14/08/2022
Patient Compliance and Non Compliance:
Introduction
Improving the overall global disease burden is no easy task. More so, with the number of increasing incidences of fatalities, it has become all the more important to stress upon the root causes of such conditions and treat them accordingly.
Compliance is the process whereby the patient follows the prescribed and dispensed regimen as intended by the prescriber and dispenser. It is defined as “the extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice. Compliance with therapy is an indication of a positive behavior in which the patient is motivated sufficiently to adhere to the prescribed treatment because of a perceived self-benefit and positive outcome.
Compliance, Adherence, and Concordance
The terms compliance, adherence, and concordance are often used interchangeably in practice. While related, these terms have somewhat different meanings.
Compliance is defined as “the extent to which the patient’s behavior matches the prescriber’s recommendations.” Its use implies the “lack of patient involvement” and is associated with negative characteristics such as yielding and submission. The definition of compliance assumes that all medical advice and drugs given to the patient are good for the patient and that the patient should adjust his or her behavior to follow the therapeutic regimen.
Adherence is defined as “the extent to which the patient’s behavior matches the agreed recommendations from the prescriber.” It takes the definition of compliance one step further by stressing the need for agreement. In this context, the patient has the flexibility to decide whether to adhere to the doctor’s recommendations. Nonadherence is not associated with blame on the part of the patient.
The term concordance is different in that it relates to the behavior between the doctor and the patient, whereas adherence and compliance are used with respect to the medication-taking nature of the patient. It refers to an agreement that is reached after a discussion between the health care professional and the patient in which the health care professional respects the feelings and beliefs of the patient with regard to whether, when, and how the medications are to be taken.
Measurement of Compliance
Direct methods include various assays conducted using biological markers and tracer compounds to detect medication levels in the bodily fluids. These methods are more accurate than indirect ones but are costly and require close monitoring. Direct methods of measuring compliance are most practical in hospitals and other inpatient settings. A common problem encountered with the measurements is that they do not account for the variability of pharmacokinetic factors of different medications and different individuals.
Indirect methods are subject to greater bias and are not as accurate as direct methods. These include interviews, diaries, pill counts, prescription filling dates, and therapeutic and preventive outcome measures. Patient self-reports and family interviews are highly
subjective and tend to overestimate compliance, but may provide useful data in customizing that patient’s medication. Pill counts are useful in assessing about 80% of true compliance, but they encourage pill dumping. Prescription refill dates are only accurate if the patient uses the same pharmacy to fill prescriptions and the database is accurate. However, filling a prescription on time does not necessarily mean that the patient is taking the medication correctly, or taking it at all.
Using therapeutic outcomes to determine the degree of compliance may encourage what is known as the toothbrush effect (i.e., patients may load up on or adhere to medication regimens a few days before the next visit to their health care professional). Additionally, the condition of the patient may change due to factors other than the medication, and the resulting therapeutic outcome may be skewed. Medication event monitoring systems (MEMS) are newer, electronic forms of monitoring that note the time and date when a medication vial was opened. Once again, however, this may not necessarily mean the patient took the medication at the time the vial was opened.
When one seeks medical attention, the first and foremost task is handed upon the physician and/or the examiner to assess the patient’s medical history and then prescribe an appropriate personalized medical regimen. Be it infectious diseases, chronic conditions or metabolic disorders, prescription of medication is only the first step of proceedings. It is equally upon the patient, as much as it is upon the doctor and healthcare professionals examining him, to stick to his/her prescribed routine and get a follow-up check done on a regular basis.
Adherence: Adherence is defined as the degree to which a patient voluntarily integrates and collaborates with the healthcare provider in terms of instructions regarding dosage, timing
and frequency of medication and gets a refill of prescriptions whenever necessary - eventually leading to a better therapeutic outcome. A related term, ‘medication persistence’ is defined as the time from the initiation of therapy, till the time it is aborted, which might be the exact prescribed time span or a part of it.
I. Adherence and compliance are pivotal in ensuring an improved health outcome for the patient especially if he is suffering from a chronic condition and needs prolonged medical attention. Examples in this category include those with cardiovascular complications, diabetes and different forms of cancer.
II. Studies have found that patients with chronic conditions, post discharge from hospitals, mostly stop adhering to their medical routines by the end of the month, with very few patients reporting to continue with medications beyond 6 to 12months, depending on the particular class of drugs used.
