Medication Nonadherence: Finding Solutions to a Costly Medical Problem

This article is sponsored by Thomas R. Beam, Jr., Memorial Institute for Continuing Medical Education. To apply for CME credit, read the article, then follow the link to the CME test at the end of the article.

Valid until 07/01 Article ID. d1206.01

About the Program (Instructions and Sponsor)

Learning Objective: Discuss the factors involved in patient medication nonadherence, assessment techniques, and strategies that may help improve adherence.

http://www.medscape.com/SCP/DBT/2000/v12.n06/d1206.01.gott/d1206.01.gott-01.html

Medication Nonadherence: Finding Solutions to a Costly Medical Problem CME

Harold Gottlieb, PhD

Abstract

This article explores factors that have an impact on patient medication nonadherence. It presents a number of strategies to enhance adherence and outlines personality characteristics of noncompliant patients, characteristics of diseases that affect nonadherence, and aspects of the health care setting that may affect patient nonadherence.

Introduction

As the population continues to age and cost-containment pressures increase, the health care industry will be challenged to find ways to empower patients to play a greater role in the management of their illnesses. One way in which patients will be better able to manage their illnesses is by adhering to their medication regimens.

Medications are dispensed with the expectation that they will be taken exactly as prescribed. However, most patients do not follow their doctors' orders. Excuses take many forms: "The medication was too expensive," "If 1 pill is good, then 2 pills should be twice as good," or "I didn't understand the directions on the label."

Medication nonadherence can have negative consequences for the patient, the provider, the physician, and even the medical researchers who are working to establish the value of the medication for the target population.

Depending on the characteristics of the condition, the treatment, the patient, and the setting, estimates of medication nonadherence rates typically range from 30% to 60%, with the nonadherence percentage being greatest when the patients are symptom-free.^[1] In an era when efficacious drug therapies exist or are being developed at a rapid rate, it is discouraging that one half of the patients for whom appropriate medication is prescribed fail to receive the full benefits because of inadequate adherence to treatment.^[2] One study showed that 77% of patients demonstrated degrees of compliance with their medication regimen when the treatment was designed to cure a disease and only 63% of patients complied when treatment was aimed at prevention. However, when medication was to be taken over a long period, compliance rates dropped dramatically to approximately 50% for either prevention or cure.^[3]

Studies show that 20% to 80% of patients make errors in taking medication and that 20% to 60% stop taking medications before being instructed to do so.^[1,3] With older populations, the literature concerning adherence reports that compliance rates range roughly from 38% to 57%, with an average rate of less than 45%.^[3,4] Patients forget to take their medications, creatively alter their medications, engage in unendorsed polypharmacy, mix their medications, and take medications in combinations that may have dire synergistic interaction effects, such as dizziness and confusion.

Medication adherence presents a particularly complex issue for the elderly patient.^[5] The relationship between adherence and age depends on the specific illness, the treatment time frame, medication regimen, and the cognitive/affective status of the patient. For the elderly patient, medication issues and/or abuses may also result in accidents, such as a fall that causes a hip fracture. Furthermore, an elderly patient could forget that he or she had already taken the prescribed amount of medication and unwittingly overdose.^[5]

The Minnesota Colon Cancer Control Study found a linear relationship between age and compliance with regard to colorectal cancer screening.^[6] In this large, long-term, longitudinal study of men and women, the best compliers were approximately 70 years old; the worst compliers were patients younger than 55 years and those older than 80 years.

Why Nonadherence?

Many factors are involved in patient nonadherence -- factors related to the characteristics of the disease, medication side effects, duration of treatment, frequency of expected intake, complexity of treatment, and severity of the disease. It has been demonstrated, for example, that people are less likely to continue their medication regimen over long periods and are less likely to be adherent when the daily doses increase from 1 pill to 4 pills.^[7] In a study of patients who had seizures, those who were required to take only 1 pill a day showed 81% adherence rates, those who were required to take 3 pills a day adhered 77% of the time, and those who were required to take 4 doses a day showed adherence rates of 39%. To help prevent this problem of nonadherence in a multipill regimen, pills to be taken once a day should be prescribed for ingestion early in the morning, those prescribed twice a day can be scheduled to be given early in the morning and late at night, and those prescribed 3 times a day can be taken after each meal. Schedules calling for medication to be taken 4 or more times a day create an unnatural division of the day for most people, increasing the possibility of nonadherence.

