Adherence and Compliance in Therapy, Research Paper Example

Abstract

Low medication adherence results in several negative outcomes; poor health, higher rate of hospitalization, risen health care costs and wasted time and energy. Brenner et al. (2002) stated that over time adherence to medication drops among patients requiring long-term treatment. In order to be compliant,  health care staff needs to be able to diagnose and treat non-adherance. The below paper is designed to create an overview of statistical data and studies related to the effectiveness of intervention plans to increase treatment compliance, adherence and create a framework for health care professionals to support patients and increase adherence to therapy. This intervention should result in better health outcomes and lower rate of complications, hospitalizations, and eventually reduced health care spending.

The below study will review research related to adherence to therapy, the impact of health care interventions on drop-out rates. Further, the authors are examining related research and recommendations of health organizations in order to reveal the most effective intervention approaches.

Introduction

Adherence and compliance is an issue that needs to be addressed worldwide, in order to improve health care outcomes. Jin, Sklar, Oh & Li (2008) use Sackett’s (1976) definition of compliance as “patient’s behaviors (in terms of taking medication, following diets, or executing life style changes) coincide with healthcare providers’ recommendations for health and medical advice from a health care provider”. The WHO (2003) also uses a similar definition: “the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations”. (p. 3.)

The authors of the current study will also apply the above definitions in the current research. Further, the main issues associated with therapeutic non-compliance, according to Jin et al.(2008) are negative impact on health care outcomes and an increased financial burden on the society.

The recent report created by WHO (2003) states several findings related to adherence. First, the report confirms that non-adherence is a “worldwide problem of striking magnitude”. (p. 7.) Chronic conditions create an increased burden for health care and the society, and,

according to the WHO report (2003), the burden of these health issues worldwide are likely to rise worldwide.

Adherence and Compliance

The Significance of the Problem

The WHO report (2003, p. 11) asks the important question: how poor adherence affects health care managers and policymakers. The study breaks down the research to different chronic conditions. According to reviewed studies, in diabetes treatment, the authors state that the financial and health implications of non-adherence are clearly documented and proven by related studies. The research conducted also shows that costs associated with non-adherence are not limited to extra intervention, higher rate of hospitalization, but also treatment of complications due to poor adherence to asthma, diabetes and hypertension therapies.

Types of Non-Adherence

Wilson (2010) talks about voluntary non-adherence and involuntary non-adherence. Voluntary non-adherence, according to the author, is based on a conscious decision of the patient and their perception about the treatment. Involuntary non-adherence, however, occurs when patients forget about medication or are unable to obtain it, while they have the intention to adhere to the treatment plan.

Jin et al. (2008) reviewed literature related to adherence and compliance from the patient’s perspective. Before reviewing the publications and research on non-compliance, the authors try to categorize reported types of non-compliance. These categories are important for the current study in order to reveal methods based on behavior patterns of patients to improve health outcomes for chronic illnesses. The main types of non-adherence are:

• receiving prescription but not filling it (not starting the treatment at all)
• Incorrect dosage
• taking the prescribed medication at the wrong time
• modifying doses prescribed
• stopping medication too soon
• delay in seeking health care advice and treatment
• missing visits to the clinic for check-up and medication review
• not following instructions (lifestyle, diet)
• taking “drug holidays”: stopping medication and starting again
• white coat compliance: only taking medication before and after visits to the clinic

While all the above types of non-compliance affect health care outcome in different ways and to a different extent, it is important to tackle the reasons behind all types of non-adherence. For example, taking “drug holidays” in some cases have a greater consequence to one’s health than taking medication at the wrong time, especially in case of mental health illnesses that require strong prescription drugs.

Measuring Compliance and Adherence

One of the problems with compliance is that it is hard to measure, according to Vermeire, Hearnshaw, Van Royen & Denekens (2001, p. 333). Measurements can be direct (taking blood or urine samples) or indirect (based on interviews and diaries). While self-report has a potential of low reliability, measuring compliance directly can be considered as an unnecessary intervention by patients. Measuring adherence, on the other hand, can only be completed through observation or interviews.

The Causes of Non-Compliance

The causes of low compliance have been studied by several authors in the past. Vermeire et al. (2001) name psychiatric disorders, demographic variables, duration of the treatment, cost and frequency as main determinants of compliance. The authors, however, suggest that causes of non-compliance differ on an individual level. As an example, the presence of confronting information related to treatment can greatly affect compliance. Likewise, doctors’ compliance with standards of providing adequate information about the treatment’s benefits and risks can decrease patients’ confidence in the treatment.

The WHO report (2003) addresses an important aspect of patient adherence; economic status. Quoting several studies, the authors state that on a global scale, the poor are “disproportionally affected” by poor adherence. This is especially true in case of noncommunicable diseases, such as mental illnesses, HIV and AIDS. Further, there is a two-way relationship between poverty and health. When a patient is unable to seek help in time due to their poverty, their chances for recovery are already reduced. However, when they become seriously ill, they are unable to work and earn a living, and this will affect their adherence to the therapy based their lack of ability to pay for the medication or treatment. (WHO, p. 22)

Jin et al. (2008) reviewed 102 qualifying article to research the findings of related studies related to patient non-compliance. Several studies examined correlation between compliance and either race, age, gender, education level or marital status. Further, the authors found that several studies confirmed psychological factors’ influence on adherence. Patients’ beliefs and motivations about the therapy was mentioned in 23 articles reviewed, and Jin et al. (2008, p. 276) state that “patients’ beliefs about the causes and meaning of illness, and motivation to follow the therapy were strongly related to their compliance with healthcare”. Further factors influencing adherence and compliance mentioned by the study are fears and negative associations regarding the therapy, the relationship between patient and the prescriber, the patient’s health literacy and knowledge of the treatment.

