleared up, and then I discovered that they weren’t using the medicine. And when I figured that out, I learned the tricks to get people to do it. If you can get them to treat their scalp, as hard as that is, you can get them to do pretty much anything,” Dr. Feldman said.
Involve the patient
One of the ways Dr. Feldman improves adherence is to include the patient in the treatment decision. Brad Yentzer, MD, a dermatology resident at Wake Forest School of Medicine, strongly agrees. [pagebreak]
“The old teaching that you need to use ointments to improve psoriasis is completely untrue.... You don’t need moisture — what you need is a patient to use the medicine,” Dr. Yentzer said. Even though many residents are still taught to prescribe oils and ointments for psoriasis, it may not be what’s best for the patient, regardless of the medication’s efficacy. There are other effective vehicles of treatment, such as hydrogel, foam, and shampoo, which are generally preferred by patients over ointments, Dr. Yentzer noted.
“Involve patients in the choice of treatment. It doesn’t make sense to give them a treatment that they don’t want to put on,” Dr. Feldman said.
It’s also important to discuss the cost of the treatment. If a dermatologist prescribes a more elegant vehicle, but it’s branded, the patient may not even fill the prescription. Many typical problems become non-issues when an individual patient’s needs are addressed.
Schedule a return visit
The more troublesome the topical treatment is to use, the more important it is to shorten the timeline between office visits, Dr. Feldman said. “The return visit is the most powerful tool to get the patient to use the medicine,” he said. [pagebreak]
“There is a variety of topical therapy treatments used in psoriasis with evidence for their effectiveness,” Dr. Feldman noted in a review published in the Journal of the American Academy of Dermatology (2008;59:1009-1016). However, in clinical practice topical treatments often fail.
An example of the power of the return visit can be seen in the clinical trials for calcipotriene. The trials yielded dramatic results: Over eight weeks, about 70 percent of patients had clearer skin. However, when Dr. Feldman prescribed the same medicine for his patients, he found that after eight weeks, none of the patients had improved.
“In the clinical trials, they brought the patients back at weeks one, two, four, six, and eight to record the progress of the disease. And in doing so, they made the patient use the medicine, because just like people floss their teeth right before seeing the dentist, they use their medicine right before seeing the dermatologist. You take away the visits and they don’t use the medicine nearly so well,” Dr. Feldman said.
Realistically, of course, dermatologists may not be able to see many of their patients soon after prescribing a topical treatment because of full schedules. And some patients are unable to return themselves because of work schedules and high co-pays. [pagebreak]
Dr. Yentzer has worked on ways to combat this dilemma through deliberately timed virtual or electronic office visits. His idea is to give patients a business card with a link to an Internet survey that collects the same data that an actual office appointment would collect. He’s already performed a pilot study for teenagers using topical treatments for acne. The results were encouraging — the patients using the weekly virtual appointment had better adherence (Arch Dermatol 2011;147(10):1223-4). Dr. Yentzer is currently working on testing this strategy further on a larger population of patients.
Dealing with side effects and patient perception
Another common reason that patients do not take their medicine is because they fear the side effects. The package label inserts that detail all possible side effects of the medication can be overwhelming and frightening, especially if patients have not been well prepared to sift through the information.
For example, topical steroids are often used to treat psoriasis; however, for many people, the word “steroid” is instantly associated with anabolic steroids. Once that connection has been drawn, patients aren’t likely to use the treatment.
“When [patients] hear the word “steroid,” they worry about dermal and epidermal atrophy. You need to sit down and properly educate your patients about how they use the medicine. This is when written action plans can really come in handy,” Dr. Yentzer said. [pagebreak]
Being proactive about possible side effects can help ease patient apprehension. Dr. Feldman suggests making the side effects work for the dermatologist. When he treats scalp psoriasis, sometimes the alcohol-based solutions sting. He’ll tell patients, “This may sting; that’s a sign that it’s working.”
Make it simple, make it quick
When it comes down to whether or not a patient is going to use a medicine, more often than not simplicity of routine will be a decision-making factor. Some dermatologists want patients to use multiple topical treatments, making the routine exponentially harder to do, Dr. Feldman said.
“The combination drug therapies can be more expensive if they’re branded, but they have tremendous advantage on the adherence side,” Dr. Feldman said. Adherence levels dramatically increased using single combination drug therapy.
In addition to not wanting to use multiple vehicles of treatment, patients don’t want to think about their medicine multiple times a day. Any time a patient has to use a treatment that’s prescribed more than once a day, adherence declines, Dr. Lebwohl said.
“This led to a number of topical drugs, such as the combination of betamethasone dipropionate and calcipotriene, that were tested for use twice a day, which were then tested again for use once a day,” Dr. Lebwohl said. The results showed that the once a day use was just about as effective as the twice a day use possibly because it was a more manageable treatment plan for patients. [pagebreak]
As important as simplicity of treatment is, it’s also a good idea to prescribe a fast-acting medication, if possible. “If it works slowly, then they’re not going to stick with it. Patients need to see benefits quickly,” Dr. Feldman said.
While there are many fast-acting treatments available, the problem is that they tend to be short-acting. “The treatments are quick to work and clear the psoriasis, but as soon as they put the medicine down, even after only a day or two, it [the psoriasis] starts to come back,” Dr. Yentzer said. In order to have long-term efficacy, patients need to use the medicine as prescribed.
Dermatologists need to remember that there is no “fast-acting” treatment for patient adherence. No single “trick” or treatment will magically get all patients to follow instructions properly. But making adherence a priority in practice is something that can yield long-term practice efficacy.
Before and after
In a study published in the Journal of the American Academy of Dermatology (2007;57:81-3), adherence was shown to improve around the time of office visits for multiple conditions, especially in the period two days before and two days after office visits. Adherence behavior was assessed in three previous studies of atopic dermatitis, psoriasis, and hand dermatitis. The percentage of subjects who did not open the bottle at all on any given day is shown. For each of these three groups, the probability of not opening the bottle on a given day is lowest right around the time of an office visit. The atopic dermatitis group showed lower adherence than the other groups; however, this group contained only children. This was also the only group that was not informed of their participation in the study.