Patients’ perceptions of their “most” and “least” important medications: a retrospective cohort study
© Linsky and Simon; licensee BioMed Central Ltd. 2012
Received: 5 September 2012
Accepted: 30 October 2012
Published: 2 November 2012
Despite benefits of adherence, little is known about the degree to which patients will express their perceptions of medications as more or less important to take as prescribed. We determined the frequency with which Veteran patients would explicitly identify one of their medications as “most important” or “least important.”
We conducted a retrospective cohort study of patients from ambulatory clinics at VA Boston from April 2010-July 2011. Patients answered two questions: “Which one of your medicines, if any, do you think is the most important? (if none, please write ‘none’)” and “Which one of your medicines, if any, do you think is the least important? (if none, please write ‘none’).” We determined the prevalence of response categories for each question. Our cohort of 104 patients was predominantly male (95%), with a mean of 9 medications (SD 5.7). Regarding their most important medication, 41 patients (39%) identified one specific medication; 26 (25%) selected more than one; 21 (20%) wrote “none”; and 16 (15%) did not answer the question. For their least important medication, 31 Veterans (30%) chose one specific medication; two (2%) chose more than one; 51 (49%) wrote “none”; and 20 (19%) did not directly answer the question.
Thirty-five percent of patients did not identify a most important medication, and 68% did not identify a least important medication. Better understanding of how patients prioritize medications and how best to elicit this information will improve patient-provider communication, which may in turn lead to better adherence.
KeywordsCommunication Adherence Veterans Quality of care Patient safety
Background and objectives
Medication adherence may improve clinical outcomes, but approximately half of all prescriptions are not taken as prescribed [1–3]. Patient medication-taking behavior is influenced by many factors, including health literacy, socioeconomic status, perceived medication necessity, future health concerns and whether the drug provides symptom relief [4–6]. Further, patients’ beliefs about their medications are dynamic and can fluctuate with changes in symptoms, competing health- and non-health-related demands and trust in the health care provider [5, 7].
Patient non-adherence appears to imply that some degree of prioritization of medications is occurring, although not necessarily in an explicit manner. Moreover, it is unclear to what degree patients will express their perceptions of medications as more or less important to their treating health care provider and whether clinicians concur with patients’ prioritization schemas. To begin to address these questions, we sought to determine the frequency with which Veteran patients would explicitly identify one of their medications as “most important” or “least important,” as well as to characterize the medications selected.
We conducted a retrospective cohort study of a convenience sample of patients from ambulatory care clinics at Veterans Affairs (VA) Boston Healthcare System from April 2010 until July 2011. Patients were former members of the United States military who sought and were eligible to receive care at the VA. Data were collected by fourth-year medical students, who were individually instructed on project processes as part of their Ambulatory Medicine Quality Improvement rotation. One student per month was assigned to the rotation. Immediately prior to a student-led clinical encounter, patients were given a printout of the electronic health record (EHR) listing of their medications and asked to answer two questions: “Which one of your medicines, if any, do you think is the most important? (if none, please write ‘none’)” and “Which one of your medicines, if any, do you think is the least important? (if none, please write ’none’).” If needed, the student assisted the Veterans by reading the questions or writing their responses.
Because the data collection was intended as a quality improvement educational project, informed consent was not obtained. One of us (AL) entered all data into an Excel database, and we analyzed only the first chronologic encounter for each Veteran. Patient responses were entered exactly as written. Specific medications identified by patients were classified into medication classes using VA Drug Class Codes. Other data extracted from the EHR included patient sex, age at visit and number of actively prescribed medications.
Our two primary outcomes were patients’ responses to the “most important” and “least important” questions. Responses to each question were categorized as one of four types: 1) One specific medication – the patient identified one medication only; 2) More than one medication – the patient reported more than one medication, chose medications to treat a diagnosis (e.g. “heart meds”) or wrote “all”; 3) None – the patient wrote “none”; and 4) Did not answer the question – the patient left the response blank or wrote “n/a,” “don’t know,” “uncertain” or “not sure.”
