Physician Spotlight: Steven R. Feldman, MD, PhD
The new thinking on improving adherence in dermatology.
Steven R. Feldman, MD, PhD, a professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC, wrote the book on adherence in dermatology—literally. Practical Ways to Improve Patient Adherence, which Dr. Feldman co-wrote with Daniel J. Lewis, became available in late 2017. He shared some of the new thinking on improving adherence including switching the blame away from patients and on to physicians with Practical Dermatology®.
What are main hurdles to patient compliance?
Dr. Feldman: The standard way to look at it is that the biggest hurdles are lack of motivation, patients’ forgetfulness, their fear of side effects, inconvenience of treatment, perception of weak efficacy, not understanding what to do, and cost, among other things. All these hurdles are patient-oriented—we are blaming the patient. A more fruitful way to consider the hurdles is to look at what we have direct control over ourselves and frame these issues a little differently. In this way, we would see the hurdles as physician hurdles: We don’t adequately motivate patients, we don’t get them to use adequate reminders, we don’t give them enough reassurance regarding safety, we prescribe regimes that are complex and inconvenient, we don’t give patients treatments that work fast enough, we don’t educate patients well enough and we sometimes prescribe things patients can’t afford. If we look at it from the latter perspective, it’s easier to see what we can work on to help improve our patients’ adherence and outcomes.
What are some specific compliance issues in regard to psoriasis and/or atopic dermatitis?
Dr. Feldman: First, the great majority of people with psoriasis and atopic dermatitis have limited disease that can be treated with topical agents, but adherence to topicals is miserable. Just getting patients to fill the prescription is difficult; about 30 to 50 percent of prescriptions for atopic dermatitis and psoriasis aren’t even filled. When patients don’t fill or start on treatment, we call that primary non-adherence. But even if we get them to start on treatment, they may use the treatment poorly or discontinue treatment early, a phenomena we call secondary poor adherence. Even patients with severe disease, patients treated with oral or injectable treatment, don’t take medication as directed. In one of our studies, we used electronic monitors to assess adherence to every two week self-injection of adalimumab. Half the patients would go months between injections.
Is technology helping to improve compliance?
Dr. Feldman: Individual patients often find that setting up reminders on their smart phone helps. Research has begun to investigate what apps may be helpful. But so far, there’s lots of room for improvement as no app is widely deployed or effective. Simple technologies have been helpful. A seven-day pill container is a huge help to adherence to pills; I know from personal experience! Also, packaging can be helpful; the packaging of oral contraceptives is a key feature that makes the pill as effective as it is. I don’t know why all our medications aren’t similarly packaged. Human contact, even if digitized, has a huge potential to impact adherence. I encourage patients to reach out to me by cell or through our medical center electronic medical record portal one week after starting a new treatment to let me know how it is working. I figure that that contact lights a fire under patients to fill the prescription and use it well.
Do closer follow-up visits improve compliance?
Dr. Feldman: The timing of the first office visit impacts adherence. If you tell patients, “Use this on your scalp, and I’ll see you back in eight weeks,” they don’t use the medication and don’t get well. If you tell patients, “Use this on your scalp, and I’ll see you back in three days,” they use the medication those three days, and the scalp clears right up. This is not more frequent visits. There will be more visits if you see patients every eight weeks, over and over again, not doing well, than you would seeing them one time at three days, the medication working, the patient happy with their treatment outcome, with follow ups for refills from their family physician.
What other solutions are helping?
Dr. Feldman: There are endless things to do! For kids, I recommend sticker charts. For complicated treatments, I recommend a standard protocol handout. For all patients, making sure the patient realizes you care about them may be critical. All sorts of psychology can be used to promote better adherence. We compiled a lot of our techniques in the new book.
Using patient support groups, like the National Psoriasis Foundation, can be helpful, too. The Foundation encourages patients to be adherent to treatment and helps patients in a host of other ways. The Foundation is honoring Dr. Jerry Bagel with its Excellence in Leadership Award at the upcoming Commit to Cure Gala on June 7, 2018. Supporting the Foundation by attending or donating to the event is a good way to support the Foundation and its many activities in support of our patients and our specialty.