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Adherence

Mar 07, 20254 min read

The Drug Adherence

  • The definition
  • Compliance VS Adherence

What is Adherence

  • Compliance

    • “The extent to which a person’s behavior coincides with medical or health advice.” Haynes, 1979

  • Adherence

    • “The extent to which the patient continues an agreed-upon mode of treatment (under limited supervision) when faced with conflicting demands.”

American Heritage Medical Dictionary, 2007

Types of Non-Adherence

  • Taking an incorrect dose.
  • Taking medication at the wrong times.
  • Increasing or decreasing the frequency of doses.
  • Stopping the treatment too soon.
  • Delaying in seeking healthcare.

Additional Types of Non-Adherence

  • Non-participation in clinic visits.
  • Failure to follow doctor’s instructions.
  • “Drug holidays”, which means the patient stops the therapy for a while and then restarts the therapy.
  • “White-coat compliance”, which means patients are compliant to the medication regimen around the time of clinic appointments.

Factors Affecting the Adherence

  • Doctor factors
  • Patient factors
  • Medication factors
  • Disease factors
  • Organizational factors

Causes of Poor Adherence

Non-Adherence—Economic

  • Direct cost estimated at 289 billion annually
  • Improved self-management of chronic diseases results in an approximate cost-to-savings ratio of 1:10
  • Cost-related non-adherence reported by 11.4% (~543,000 individuals) of stroke survivors, mostly among the uninsured and younger (45 to 64 years)

Sources: Ho 2009, Circulation; Levine et al. 2013, Annals of Neurology

Non-Adherence—Clinical Outcomes

  • High adherence to antihypertensive medication is associated with higher odds of blood pressure control.
  • Each incremental 25% increase in proportion of days covered for statins is associated with ~3.8 mg/dl reduction in LDL cholesterol.

Source: Ho 2009, Circulation

Non-Adherence Mortality, Hospitalizations, ED Visits

  • Non-adherence causes ~30% to 50% of treatment failures and 125,000 deaths annually
  • Non-adherence to statins increased relative risk for mortality (~12% to 25%)
  • Non-adherence to cardioprotective medications increased risk of cardiovascular hospitalizations (10% to 40%) and mortality (50% to 80%)
  • Poor adherence to heart failure medications increased the number of cardiovascular-related emergency department (ED) visits

Sources: Ho 2009, Circulation; Edmondson 2013, Br J of Health Psychology; George & Shalansky 2006, Br J Clin Phar

SIMPLE

  • S — Simplify the regimen
  • I — Impart knowledge
  • M — Modify patient beliefs and behavior
  • P — Provide communication and trust
  • L — Leave the bias
  • E — Evaluate adherence

[Source](http://www.acpm.org/?MedAdherTT ClinRef)

S—Simplify the Regimen

  • Adjust timing, frequency, amount, and dosage
  • Match regimen to patient’s activities of daily living
  • Recommend taking all medications at the same time of day
  • Avoid prescribing medications with special requirements
  • Investigate customized packaging for patients
  • Encourage use of adherence aids
  • Consider changing the situation vs. changing the patient

I—Impart KnowledgeÏ

  • Focus on patient-provider shared decision making
  • Keep the team informed (physicians, nurses, and pharmacists)
  • Involve patient’s family or caregiver if appropriate
  • Advise on how to cope with medication costs
  • Provide all prescription instructions clearly in writing and verbally
  • Suggest additional information from the Internet if patients are interested
  • Reinforce all discussions often, especially for patients

[Source](http://www.acpm.org/?MedAdherTT ClinRef)

M—Modify Patient Beliefs and Behavior

  • Ensure that patients understand their risks if they don’t take their medications
  • Ask patients about the consequences of not taking their medications
  • Have patients restate the positive benefits of taking their medications
  • Address fears and concerns
  • Provide rewards for adherence

[Source](http://www.acpm.org/?MedAdherTT ClinRef)

P—Provide Communication and Trust

  • Improve interviewing skills
  • Practice active listening
  • Provide emotional support
  • Use plain language
  • Elicit patient’s input in treatment decisions

[Source](http://www.acpm.org/?MedAdherTT ClinRef) Source

L—Leave the Bias

  • Understand health literacy and how it affects outcomes
  • Examine self-efficacy regarding care of racial, ethnic, and social minority populations
  • Develop patient-centered communication style
  • Acknowledge biases in medical decision making
  • Address dissonance of patient-provider, race-ethnicity, and language

Sources:
[http://www.acpm.org/?MedAdherTT ClinRef](http://www.acpm.org/?MedAdherTT ClinRef); Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman; Bandura, A. (1994). Self-efficacy. In V.S. Ramachaudran (Ed.), Encyclopedia of human behavior; 4. New York: Academic Press, pp. 71-81

E—Evaluating Adherence

  • Self-report
  • Ask about adherence behavior at every visit
  • Periodically review patient’s medication containers, noting renewal dates
  • Use biochemical tests—measure serum or urine medication levels as needed
  • Use medication adherence scales—for example:
    • Morisky-8 (MMAS-8)
    • Morisky-4 (MMAS-4, also known as the Medication Adherence Questionnaire or MAQ)
    • Medication Possession Ratio (MPR)
    • Proportion of Days Covered (PDC)

Sources: [http://www.acpm.org/?MedAdherTT ClinRef](http://www.acpm.org/?MedAdherTT ClinRef); Morisky, D.E & DiMatteo, M.R. Journal of Clinical Epidemiology 2011; [https://www.urac.org/MedicationAdherence/includes/Nau Presentation.pdf](https://www.urac.org/MedicationAdherence/includes/Nau Presentation.pdf); 64:262-263

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