We determined the prevalence of each primary outcome. Frequency counts identified the medication classes involved for responses where specific medications were chosen. Finally, we used chi-square tests to assess for associations between patient factors and choosing one specific medication as most or least important. All analyses were performed with SAS version 9.2 (SAS Institute, Inc) or Excel (Microsoft). Statistical significance was set at alpha < 0.05. This study protocol was approved by the Institutional Review Board of the VA Boston Healthcare System.
Baseline characteristics (n=104)
Age 65 or older
Total number of medications [mean (SD)]
Categories of responses to identification of most and least important medication
Most important n (%)
Least important n (%)
One specific medication
More than one medication*
More than one medication
Chose medications for a condition (did not name a specific medication)
More than one medication and chose it by condition
Did not answer the question*
Left it blank
Wrote “don’t know,” “uncertain,” or “not sure”
Wrote something undecipherable
Medication classes chosen as most or least important
Most important medication
Angiotensin converting enzyme inhibitors
Calcium channel blockers
Platelet aggregation inhibitors
Local anesthetics, topical
Oral hypoglycemic agents
Skeletal muscle relaxants
Least important medication
Angiotensin converting enzyme inhibitors
Local anesthetics, topical
Skeletal muscle relaxants
Approximately one in three Veteran patients did not identify a most important medication, and more than two in three patients did not identify a least important medication. There are several possible reasons to explain this finding. Patients may not have understood the questions, leading them to choose medications to treat a particular condition – therefore not selecting a single medication – or simply to leave the response blank. Limited health literacy, reflected as poor understanding of their health conditions or of their medications and associated indications, may have contributed to low response rates [8–10]. Without full understanding of their medical problems, the potential consequences of untreated health conditions and the possible benefits and risks of medication for those conditions, some patients may have been unable to make an informed selection from their medication list. This notion highlights the importance of education and knowledge in enabling patients to maintain an active role in their health care decisions.
Another hypothesis for the observed pattern of responses is that the use of the word “important” may not accurately reflect the construct that we were attempting to measure. That is, patients may have perceived medications as important but may not have believed that they are of a necessity or benefit to their future health to warrant full adherence. Others have demonstrated that perceived adverse effects of medications often outweigh preventive benefits of medications . Competing demands, such as financial or social obligations, may further outweigh patient perceptions of importance. Psychometric testing of the best way to assess patient prioritization of medications with reliability and validity will improve measurement in future studies.
Another possible explanation for our findings is that Veteran patients were in fact able to understand and identify a medication yet they were unwilling to share these beliefs with their providers. Patients discontinue prescriptions for a variety of reasons without informing their healthcare provider of this decision . Improving communication between patients and providers can lead to better shared decision making and better adherence .
Our study results need to be interpreted in the context of several limitations. We analyzed a small convenience sample of patients from one site within a larger health care system, and the study participants’ responses may not reflect the views of Veterans receiving care elsewhere or the perceptions of non-Veterans. Future research involving multiple settings and patient populations will enable better generalizability. We also had limited information on patients’ comorbidities and other medications, restricting us from appraising patient responses as concordant with clinician opinion. However, these answers still reflect what the patient perceived, and it is recognized that patient beliefs are associated with medication adherence . Additionally, explicit discussions may enable providers to better reconcile known conflicts between what they believe is clinically best and what the patient perceives as important [13, 14]. Finally, the training status of providers (i.e., medical students) theoretically could have influenced patients’ willingness to divulge their prioritization.
In this study population where the mean number of medications was nine, higher than most commonly accepted definitions of polypharmacy , a minority of patients were able to express a medication as least important. Better understanding of how patients prioritize their medications and how best to elicit this information will improve patient-provider communication and perhaps lead to discontinuation of medications that both the patient and the clinician feel have less importance.
Electronic health record (EHR)
We thank Anand Kartha, MD and Pamela Bellino, MA for the opportunity to engage medical students, as well as all medical students who participated. The study was conducted using resources of the VA Boston Healthcare System. The work was initiated while AL was a fellow supported by Boston Medical Center and the Center for Organization, Leadership, and Management Research at VA Boston Healthcare System. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or in the decision to submit the manuscript. Findings from this paper have been presented at the Society for General Internal Medicine annual meeting (Orlando, May 2012) and at the Academy Health annual research meeting (Orlando, June 2012).
