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 [11]. 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 [12]. Improving communication between patients and providers can lead to better shared decision making and better adherence [2].
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 [4]. 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 [15], 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.