Martha (a fictional patient with a very real story) arrives for an appointment with her new primary care provider. She hesitantly hands over her pill boxes at the nurse’s request; it seems to take forever to enter them all into the computer. “You are taking a lot of blood pressure pills,” she comments. The doctor comes in and after a brief introduction, notes that she is taking five medications for her blood pressure. “5?” Martha exclaims in disbelief. She hadn’t realized it was that many.
Martha recently retired after 40 years as a business consultant. She was successful in her career - detail-oriented and good with numbers. But over the years, with all the travel, dinners out and stress, she gained weight and her blood pressure remained high. She saw different doctors at her employer’s health clinic, all of whom had different ideas about how to better control her blood pressure. She followed their advice as best as she could, but was sometimes confused by conflicting advice and didn’t have time to get more involved in her care and improve her health literacy.
At the appointment, the doctor systematically goes through each medication, seeking to establish a timeline for when it was prescribed and whether it had any effect on her blood pressure. Martha is uncertain about the timeline; now that she is on so many medications, it’s hard to keep them straight.
“Have you had any side effects?” the doctor asks. Martha had some ankle swelling and dizziness a few years ago but is not sure which medications caused it. She now wonders whether it is worth mentioning. The doctor asks, “Have you been able to take your pills as prescribed, or do you miss doses?” Feeling deflated, Martha admits that she forgets to take them once in a while. The doctor then takes her blood pressure. It is 160/95 mmHg.
How did we get to this point?
Unfortunately, when it comes to managing chronic conditions, patients are often the victim of “medication creep.” In an attempt to reach target numbers, there is a natural tendency to escalate doses and add medications. Often, we as clinicians fail to evaluate whether a prior therapy was effective, and to stop it if it isn’t. We frequently do not assess other factors, like stress, side effects from other medications, and adherence challenges, which may contribute to uncontrolled levels.
The problem worsens when multiple providers make changes in response to a singular abnormal blood pressure reading. At best, we land on the right combination. At worst, we subject our patients to the medication creep – in which more and more medications are added and neither the doctor nor the patient know what is working. Too often, we have lost sight of the intended goals of therapy. The medication creep takes its toll on patients, increasing the number of pills to swallow, out-of-pocket monthly prescription costs, and the likelihood of drug-drug interactions and side effects.
Missing the Milestones
In shared decision making, patients participate in decisions about their care. Providers describe the risks and benefits of different options, and patients consider what matters most to them. Yet shared decision making is largely built around “milestone” decisions: whether to proceed with a surgery, or whether to undergo a certain medical intervention. In chronic disease management, we often miss the milestones for shared decision making, including decisions to escalate or de-escalate therapy. We fail to assess the utility of each medication, including its efficacy, cost, side effects and burden to patients. It is easier to make decisions based on numerical targets rather than the unique biological and social context of the condition, treatment response, or preferences, values and goals of management.
How to Prevent Medication Creep and Stay Goal-Oriented
- Identify medication creep when it occurs.
- Redesign chronic disease management to engage patients in their care.
- Work with patients to create short and long-term treatment goals.
- Develop dashboards from electronic medical records that document the disease course and chronologically organize when medications are added or subtracted and the associated impact on short and long-term goals.
- Give patients access to their medical records so that they can contribute to and correct the story line.
- Utilize technology to enable transportability of medical records so that new providers can easily analyze a patient’s chronological history.
Simplify & Clarify to Empower Patients
At the end of the visit, the doctor and Martha establish that the main goals are to get her blood pressure under control to avert heart attack and stroke – both of which run in Martha’s family. “In order to figure out which medications to continue and which to stop, I need your help. What matters most to you?” the doctor asks Martha.
Martha becomes tearful. “I wish I didn’t have to take so many pills. I actually have trouble swallowing them.”
Suspecting that Martha does not need all 5 medications, the doctor simplifies the regimen to 3 medications, eliminating the 2 that needed to be taken twice daily. The doctor asks Martha to document her daily symptoms and blood pressure readings so they can discuss them at a 2-week follow-up appointment. On her way out, the doctor gently rests her hand on Martha’s shoulder and says, “Just remember, you are not alone; we’ll get there together.”
Andi Shahu, BS is a medical student currently pursuing a joint MD/MHS degree at the Yale School of Medicine. He is interested in the development of more personalized approaches to management of chronic health conditions, as well as the interplay between patient health education and public health policy. @AndiShahu
Dr. Erica Spatz, MD, MHS is a general cardiologist and clinical investigator at the Center for Outcomes Research and Evaluation at Yale University School of Medicine. Her clinical and research interests include the development of individualized approaches to disease management, along with tools to help patients become more active in their healthcare decisions. @SpatzErica