For the most part, patients try to please their physicians. They typically give the impression, often convincingly, that they have been following or intend to follow the physician's medication orders. However, a patient soon forgets much of what he has been told by a physician and a pharmacist. Moreover, patients tend to remember what they are told first, what they consider most important, and what will have the least impact on their daily lives.

Highly anxious patients forget more of what they are told than less anxious patients. And if the information is consistent with previously held beliefs about the disease and about what the medication can and cannot do, the patient is more likely to adhere to the medication regimen. In addition, patients who write down what the doctor says are more likely to remember their medication instructions than patients who do not.^[8]

Studies reported that 40% to 60% of patients could not correctly report what their physicians expected of them 10 to 80 minutes after they were provided with the information.^[9,10] Yet another study reported that over 60% of the patients interviewed immediately after the visit with their doctors had misunderstood the directions regarding prescribed medications.^[11]

How to Assess Adherence

The degree of patient adherence to medication regimens can be determined from information gathered from the patient, physician or pharmacist, family members, and friends. Adherence can also be shown by counting pills or examining biochemical evidence.

Asking the physician may unfortunately turn out to be the poorest of choices. Physicians generally overestimate their patients' compliance rates and, even when their guesses are not overly optimistic, they are usually wrong. One early study reported a correlation of only.01 between physicians' estimates of compliance and an objective pill count.^[12] Asking patients themselves is a more valid procedure, but it is fraught with difficulties. The same study showed that about 10% of the patients claimed that they were 100% compliant; however, a pill count of the medications indicated that the patients were using from 2% to as much as 130% of the prescribed pills. Some patients took more medication than recommended, and others took far less.

Self-reports are inaccurate for at least 2 reasons: Patients may lie to avoid displeasing their physicians or they may simply not know their rate of compliance. Patients not only underreport poor adherence but also overreport good adherence.

To improve overall adherence/ compliance rates, trained interviewers could help improve the accuracy of self reports and, at the same time, identify the types of medication errors typically made by patients. Constant observation by family, friends, or hospital staff may be physically impossible, and the quality of family relationships can affect accuracy. Pill counts -- pills gone from the bottle minus pills dispensed -- may seem ideal because of the mathematical certainty; however, even if the required number of pills are gone, the patient may not have been compliant. The patient, for a wide variety of reasons, may have discarded some of the medications or taken them in a manner other than had been prescribed.

In some cases, biochemical evidence from urine or blood samples can indicate whether there is medication adherence. While blood and urine levels may be more reliable measures of medication intake than pill counts, this approach may not be worth the cost or the risk of decreasing the level of trust between physician and patient. In addition, some drugs are not easily detected in blood or urine, and individual differences in absorption and metabolism of drugs can lead to a wide variation among people who are equally compliant. This is the case especially for the elderly patient population, in whom absorption rates and metabolism are an issue. Furthermore, biochemical checks may reveal that the patient ingested some amount of the drug at some time, but it may not indicate that the patient took the proper amount at the proper time as prescribed.

While there is no foolproof method that will guarantee the detection of adherence or nonadherence, physicians are encouraged to try more than 1 strategy and to implement an adherence plan early in the treatment process.

Gender, Personality, and Cultural Factors

Gender, personality, and cultural factors may influence adherence-compliance rates. For instance, women may be better at adhering to their medication regimens than men. This may be particularly so for drugs that treat behavioral health conditions, such as antidepressant medication.^[13]

An authoritarian and dictatorial manner can alienate some patients, particularly those who prefer participatory involvement. Patients are more likely to follow the advice of doctors who are seen as warm, caring, and friendly. Thus, physicians are encouraged to maintain good eye contact, smile, lean forward, and even joke and laugh when appropriate to promote medication compliance.

Some patients may deny that they are seriously ill. Thus, a prescribed medication regimen can only serve as an unwelcome reminder, and the patient is unlikely to adhere to it.