III. Increasing non-adherence has been associated with adverse health outcomes, increased rates of morbidity and mortality and increased healthcare costs.
IV. Some of the major obstacles in patient adherence include overlapping medication regimes from constantly changing healthcare providers, lack of proper education and discontinuation of medication, knowingly or unknowingly, socio-economic barriers within populations and lack of family support, social stigma and discrimination.
V. An effective way to plummet the soaring healthcare costs is to invest a fraction of the projected healthcare costs into patient adherence and compliance programs and interventions instead of using them to come up with new medications and drug combinations, especially for patients with diabetic and cardiovascular complications, hypertension and cancer.
Factors related to non-adherence and non-compliance
Patient-related factors
1. Inadequate health literacy and knowledge (mostly in case of asymptomatic diseases).
2. Inadequate knowledge about the medical decision-making process.
3. Socio-economic status poses a threat towards bearing treatment costs which are often expensive and complicated.
4. Lack of communication and transportation, mostly in rural areas.
5. Lack of family support.
Physician-related factors
i. Prescribing complex medication regimes which are beyond the patient’s understanding.
ii. Lack of communication between different healthcare officials (eg. Hospital officials, nurses, general physicians and consultants during post-discharge visits).
iii. Inadequate knowledge about a patient’s disease background.
iv. Inadequate knowledge about a patient’s financial burden before prescribing any medication.
Health system-related factors
A. Fragmented healthcare systems, lack of co-ordination between healthcare providers, hinder a patient’s access to effective health care.
B. Health information technology, though looks promising, is laced with its own loopholes which hamper effective healthcare monitoring by doctors and healthcare professionals. Healthcare IT systems need to look at the bigger picture instead of focusing on proprietary and local needs.
C. Creating an effective electronic health record (EHR) would help manage most of the shortcomings of the healthcare IT system.
D. Insufficient interaction time between healthcare providers and patients.
Measures to increase adherence and compliance
a. Understand the root cause of non-adherence and plan appropriate interventions and interviews to bridge the gaps.
b. Increase patient literacy and educate patients to understand the underlying importance of adherence and compliance.
c. Self-reporting by patients, though economical and effective, have poor sensitivity and specificity. They often lead to over-estimation of their adherence and compliance to the prescribed routine. It might also lead to ‘stockpiling’ of medication, without actually using them effectively. Hence there lies a need to supplement these patient reports in order to ensure effective utilization of the prescribed drug regimen. Studies indicate that measures involving Electronic Medication Packaging (EMP) devices (like Medication Event Monitoring Systems, MEMS) and pill counts have been proved to be more accurate and effective.2,11
d. Countries with a centralized medical database should synchronize between care givers, prescribers, dispensers and patients regarding the refill of prescriptions and then feed data
into their systems, in order to have a uniform and unbiased electronic health record (HER) to ensure a patient’s medication regime and compliance. A consistent review of these prescription refill records increases specificity of the process.
e. Telemedicine is another evolving tool to bridge gaps in healthcare, and can be looked upon as a strong contender to spread awareness regarding the importance of adherence and compliance in both developing and developed countries.
f. Educate, empower and encourage the family members and supporters to help the patient stick to his/her prescribed routine.
g. Patients under single-dose therapy, intermittent administration or are hospitalized, can have their metabolite and drug concentration in body-fluids monitored, in order to correlate their dosing frequencies.
h. Patient-centric healthcare paradigms can be prescribed after assessing the patient’s behavioral psychology and medical history. Be it medication or lifestyle modifications, discussing with the patient on a one-on-one basis, and mutually agreeing on a regime (the evolving concept of ‘Shared Decision Making’) might also be beneficial in improving patient adherence and compliance.
i. Lastly, there are a set of questionnaires which help in evaluating the rates of adherence in patients, like the Eight Item Morisky Medication Adherence Scale, Hill-Bone Compliance scale, Brief Medication Questionnaire, Medication Adherence Report Scale. Combining patient interviews along with such questionnaires helps minimizing discrepancies in measurement of adherence and compliance. It is only when both sides (physician and patients) adhere and comply to the norms; one can hope to reduce the burden of diseases and lead a healthy and wholesome life.
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