Adherence

• Adherence


  The extent to which a person's behaviour (in terms of taking medication, following diets or implementing other lifestyle changes) coincides with medication or health advice
• Compliance


  The extent to which a person's behaviour- taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider
• Persistence


  A measure of the duration of treatment
• Concordance


  The work of the prescriber and the patient in the consultation is a negotiation between equals and that therefore the aim is for a therapeutic alliance between them
• Adherence, compliance, persistence: Patient behaviour
• Patient medication adherence journey

  1. Initiation

  2. Implementation

  3. Discontinuation
• Non-compliance or non-adherence: The patient is viewed to be at fault, irrational in decision making about taking their medications, denies the legitimacy of patient choice, does not consider the patient-health professional relationship
• To take medications appropriately


  • Motivated
  • Competent
• Prescribers and Pharmacists should consider patients' beliefs about their disease and therapy, and patients' ability to take their medication
• Success of a treatment depends on effectiveness of the medication and adherence to therapy
• Correct treatment, appropriate for the patient, prescribed appropriately
• Pharmacist's role


  • Establishing concordance with patients and ensuring a patient-centred approach to care
  • Information giving (medication and disease state to patient and physician)
  • Counselling and patient education
  • Monitoring of effectiveness of therapy
  • Provision of behavioural strategies to assist with adherence
• Medicine taking statistics


  • 1/3 of prescriptions written are never dispensed
  • 20-80% of patients adhere to therapy
  • 50-90% adherence rate to chronic regimens
  • 20-60% of elderly adhere to therapy
  • Adherence to short term therapy better than long term
  • Adherence is greatly reduced in the first 10 days
  • 50% discontinued their lipid lowering therapy within 6 months of starting
  • 10% of all hospitalisations and 23% of nursing home admissions are due to non-compliance
• Non-adherence rates by condition


  • Asthma - 20%
  • Arthritis - 55-71%
  • Contraception - 8%
  • Diabetes - 40-50%
  • Epilepsy - 30-50%
  • Hypertension - 40%
• Patient adherence rates by condition

  • High Blood Pressure - 72%
  • Hypothyroidism - 68%
  • Type 2 Diabetes - 65%
  • Seizure Disorders - 61%
  • High Cholesterol - 55%
• Extent of non-adherence


  • Analgesic treatment for cancer pain - 51% took 60% of analgesic dose
  • Oncology outpatients - 41% of patients were adherent to their prescribed analgesic regimen
  • Self-reported adherence to analgesia for cancer pain - 51% reported lower levels of adherence; only 8.9% of patients were in the high–analgesic adherence group
  • 70%–90% of cancer patients experience pain (final stages of cancer), but non-adherence rates ranging from 20%–33%
  • Medication adherence to DMARDs in RA ranged from 30% to 107%
• Poor adherence


  • Poor health outcomes
  • Increased use of the healthcare system
  • Increased healthcare costs
  • Increased costs for the patient and public
• Adherence rates


  Hospitalisation rates
• Improving adherence enhances patient safety and has greater impact on health than improvements in specific medical treatments
• Patients need to be supported, not blamed
• Classification of non-adherence


  • Primary
  • Secondary
  • Intentional
  • Non-intentional
  • Underdoser, overdoser, random
  • Drug holiday taker, time depend
• Patient adherence with therapy leads to


  • Improve patient's health
  • Reduce morbidity and mortality
  • Reduce costs associated with hospital admissions, alternative drug regimens and healthcare professional costs
• Poor adherence is a worldwide problem- 50% for chronic therapy
• Consequences- poor health outcomes and increased healthcare costs
• Improving adherence enhances patient safety
• Increasing adherence has greater impact on health than improvements in specific medical treatments
• Classification of Non-adherence


  • Primary
  • Secondary
  • Intentional
  • Non-intentional
• Types of Primary Non-adherence


  • Underdoser
  • Overdoser
  • Random
• Types of Secondary Non-adherence


  • Drug holiday taker
  • Time dependent
  • Previsit adherent
  • Symptom dependent
• Patient medication adherence - journey

  1. Initiation

  2. Implementation

  3. Discontinuation
• Primary non-adherence occurs at the Rx Prescriber Pharmacy Patient Dispensing stage
• Secondary non-adherence occurs at the Initiation Implementation Discontinuation stage and can be intentional and unintentional
• WHO Dimensions of Factors Influencing


  • Patient
  • Healthcare team
  • Condition
  • Therapy
  • Social / Economic
• Necessity-Concerns Framework


  • Necessity of taking medication
  • Benefits of treatment
  • Concerns about medications (Cost, Side effects)
• Examples of Factors

  • Long duration of treatment
  • Large number of medications
  • High cost of medications
  • Forgetfulness
  • Loss of faith in the medication
  • Health beliefs and attitudes
  • Poor sight or memory
  • Low income
  • Low level of education
• Major Predictors


  • Polypharmacy
  • Cost
  • Difficulty Taking meds
  • Memory
  • Access to Dr Or Pharmacist
  • Literacy/Health literacy
  • Language Difficulties
  • Side effects
• Major Predictors (Healthcare Provider)


  • Clinical Knowledge
  • Adherence Knowledge
  • Single Patient Education
  • Communication Skills
  • Attitude
  • Time or Willingness
• Adherence Measures


  • Direct (Blood levels, Direct observation, Biological markers)
  • Indirect (Patient self-reports, Pill counts, Prescription repeat collection, Clinical response, Electronic medication monitors (eg MEMS), Patient diaries)
• Examples of Questions


  • How have you been taking these medications?
  • How do you feel about taking these medications?
  • Do you find that you have difficulty remembering to take your medication?
  • If so, when and how often?
  • Have you felt that you can stop taking your medications because you feel better?
  • If so, when and how often?
• Health Belief Model


  • Patient's behaviour is a consequence of their perceptions rather than actuality
  • Components are: Perceived susceptibility, Perceived severity, Perceived benefits, Perceived barriers, Cue to action