Patient satisfaction factors can affect adherence. For example, patients may be less adherent if they have to wait a long time to secure their medications because of an overbooked waiting room.^[14]

A number of studies have found that cultural mores, folkways, and norms are important factors in determining who is and who is not likely to comply with medication regimens. One study found that Hispanic patients were more likely to comply with medication recommendations when their physicians demonstrated some understanding of Hispanic cultural norms and practices.^[15]

Improving Adherence

Better Communications

Patients should be encouraged to indicate to their physicians verbally or in writing that they understand medication requirements. Physicians should be aware that patients are more likely to adhere to medication regimens when they are convinced that the medication they are taking is clearly linked to future health and wellness and when they are made an active participant in the decision-making process regarding the medications. Most busy physicians fail to reserve time for quality interaction with their patients and, therefore, often fail to consider adherence issues. However, failure to tackle adherence issues early may cost the physician more time and energy later.

Some physicians talk rapidly and disregard patient understanding. And many patients are not always good listeners, in part because of a number of distracting internal and external psychological factors; they are in a strange environment, and they more than likely are distressed, anxious, frightened, or in pain. Thus, to promote medication adherence, patients need to be instructed properly, asked to participate in the decision-making process, and helped to understand the benefits of taking their medications as well as the risks of not taking them. Patients must be told in a simple and clear way how to take their medications. The patient must be able to read and understand, as well as comprehend and translate what he/she understands into actions that conform to the physician's instructions.

Some patients have poor memory and concentration skills, and they seem to quickly forget over half of the physician's instructions. In fact, they are more likely to remember their diagnosis than their prescribed therapy.^[16] The provider must speak briefly and clearly, emphasize the information necessary for compliance early in the communication, and then repeat the same information both orally and in writing. We cannot assume that patients understand even simple language. Terms common to the practitioner, such as "follow-up" and "workup," may very well require explanation or substitution.^[17]

In a study of patient interpretation of written prescription instructions, researchers found that 25% of subjects interpreted the phrase "every 6 hours" as meaning "3 times a day" (since they sleep at night). "As needed for water retention" was thought to mean that the pills would be used to cause water retention.^[18] Full clarification of medical terms is strongly encouraged, and more structured follow-up sessions may be necessary to determine whether patients understood the information and instructions.

The physician should seek the support of pharmacists, nurses, and the patient's family in reinforcing instructions. Patients must be given clear instructions about when to return for medication-adjustment visits and should be alerted to the possibility that they may have to bring all of their medications to each visit for adherence assessment. Above all, patients must be made aware of their adherence and compliance responsibility at the outset.

Patient motivation must be evaluated to determine the likelihood of medication adherence. While many patients appear motivated, they actually may be in a precommitment phase in the decision-making process; that is, while patients may wish to take their medications, they may not be ready to comply with all aspects of the medication regimen.

Medication Adherence Contract

Patients can be issued a medication adherence "contract" at the initiation of treatment. The contract should include a simple and clearly written set of instructions that describe the medications; important facts about the medications, including side effects and interaction with other medications; and information as to the purpose of the medications and the consequences of not taking them as prescribed.

The contract needs to include when and how medication readjustments will occur and when and how prescriptions will be refilled. A schedule of medication intake should also be included -- that is, time contingency or pain contingency instructions plus dose frequency and length of time the patient is expected to take the medications.

A behavioral contract can include information about frequency of expected office visits; how to contact the physician in an emergency; what to do when an emergency occurs; and, most important, a relapse prevention plan. The patient should also be instructed to never change his medication regimen without the full consent of the treating physician.

The medication adherence contract can include information about community support groups and other resources that might be available to promote patient adherence to medication regimens. Moreover, a copy of the behavioral contract can be made in triplicate. One copy can be given to the physician, one to the patient or patient's family member, and one to any other designated person, such as a close friend or coworker.

The contract can be signed and treated as if it were a legally binding document. For those who have difficulty reading, the contract can be taped, and the patient can be encouraged to listen periodically to the recorded message. A designated caregiver can be assigned to those patients who exhibit special needs, with the caregiver reading the contract to the patient and helping him to adhere to its terms.

Alter Characteristics of the Regimen

Often, a particular therapy cannot be modified; but whenever possible, results from the many studies examining the relationship between various characteristics of the treatment plan itself and the likelihood of patient cooperation should be examined for medication adherence strategies. In general, compliance rates can be increased by merely altering such components of the treatment regimen as complexity of treatment, duration of treatment, requirements for lifestyle change, and even the cost of the regimen itself.^[19-21] Once again, research findings have led many reviewers to suggest a multiplicity of tactics to improve compliance. For instance, one approach could be to reduce the number of daily administrations and/or different medications by using, if clinically acceptable, fewer pills by issuing larger doses and even larger pills that are pharmacologically designed to be taken once a day. Moreover, single-tablet, combined medications can also be recommended to reduce the overall complexity of the total regimen.

