A matter of life…
designing in patient compliance
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How common is non-compliance and misuse?
- reported rates of non-compliance with drug therapy range from 13% to 93% (average rate 40%)
- according to the 2005 Adherence Dashboard, a data analysis based on patient-level data from NDC Health, adherence rates vary by therapy, but generally follow a similar pattern
- approximately 10-20 percent of patients never take a prescription given to them by the physician to the pharmacy
- the most dramatic adherence declines occur within the first 4 months of the prescription being written
- at the end of 24 months, less than 50 percent of patients are still taking the drug, even in disease areas such as cancer
Impact of medication non-compliance on health care
The negative impact of non-compliance has been well documented for many important chronic diseases.
In the case of asthma, for example, studies suggest that less than 40% of persons with the condition adhere to a recommended therapeutic regimen. This lack of adherence contributes to treatment failure and increased costs.
The American College of Allergy, Asthma & Immunology
"Most caregivers are surprised to know that the majority of non-compliance is intentional. Just as caregivers do a `value assessment' measuring outcomes and cost to choose optimal therapy, patients do their own `cost/benefit analysis' to determine what, if any, therapy they should take. This analysis is based on their own perceptions and their understanding, but is clearly influenced by the relationship with their caregiver."
"If the patient views nocturnal awakening, exercise limitation and periodic Emergency Room visits as normal and expected, then their markedly impaired quality of life is not an impetus to compliance because this is their expected norm,"
"The factors most frequently associated with medication adherence in asthma are those related to the medication regimen, which includes duration, dosing complexity, perceived efficacy, benefits and side-effects… Inappropriate medication compliance is not attributable to the same factors for all patients. Dr. Rand describes three types of non-compliance:
Unwitting non-adherer includes patients who misunderstand their prescribed regimen or patients who were never sufficiently educated by their health care provider to adequately adhere.
Unwilling non-adherer includes patients unable to adhere to the prescribed asthma therapy because of economic, physical, environmental or personal barriers to adherence. These barriers to adherence may be embarrassing to the patient and will often go undiscovered in routine clinical interviews.
Intelligent non-adherer includes patients who make personal choices to alter asthma therapies, often undiscovered by health care providers.
Lingua Medica
From: John F. Steiner, MD, MPH; and Mark A. Earnest, MD. Pages 926-930 Ann Intern Med. 2000;132:926-930
"Like other dichotomies in medicine, terms such as non-compliant and non-adherent blur important distinctions between different patient behaviours. These terms do not differentiate patients who do not fill their prescriptions from patients who miss an occasional pill, take a consistent but reduced dose of their medication, consume medication sporadically, or completely discontinue medication use. These behaviour patterns arise for different reasons and may require different interventions. For example, failure to fill a prescription may identify an unrecognised cost barrier that should dictate a different medication choice. Dichotomous descriptions of medication-taking also fail to recognize that, for some health conditions, consumption of less than the recommended amount of medication is sufficient to attain the goals of treatment. Several studies have described a strategy of "intelligent non-compliance," in which patients accurately conclude that they can attain the treatment goal by unilaterally reducing their medication dose. This problem may be relatively common in clinical practice; epidemiologic studies of hypertension treatment have found that 19% to 43% of patients attain blood pressure control despite taking less medication than prescribed."
Morris and Schulz explored the issue of medication compliance from the patient’s perspective. They found that:
Patients have a greater concern for how the prescribed medicine affects their lives, than for outcome measures e.g. results of blood tests, PEFR results etc.
They may place equal or greater value on personal and often competing non-clinical outcomes.
Physical, economic, psychological, and social factors may all influence the complex act of taking medication "as directed."
Patients place a value on their medication if it in some way improves their quality of life by, for example, reducing pain or allowing them to resume normal activities.
Risk factors of medication non-compliance and misuse
Numerous risk factors have been associated with medication non-compliance/misuse:
- Regimen Complexity
- Disease
- Relationship with family
- Quality of written information
- Elderly
- Poor professional communication
Adherence with medical regimens is sometimes an even more severe problem for particular populations. The elderly, for example, may experience more problems than other age groups:
Rates of adverse drug effects of medication may be 3 to 4 times higher than for younger members of the population (Roth 1990)
Ostrom et al identified the problems that 182 independently living elderly patients encountered most frequently with prescription drugs. The most frequently encountered problems regarding non-compliance in their study were:
- label discrepancy (37%, discrepancies between the labelled dosage on the prescription bottle and the dosage actually used)
- under-use of medications (24%)
Other less frequently encountered problems included:
- an inability to read the label
- could not open childproof container
- did not know the purpose of the prescription medication
- shared prescription medication with another
- stored medication improperly
- used outdated prescription medication
- used a duplicate prescription
- overused medication
References
Stone VE, Clarke J, Lovell J, Steger KA, Hirschhorn LR, Boswell S, et al. HIV/AIDS patients' perspectives on adhering to regimens containing protease inhibitors. J Gen Intern Med. 1998;13:586-93.
Smith MY, Rapkin BD, Morrison A, Kammerman S. Zidovudine adherence in persons with AIDS. The relation of patient beliefs about medication to self-termination of therapy. J Gen Intern Med. 1997;12:216-23
Arluke A. Judging drugs: patients' conceptions of therapeutic efficacy in the treatment of arthritis. Hum Organ. 1980;39:84-7
Conrad P. The meaning of medications: another look at compliance. Soc Sci Med. 1985;20:29-37.
Trostle JA. Medication compliance as an ideology. Soc Sci Med. 1988;27:1299-308.
Donovan JL. Patient decision making. The missing ingredient in compliance researchInt J Technol Assess Health Care. 1995;11:443-55
Earnest MA, Steiner JF. Patterns of adherence with oxygen therapy in COPD [Abstract]. J Gen Intern Med. 1999;14(Suppl 2):26.