Montse Gil


"Whether or not to start a new drug treatment should be an informed and shared decision made jointly by the prescriber and the patient."

Dr Montse Gil, a member of the research group Assessment of Health Technologies in Primary Care and Mental Health (PRISMA), has just presented her doctoral thesis, "The Problem of Non-Initiation of Drug Treatment: Assessment with Qualitative Methods", where she analyses why patients decide not to initiate a new pharmacological treatment.

Non-initiation occurs when a new pharmacological treatment is prescribed to a patient and the patient makes the decision not to initiate it. The incidence of non-initiation currently ranges from 6% to 13% in primary care in Spain and is associated with poorer clinical outcomes, more days off work and higher health costs.

What are patients' main reasons for not starting a drug treatment?

When prescribed with a new drug, patients weigh up the risks and benefits of the treatment. This is influenced by multiple factors, one of the most important being the patient's perception of the illness and the medication prescribed, which in turn is influenced by cultural, linguistic and emotional factors affecting the patient himself. The patient's relationship with the health system also carries a lot of weight.

Whether or not to start a new drug treatment should always be an informed shared decision made between the prescriber and the patient. While the patient always has the final word, from the standpoint of the health system we must ensure that patients are well informed about both their illness and the medication prescribed.

Thanks to the results obtained, I was able to design a Theoretical Model of Initiation to Medication.

After analysing the various treatment profiles, did you find any differences between them?

The results were very similar among all the therapeutic groups I studied (acute, chronic asymptomatic, chronic symptomatic and mental pathologies). There were only some slight differences in the case of mental pathologies and some chronic diseases. In these cases we saw that the pathologies were closely related to stigmatisation, a lack of knowledge or low awareness of the pathology.

Later, we also found that there were differences among those patients who were prescribed drugs that are potentially addictive, have a delayed action, or are either very strong or very weak.

Is it always harmful for a patient not to start a prescribed drug treatment?

No, there are situations where not starting a new treatment is not harmful for the patient, as long as the patient is well informed and considers he is too. This can happen with the prescription of analgesics, for example. In other situations, however, non-initiation is dangerous because it can pose a significant risk to the person's health, especially in the case of drugs that are a primary treatment for cardiovascular disease or diabetes; and also in the case of those drugs that provide a second line of prevention in chronic diseases.

What tools do primary care medical staff need to improve initiation?

First of all, if primary care professionals are to help the patients, they need to know exactly what non-initiation is and what the patients' decision-making processes consist of. For instance, the study showed that patients often know very little about their illness or how it evolves, or what the prescribed medication is for.

Second, when professionals are dealing with a new drug prescription, it is important that they ask the patients whether they will take the medication, whether they have any doubts, whether there is something worrying them that has gone undiscussed, and so on. However, at the present time the pressure on care-workers is an obstacle to personalised care that has to be overcome.

Apart from the doctors, what other health professionals can play a role in improving initiation?

Everyone. Work needs to be done at all levels and with all the parties providing mutual support. It is very important to make informed shared decisions in the consulting room and to count on the support of nursing professionals and pharmacists outside. In fact, in the strategy for improvement that I have designed in my thesis for cardiovascular diseases and diabetes, nursing staff and community pharmacists would be involved as a flexible source of support to help make informed shared decisions. A pilot study with these two pathologies is currently being carried out.

Your doctoral thesis was written as a complement to a previous study. Why?

The results of Dr Ignacio Aznar's doctoral thesis, "The Problem of Non-Initiation of Drug Treatment: Assessment with Quantitative Methods", showed us the importance of the problem and how it affects a high percentage of the population, but they did not tell us why it happens, as the research only used quantitative methodology. The explanation to this behaviour is provided by qualitative methodology, which can be used to go deeper into the reasons for not starting a new drug treatment.

Thanks to the results of the two doctoral theses, we have been able to propose an effective strategy, applicable to current clinical practice and aimed at improving non-initiation of treatments for cardiovascular diseases and diabetes in primary care.

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