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Medical adherence

In medicine, patient compliance, adherence,  describes the degree to which a patient correctly follows medical advice. 

Compliance, synonymous with adherence, describes the degree to which a patient correctly follows medical advice. 

Most commonly, it refers to medication or drug compliance, but it can also apply to other situations such as medical device use, self care, self-directed exercises, or therapy sessions. 

A positive physician-patient relationship is the most important factor in improving compliance.

Access to care plays a role in patient adherence, whereby greater wait times to access care and the  cost of prescription medications are contributors.

Non-compliance is a major obstacle to the effective delivery of health care. 

Only about 50% of patients with chronic diseases follow treatment recommendations with particularly low rates of adherence to therapies for asthma, diabetes, and hypertension.

Barriers to compliance include: the complexity of modern medication regimens, poor health literacy and not understanding treatment benefits, the occurrence of undiscussed side effects, poor treatment satisfaction, cost of prescription medicine, and poor communication or lack of trust between a patient and their health-care provider.

Improving compliance: simplifying medication packaging, providing effective medication reminders, improving patient education, and limiting the number of medications prescribed simultaneously. 

Most commonly, it refers to medication or drug compliance, but it can also apply to medical device use, self care, self-directed exercises, or therapy sessions. 

Abpositive physician-patient relationship is the most important factor in improving compliance.

More commonly used is the term adherence to apply to a regimen rather than compliance, because it has been thought to reflect better the diverse reasons for patients not following treatment directions in part or in full.

The term adherence includes the ability of the patient to take medications as prescribed by their physician with regards to the correct drug, dose, route, timing, and frequency.

Compliance may only refer to passively following orders.

The term adherence often implies a collaborative approach to decision-making and treatment between a patient and clinician.

Concordance is used to refer specifically to patient adherence to a treatment regimen which the physician sets up collaboratively with the patient, to differentiate it from adherence to a physician-only prescribed treatment regimen.

An estimated half of those for whom treatment regimens are prescribed do not follow them as directed.

Negative side effects of a medicine can influence adherence.

Health literacy is known to be a major barrier to treatment adherence.

Poor educational attainment is a key factor in the cycle of health inequalities.

Increase in patient medication cost share was found to be associated with low adherence to medication.

In order to manage medication costs, many patients on long term therapies fail to fill their prescription, skip or reduce doses. 

Both young and elderly status have been associated with non-adherence.

Elderly individuals may face challenges, including multiple medications with frequent dosing, and potentially decreased dexterity or cognitive functioning.

Despite receiving written and verbal information, 27% of older people discharged after heart failure were classed as non-adherent within 30 days. 

Half the patients surveyed could not recall the dose of the medication that they were prescribed and nearly two-thirds did not know what time of day to take them. 

A study evaluating the medical knowledge and factors of adherence in a population of 75-year-olds living at home found that 40% of elderly patients do not know the purpose of their regimen and only 20% knew the consequences of non-adherence.

Comprehension, polypharmacy, living arrangement, multiple doctors, and use of compliance aids was correlated with adherence.

Young people who feel supported by their family and doctor, and have good motivation,  are more likely to comply.

Young adults may stop taking prescribed medication to fit in with their friends, or because they lack insight of their illness.

Patients  who do not feel their condition is a threat to their social well-being were eight times more likely to comply than those who perceived it as such a threat.

Non-adherence is often encountered among children and young adults.

Young males are relatively poor at medical adherence.

Ethnicity and culture influence some health-determining behavior, such as participation in screening programs and keeping follow-up appointments.

Measures of adherence may need to be modified for different ethnic or cultural groups.

Studies have shown that black patients and those with non-private insurance are more likely to be non-adherent.

tions because of the price, which is similar to the 20–30% overall rate of unfilled prescriptions.

Other factors are doubting the need for medication, are preference for self-care measures other than medication, convenience, side effects and lack of demonstrated benefit are also factors.