Other Strategies

There are a variety of other strategies that can help promote medication adherence (Table 1). One strategy involves linking a medication schedule with other daily activities. Patients can be told, for example, to place their medication schedule next to their toothbrush as a mnemonic strategy in that they would be reminded of their medication schedule every time they brushed their teeth. Patient reminders can be linked to other daily routines that match the medication intervals related to the patient's recommended medication dose and the frequency and duration of the medication schedule.

The patient's family can help ensure medication compliance. Routine automated phone call reminders can also serve to periodically remind the patient of the proper medication regimen. Some health care workers give lectures, which can include audiovisual aids, and distribute educational materials to patients during evening classes held in the physician's office. The classes serve as an opportunity to inform the patient about the disease and how best to handle it, including the importance of medication adherence.

Drug manufacturers can also provide once-a-day medications, when feasible, and more user-friendly dosage forms. They can offer products that have simpler regimens, rather than multiple-dose regimens, and they can discourage awkward packaging of medications by favoring single-unit packaging. The community-based pharmacist can help implement the medication adherence strategy by providing periodic telephone calls to remind patients to take their medications.

The above suggestions are just some of the ways patient noncompliance to medication regimens can be remedied and are by no means meant to be an exhaustive list. Clearly, not all patients require an extensive behavioral contract or a medication-adherence compliance plan, but all patients should be provided with at least some relevant, behaviorally oriented set of instructions. In the final analysis, compliance will never happen unless the health care practitioner who treats the patient enforces it.

Conclusion

While patient nonadherence to medication regimens remains one of the most important health care concerns, it is surprising that research in this area is sorely lacking. There is evidence, however, that patient nonadherence to medication is a multicausal phenomenon. The seriousness of the illness, the cost of treatment, and treatment side effects can all affect compliance. The patient's age, mental status, and memory capacity are also important factors in the patient's compliance. The complexity of the recommendation, the duration of the regimen, the type of medical advice, the clarity or unclarity of the written instructions, and the amount of instruction provided are examples of factors that impact patient adherence.

Strategies for adherence include raising information and skill levels, altering characteristics of the regimen, and improving the relationship between the provider and the patient. Provider and patient awareness with regard to medication adherence can be enhanced with the creative application of behavioral contracts. Adherence-promoting efforts can also include rewards and reinforcement strategies.

Table 1. Suggested Strategies for Physicians and Pharmacists to Help Ensure Medication Adherence

Greet patient by name and mention the name often.

Ask the patient to repeat what has to be done.

Keep the directions on the prescription label as simple as possible.

Give clear instructions on the exact treatment regimen, preferably in writing.

Make use of special reminder containers and calendars.

Call the patient if a refill is needed.

Emphasize the importance of adherence at each office visit.

Acknowledge the patient's efforts to adhere at each visit.

Involve the patient's spouse or partner.

Instruct the patient that a scheduled office visit will be required so that the patient can be helped to understand issues relevant to disease management and medication adherence.

Avoid medical jargon.

Use short words and short sentences.

Repeat instructions.

Make advice as specific and detailed as possible.

Find out what the patient's worries are; do not confine yourself merely to gathering objective medical information.

Find out what the patient's expectations are; if they cannot be met, explain why.

Provide information about the diagnosis and the cause of the illness.

Adopt a friendly rather than a business-like attitude.

Spend some time conversing about nonmedical topics.

Long-term therapy should include more frequent office visits to ensure patient medication adherence.

Provide patient with behavioral contract.

Ask patients to monitor their drug intake.

Explain consequences of medication nonadherence.

Provide a card listing medication dose, indication, and time.

Link medication times to daily routine events.

Ask the patient to recall in detail the medication(s) taken.

Involve family members.

Make available audiovisual aids, written materials, and computerized drug information.

Instruct patients to pay attention to adverse side effects and to inform the physician about adverse reactions.

Increase motivation by enlisting the patient in the decision-making process.

Adapted from Haynes RB et al. Patient Education and Counseling. 1987.^[21]

CME Post-Test

Dr Gottlieb is professor of psychology at California State University, Los Angeles, and is director of Behavioral Medicine Services at the Pain and Rehabilitation Medical Group in Torrance, Calif.

No financial disclosure information provided.

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