Adherence to Medication Regimens Among Patients with Multiple Co-Morbid Chronic Conditions: A Qualitative Assessment

Abstract

Background: Understanding the illness experience from the point of view of patients who have multiple chronic conditions and are managing multiple medications is an area that is largely understudied. One in four Americans lives with two or more chronic conditions and by age 65 the prevalence rises to almost 70%. Almost all of these individuals who seek medical care are treated with multiple prescribed medications but non-adherence is highly prevalent especially when multiple medications are taken for each co-occurring medical illness. Patients who take multiple medications tend to incur higher out-of-pocket medication costs, are reluctant to take multiple medications and have a preference to minimize medicine intake, experience drug interactions that may result in hospitalizations, and have a higher likelihood of incurring inpatient admissions. These effects, which are more pronounced in economically disadvantaged, minority populations with fewer resources, may lead to poor adherence and adverse health outcomes. This study used qualitative methods with adult, predominantly low income and minority patients who were living with at least two chronic co-occurring conditions and who received prescribed medications for each condition to determine barriers and facilitators to medication adherence, and their self-care strategies. Methods: Qualitative study consisting of five focus groups of 50 men and women diagnosed with at least two chronic conditions receiving care at University-affiliated primary care outpatient clinic in urban Baltimore, Maryland. Data comprised pre-focus group socio-demographic and medical history surveys, focus group discussion transcripts, and focus group facilitator notes. We used template analysis for coding the focus group transcripts.

Results: The participants identified personal/contextual and health system factors as major impediments to adherence to multiple medications. Some of these factors included: medication side-effects, fear of harm from medication, fear of dependence on medication, complex instructions, suboptimal communications with doctor, suspicion about doctors' and pharmaceutical companies' motives in prescribing medication, and the high cost of medications. Participants also identified motivators, both internal (self-initiated) and external (initiated by family, doctor, support groups), to ensure adherence to multiple medications. These motivators included: self-discipline, sense of personal responsibility, faith, support from family members and/or doctors, and focused health education and self-management support. Our framework for organizing the emergent themes has identified four constructs crucial to understanding adherence to multiple medications. These constructs include a threshold for medication adherence, shared decision-making, experiences of suboptimal medication adherence, and personal decisions regarding medication adherence. Our analysis revealed that the patients perceived a lack of shared decision-making in the management of their co-morbid chronic conditions and their medication regimen.

Conclusions: Findings suggest the need for interventions aimed towards enhancing shared decision-making when developing management plans for chronic co-morbid conditions in order to improve adherence to complex regimens involving multiple medications.