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Why Don’t Patients Fill Their Primary Care Physician’s New Prescriptions?

A Canadian study published today in the Annals of Internal Medicine suggests that about one third of new prescriptions (written by primary care physicians) are never filled. Over 15,000 patients were followed from 2006 to 2009. Prescription and patient characteristics were analyzed, though patients were not directly interviewed about their rationale for not filling their prescriptions.

In short, patients were less likely to fill a prescription if the treatment was expensive, but certain types of drug indications had consistently higher non-fill rates:

  • Headache (51% not filled)
  • Ischemic heart disease (51.3% not filled)
  • Thyroid agents (49.4% not filled)
  • Depression (36.8% not filled)

Overall, hormonal (especially Synthroid), ENT (especially Flonase), skin, and cardiovascular drugs (especially statins) had the highest non-fill rates.

As far as those prescriptions more likely to be filled, antibiotics (especially for urinary tract infections) ranked number one.

Trends towards prescription compliance were seen among older, healthier patients, and those who were switching medications within a class rather than starting an entirely new drug. Patients who received prescriptions from a doctor that they visited regularly (rather than a new provider) were also more likely to fill their prescriptions.

This study was not designed to elucidate the exact rationale behind prescription non-adherence, but I am willing to speculate about it. In my experience, patients are less likely to fill a prescription if a reasonable over-the-counter alternative is available (think headache or allergy relief). I also suspect that they are less likely to fill a prescription if they believe it won’t help them (skin cream) or isn’t treating a palpable symptom (statin therapy for dyslipidemia). Finally, patients are probably nervous about starting a medicine that could effect their metabolism or cognition (thyroid medication or anti-depressant) without a full explanation of the possible benefits and side effects.

I was surprised to see how compliant patients seem to be with antibiotic agents (at least, filling the initial prescriptions). Given the increasing rates of antibiotic resistance, this reinforces the need to limit prescriptions to those agents truly indicated, and to analyze bacterial sensitivities during the treatment process to optimize medical management.

My take home message from this study is that providers need to do a better job of explaining the reasoning behind new prescriptions (their necessity, consequences of non-compliance, and risk/benefit profiles) and reviewing the overall cost to the patient. If a cheaper, effective alternative is available (whether OTC or generic), we should consider prescribing it. Providers can likely improve medication compliance rates with a little patient education and price consciousness. Extra time should be spent with patients at higher risk for non-compliance due to their personal situation (age, degree of illness, income level) or if a specific drug with lower compliance rates is being introduced (Synthroid, statins, etc.) Regular follow up (especially with the same prescriber) to ensure that prescriptions are filled and taken as directed is also important.

Understanding Melatonin: Are People Taking Too Much?


Many of my patients, over the years, have taken melatonin. Many other patients have asked me about it, but I’ve never had much to say. I hadn’t heard anything particularly bad about it, but couldn’t really recommend it. “Research melatonin” has been on my “To Do” list for a long time.

So here’s what I’ve discovered: Melatonin is a hormone. I’ve known that since medical school, of course, but that fact has struck me as peculiar these past few weeks. Why? Because it’s sold over the counter, and many people take massive amounts of it. No other hormone is available like this. The use of other hormones, such as insulin and thyroid hormone, need careful monitoring. Is melatonin so universally safe that it can be taken at any dose, for however long? The more we learn about melatonin, the less that seems to be the case. Read more »

*This blog post was originally published at Making Sense of Medicine*

Why No One Knows What Generic Lipitor Costs

Several days ago, the world’s leading cholesterol-lowering “statin” drug, Lipitor, went generic. Doctors are bearing the brunt of the conversion with little information about what the new drug will cost for their patients.

This, of course, is the plan.

Even the Wall Street Journal which has an excellent “user’s guide” to making the switch from name-brand to generic Lipitor offers little help as it mentions “co-pays” rather than actual drug cost:

How much cheaper will generic Lipitor be?

Insurance copayments should drop considerably, if patients are getting Lipitor or atorvastatin on the generic tier of their health plans. Currently, Lipitor has been on a higher, branded tier for prescription drugs. Copays for branded drugs average either $29 or $49 depending on the tier, according to Kaiser Family Foundation. Copays for generics average $10.

In addition, Ranbaxy Laboratories Ltd, one of the generic manufacturers of generic Lipitor, won concessions to maintain elevated prices for 180 days from the government (a la our own Food and Drug Administration while the Federal Trade Commission stands idly by complaining how consumers are gouged with this arrangement) to assure prices stay high a bit longer.

But if we forget the insurers and copays, how much will the generic drug actually cost consumers? Read more »

Minute Clinics Fill A Legitimate Need, But Are They A Good Idea?

All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.

We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that Read more »

*This blog post was originally published at MD Whistleblower*

Dealing With This Canadian Pharmacy Is More Trouble Than It’s Worth

Looking to obtain a break on my practice’s botulinum toxin of choice (Myobloc) I yielded to curiosity and ordered from a Canadian Pharmacy…Northwest I figured we would try to break the price point of this popular product. Thankfully I used my credit card.

Botulinum toxin must be kept cold to retain its potency. We traditionally receive this product on dry ice and have never had much of a problem with effectiveness. I was promised by the pharmacy rep that this product would arrive cold within 2-5 days of shipping. Only after I gave her my credit card information did she share with me that the product would be coming from Great Britain. This was not welcome news. I was reassured that the product would be cold and usable.

The product arrived Read more »

*This blog post was originally published at Truth in Cosmetic Surgery*

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