Prescription medical claims records can be used to estimate medication adherence based on refill rate.

Compliant individuals see protective measures as effective, while non-compliant people see them as problematic.

Patients frequently do not  follow treatment regimens as directed, and seldom complete the course of treatment.

50% of hypertensive patients completely drop out of care within a year of diagnosis.

Persistence with first-line single antihypertensive drugs is low during the first year of treatment.

Only one third of patients are compliant with at least 90% of their lipid lowering treatment.

It is estimated that only 50% of people complete long-term therapy for chronic illnesses as they were prescribed, which puts patient health at risk.

Statin compliance has been found to drop to between 25 and 40% after two years of treatment.

Health care providers can improve adherence issues, with motivational interviewing and active listening.

Mobile phones have also played a role in improving adherence to medication.

Depot injections need to be taken less regularly than other forms of medication and because a medical professional is involved in the administration of drugs it can increase compliance. 

Depot mediation are used for oral contraceptive pills,antipsychotic medication to treat schizophrenia and bipolar disorder.

Sometimes drugs are given involuntarily to ensure compliance: commitment or if a patient is not deemed to have mental capacity to consent to treatment in an informed way.

WHO: only 50% of patients with chronic diseases in developed countries follow treatment recommendations.

Asthma non-compliance (28–70%) increases the risk of severe asthma attacks requiring preventable ER visits and hospitalizations.

Compliance issues with asthma: difficult inhaler use, side effects of medications, and cost of the treatment.

90% of cancer pain can be effectively treated, but a study in the UK found only 40% of patients adhere to their medicines due to poor understanding.

A large proportion of patients struggle to take their oral antineoplastic medications as prescribed.

The reasons for non-adherence:

The poor quality of information available to them about their treatment.

A lack of knowledge as to how to raise concerns while on medication

Concerns about unwanted effects

Issues about remembering to take medication

Hematological malignancies

Serum levels of drug metabolites Serum levels below expected threshold 83%

Breast cancer Self-report Taking less than 90% of prescribed medicine 47%

Leukemia or non Hodgkin’s lymphoma

Level of drug metabolite in urine Level lower than expected 33%

Leukemia, Hodgkin’s disease, non Hodgkin’s

Self-report and parent report More than one missed dose per month 35%

Lymphoma, other malignanciesSerum bioassay

Hodgkin’s disease, acute lymphocytic leukemia (ALL) Biological markers Level lower than expected 50%

ALL Level of drug metabolite in urine Level lower than expected 42%

ALL Level of drug metabolites in blood Level lower than expected 10%

ALL Level of drug metabolites in blood Level lower than expected 2%

Old trials evaluating Tamoxifen as a preventative agent have shown dropout rates of around one-third:

Diabetes

Diabetes non-compliance is 98% in US and the principal cause of complications related to diabetes including nerve damage and kidney failure.

Among patients with Type 2 Diabetes, adherence was found in less than one third of those prescribed sulphonylureas and/or metformin. 

Patients taking both drugs achieve only 13% adherence.

Perceived control and self-efficacy significantly correlate with each other, but also with diabetes distress psychological symptoms and have been directly related to better medication adherence outcomes.

Factors also impact a patients’ self-management behaviors include health-related knowledge/beliefs, problem-solving skills, and self-regulatory skills, which impact perceived control over one’s disease.

The  risk perception and decision-making processes surrounding one’s medication adherence are multi-faceted and complex with socioeconomic implications as well. 

Variations in patients’ perceptions of time: taking medication in the present for abstract beneficial future outcomes can conflict with patients’ preferences for immediate versus delayed gratification.

Hypertension non-compliance is 93% in US, and is the main cause of uncontrolled hypertension-associated heart attack and stroke.

As a result of poor compliance, 75% of patients with a diagnosis of hypertension do not achieve optimum blood-pressure control.

Studies find that 41–59% of patients prescribed antipsychotics took the medication prescribed to them infrequently or not at all.

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