- Kripalani S, Yao X, Haynes RB: Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007, 167 (6): 540-550. 10.1001/archinte.167.6.540.PubMedView ArticleGoogle Scholar
- Vermeire E, Hearnshaw H, Van Royen P, Denekens J: Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001, 26 (5): 331-342. 10.1046/j.1365-2710.2001.00363.x.PubMedView ArticleGoogle Scholar
- Pladevall M, Brotons C, Gabriel R, Arnau A, Suarez C, de la Figuera M, Marquez E, Coca A, Sobrino J, Divine G, et al: Multicenter cluster-randomized trial of a multifactorial intervention to improve antihypertensive medication adherence and blood pressure control among patients at high cardiovascular risk (the COM99 study). Circulation. 2010, 122 (12): 1183-1191. 10.1161/CIRCULATIONAHA.109.892778.PubMedPubMed CentralView ArticleGoogle Scholar
- DiMatteo MR, Haskard KB, Williams SL: Health beliefs, disease severity, and patient adherence: a meta-analysis. Medical care. 2007, 45 (6): 521-528. 10.1097/MLR.0b013e318032937e.PubMedView ArticleGoogle Scholar
- Fried TR, McGraw S, Agostini JV, Tinetti ME: Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc. 2008, 56 (10): 1839-1844. 10.1111/j.1532-5415.2008.01923.x.PubMedPubMed CentralView ArticleGoogle Scholar
- Piette JD, Heisler M, Harand A, Juip M: Beliefs about prescription medications among patients with diabetes: variation across racial groups and influences on cost-related medication underuse. J Health Care Poor Underserved. 2010, 21 (1): 349-361. 10.1353/hpu.0.0247.PubMedView ArticleGoogle Scholar
- Piette JD, Heisler M, Krein S, Kerr EA: The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Arch Intern Med. 2005, 165 (15): 1749-1755. 10.1001/archinte.165.15.1749.PubMedView ArticleGoogle Scholar
- Modig S, Kristensson J, Ekwall AK, Hallberg IR, Midlov P: Frail elderly patients in primary care–their medication knowledge and beliefs about prescribed medicines. Eur J Clin Pharmacol. 2009, 65 (2): 151-155. 10.1007/s00228-008-0581-8.PubMedView ArticleGoogle Scholar
- Spiers MV, Kutzik DM, Lamar M: Variation in medication understanding among the elderly. Am J Health Syst Pharm AJHP: official J Am Soc Health Syst Pharm. 2004, 61 (4): 373-380.Google Scholar
- Shrank WH, Avorn J: Educating patients about their medications: the potential and limitations of written drug information. Health Aff. 2007, 26 (3): 731-740. 10.1377/hlthaff.26.3.731.View ArticleGoogle Scholar
- Fried TR, Tinetti ME, Towle V, O'Leary JR, Iannone L: Effects of benefits and harms on older persons' willingness to take medication for primary cardiovascular prevention. Arch Intern Med. 2011, 171 (10): 923-928. 10.1001/archinternmed.2011.32.PubMedPubMed CentralView ArticleGoogle Scholar
- Moen J, Bohm A, Tillenius T, Antonov K, Nilsson JL, Ring L: “I don't know how many of these [medicines] are necessary.” - a focus group study among elderly users of multiple medicines. Patient Educ Couns. 2009, 74 (2): 135-141. 10.1016/j.pec.2008.08.019.PubMedView ArticleGoogle Scholar
- Fried TR, Tinetti ME, Iannone L: Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011, 171 (1): 75-80.PubMedPubMed CentralGoogle Scholar
- Heisler M, Vijan S, Anderson RM, Ubel PA, Bernstein SJ, Hofer TP: When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make?. J Gen Intern Med. 2003, 18 (11): 893-902. 10.1046/j.1525-1497.2003.21132.x.PubMedPubMed CentralView ArticleGoogle Scholar
- Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN: Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008, 3 (2): 383-389.PubMedPubMed CentralGoogle Scholar