Based on the above review of literature and research, it is time to summarize which factors affect adherence and compliance in order to develop an effective intervention plan that would improve health outcomes by positively influencing patient perceptions and behaviors. The above research of literature has confirmed that some patients are more at risk of low adherence than others, and that psychological factors, the presence of mental illness and perceptions about treatment outcomes have a great impact on compliance and adherence, as well as the duration of the treatment. Therefore, in order to develop a successful intervention plan, the above areas need to be targeted by health care professionals. The authors will next attempt to develop a framework based on literature review and professional recommendations to promote higher rate of adherence and compliance.

How to Improve Adherence: Review of Recommendations

Wilson (2010) recommends the implementations of three principles: patient-centered care, adult learning theory and motivational interviewing in the intervention plan. He also states that delivering information in a skillful way without trying to directly persuade patients can be a positive approach of health care professionals. Reflective listening is another method that the author recommends.

In another study, Wilson, Laws, Lee, Lu, Coady, Skolnik & Rogers (2010) reviewed provider-focused intervention methods for increasing adherence among 156 HIV patients. Adherence-counseling was found to have no impact on patient outcome, based on the study. The main finding of the authors was that providers would benefit from further training related to adherence counseling services, built upon the five “interacting dimensions” of adherence (Appendix A) determined by the WHO (2003): social and economic, condition-specific, therapy-related, patient and provider factors.

Vermeire et al. (2001) emphasize the importance of providers taking on a supportive role while allowing patients to make a decision, without exercising authority over them. This involves that patients should not be blamed for non-adherence, but supported. The presentation of information is also important, and Vermeire et al. (2001, p. 337) state that “making clear the link

between the treatment and the illness could enhance the likelihood of a better compliance”. Patient education is another intervention method the authors mention. The use of compliance aids in case of involuntary non-adherence can improve compliance. The article mentions specific low-cost aids, such as medication calendars, special containers, pill counters. However, the focus should be on health care providers’ collaborative approach when implementing adherence-related intervention programs. The authors Vermeire et al. (2001, p. 337) also confirm that there is not enough research related to the effectiveness of intervention methods and “Up to now there is no evidence that any one method improves compliance better than another” (p. 337),  but it is evident based on the research that “adherence-aiding strategies have been shown to be better when combined” (p. 337).

Wilson (2003) makes an important note regarding intervention, quoting the definition of patient-centered care by the Institute of Medicine (2001): “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions”. According to the above guideline, health care providers should approach patients with respect, taking into consideration their circumstances, values and cultural diversity, while guiding and not directing them. Jin et al. (2008) also confirm the above recommendation, stating that patients should be treated as equal partners during discussions about therapies. The quality of health care communication, according to studies quoted by Jin et al.(2008) can improve overall health outcomes. It has not been researched whether there is a direct correlation between communication quality and adherence, but it is suggested that providing clear information and options for patients, while allowing them to fully understand the need for the therapy through health education can have a positive impact on adherence.

Conclusion

The above review of the related literature and recommendations has revealed that non-adherence has a negative impact on both patient outcomes and health care budgets. Further, the factors determining and influencing compliance have been determined as socio-economic status, demographic differences, ethnic diversity, health literacy, patient perceptions and the relationship between patients and doctors. It has also been revealed that different intervention strategies need to be developed for voluntary and involuntary non-adherence. Voluntary non-adherence can be a result of lack of information, the presence of confronting data, unclear communication or fear. The only way health care professionals are able to successfully intervene in this case is through a patient-centered approach that involves active, reflective listening and skillful information. In the case of non-voluntary adherence, there is a need for implementing aids, such as pill counters and diaries in the therapy. Overall; in all cases; no matter whether the reason for non-adherence is forgetfulness or limited health literacy; health care providers need to take on a supportive role instead of directing patients, according to the principles of patient centered care.

Acknowledgments

The authors acknowledge the work of professor Ira B. Wilson related to the study of research on adherence and the statistical review of studies provided by Jin, J., Sklar, G., Oh, V., Li, S. (2008), providing essential data for reviewing the directions of research and studies related to all factors of compliance and adherence. Without their work and previous research, the above study would have lacked several important evidence-based intervention recommendations.

References

Benner JS, Glynn RJ, Mogun H, Neumann, P., Weinstein, M., Avorn, J. (2002) Long-term persistence in use of statin therapy in elderly patients. JAMA, 288:455–61

Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st century. National Academy Press

Jin, J., Sklar, G., Oh, V., Li, S. (2008) Factors affecting therapeutic compliance: A review from the patient’s perspective. Therapeutics and Clinical Risk Management 2008:4(1) 269–286

Sackett D. (1976) Introduction. In: Sackett DL, Haynes RB ed. Compliance /with therapeutic regimens. Baltimore: Johns Hopkins University Press, p 1–6

Vermeire, E., Hearnshaw, H., Van Royen, P., Denekens, J. (2001) Patient adherence to treatment: three decades of research. A comprehensive review. Journal of Clinical Pharmacy and Therapeutics (2001) 26, 331-342

Wilson, I., Laws, M., Safren, S., Lee, Y., Lu, M., Coady, W., Skolnik, P., Rogers, W. (2010) Provider-focused intervention increases adherence-related dialogue but does not improve antiretroviral therapy adherence in persons with HIV. J Acquir Immune Defic      Syndr. 2010 Mar;53(3):338-47

Wilson, I. (2010) Improving adherence to treatment. Johns Hopkins Advanced Studies in Medicine. Vol. 10, No. 2 December 2010

World Health Organization (2003) Adherence to Long-Term Therapies. Geneva: World Health Organization; 2003.