Compliance (medicine)

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Compliance (or Adherence) in a medical context refers to a patient both agreeing to and then undergoing some part of their treatment program as advised by their doctor or other healthcare worker. Most commonly it is whether a patient takes their medication (Drug compliance), but may also apply to use of surgical appliances (e.g. compression stockings), chronic wound care, self-directed physiotherapy exercises, or attending for a course of therapy (e.g. counselling).

A patient may or may not accurately report back to their healthcare workers whether they have been compliant because of possible embarrassment, fear of being chastised or for seeming to be ungrateful for their doctor's care.

Causes for poor compliance include:[1]

  • Forgetfulness
  • Prescription not collected or not dispensed
  • Purpose of treatment not clear
  • Perceived lack of effect
  • Real or perceived side-effects
  • Instructions for administering not clear
  • Physical difficulty in complying (e.g. with opening medicine containers, handling small tablets or swallowing difficulties, travel to place of treatment)
  • Unattractive formulation (e.g. unpleasant taste)
  • Complicated regimen
  • Cost of drugs

Terminology

It has been estimated that half of those for whom medicines are prescribed do not take them in the recommended way. Until recently this was termed "non-compliance", which was sometimes regarded as a manifestation of irrational behavior or willful failure to observe instructions, although forgetfulness is probably a more common reason. But today, health care professionals prefer to talk about "adherence" to a regimen rather than "compliance".

There have been many studies of the effects of different strategies in improving adherence to therapy. These include reducing the frequency of administration during the day and reducing the numbers of medicines the patient has to take. However, evidence that such measures are effective is lacking.

Nevertheless, it seems likely that adherence can be improved by taking care to explain the benefits and adverse effects of a drug; in a busy clinic it is all too easy for the prescriber to issue a prescription with little or no explanation. Reducing the frequency of administration to once, or, at most, twice a day also makes sense, despite lack of convincing evidence that this is effective.

Detection

Non-adherence can be detected by validated questionnaires and by assessing refill records[2][3].

Assessment of refill records

When refill records are accessible, many metrics can be calculated. The two most common are[4]:

  • Medication Possession Ratio (MPR): "the sum of the days’ supply for all fills of a given drug in a time period divided by the number of days in the time period"[4]
  • Proportion of Days Covered (PDC) is the same as the MPR but adjusts for days with double coverage of medications due to early refills[4].
    • The PDC is recommended by Medicare[5]the National Quality Forum (NQF)[6]


Providing refill information to health care providers can reduce clinical inertia and improve the quality of prescribing[7].

Questionnaire

Available surveys include[8]:

  • MMAS-4 (4 items). Copyrights have been reported contested for the MMAS-4[9]
  • Morisky Medication Adherence Scale, derived from MMAS-4 (8 items)[10]
  • The Adherence Estimator (3 items)[11]
  • Self-Rating Scale Item (SRSI)[8]

Interventions

Interventions to improve adherence have been reviewed[2].

Concordance

Concordance is an approach at involving the patient in the treatment process to improve compliance and is a current UK NHS initiative.[12] The patient, being informed about the condition and the various treatment options, is jointly involved in the decision as to which course of action to take and partially responsible for the monitoring and reporting back to others involved in their care. Compliance with treatment is improved by:

  • Only recommending treatments that are effective in circumstances when they are required
  • Selecting treatments with lower levels of side effect or concerns for long-term use
  • Prescribing the minimum number of different medications, e.g. prescribing for someone with two concurrent infections a single antibiotic that addresses the sensitivities of both likely bacteria, rather than two separate courses of antibiotics. However, this also raises the spectre of developing antibiotic resistant species in the wider scenario.
  • Simplifying dosage regimen, whether by selecting a different drug or using a sustained release preparations that need less frequent dosages during the day.[13]
  • Explanation of possible side effects and whether important to continue with the course of medication none-the-less.
  • Advice on minimising or otherwise coping with side effects, e.g. advice on whether to take a particular drug on an empty stomach or with food.
  • Developing trust between the patient and their doctor such that patients do not feel they will be embarrassed or seen as ungrateful if they are unable to take a particular drug, thus allowing a better tolerated alternative preparation to be tried.

See also

References

  1. ↑ British National Formulary. 45 March 2003.
  2. ↑ 2.0 2.1 Kini V, Ho PM (2018). "Interventions to Improve Medication Adherence: A Review". JAMA. 320 (23): 2461–2473. doi:10.1001/jama.2018.19271. PMID 30561486.
  3. ↑ Hamdidouche I, Jullien V, Boutouyrie P, Billaud E, Azizi M, Laurent S (2017). "Drug adherence in hypertension: from methodological issues to cardiovascular outcomes". J Hypertens. 35 (6): 1133–1144. doi:10.1097/HJH.0000000000001299. PMID 28306634.
  4. ↑ 4.0 4.1 4.2 Raebel MA, Schmittdiel J, Karter AJ, Konieczny JL, Steiner JF (2013). "Standardizing terminology and definitions of medication adherence and persistence in research employing electronic databases". Med Care. 51 (8 Suppl 3): S11–21. doi:10.1097/MLR.0b013e31829b1d2a. PMC 3727405. PMID 23774515.
  5. ↑ : Adherence to Antipsychotic Medications For Individuals with Schizophrenia. Available at https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_383_MIPSCQM.pdf
  6. ↑ dherence to Chronic Medications. Available at http://www.qualityforum.org/QPS/0542e
  7. ↑ Kronish IM, Moise N, McGinn T, Quan Y, Chaplin W, Gallagher BD; et al. (2016). "An Electronic Adherence Measurement Intervention to Reduce Clinical Inertia in the Treatment of Uncontrolled Hypertension: The MATCH Cluster Randomized Clinical Trial". J Gen Intern Med. 31 (11): 1294–1300. doi:10.1007/s11606-016-3757-4. PMC 5071278. PMID 27255750.
  8. ↑ 8.0 8.1 Stirratt MJ, Dunbar-Jacob J, Crane HM, Simoni JM, Czajkowski S, Hilliard ME; et al. (2015). "Self-report measures of medication adherence behavior: recommendations on optimal use". Transl Behav Med. 5 (4): 470–82. doi:10.1007/s13142-015-0315-2. PMC 4656225. PMID 26622919.
  9. ↑ Available at https://irb.upenn.edu/sites/default/files/2018-11-06%20v2%20Notice%20to%20Investigators%20re%20MMAS.pdf
  10. ↑ Morisky DE, Ang A, Krousel-Wood M, Ward HJ (2008). "Predictive validity of a medication adherence measure in an outpatient setting". J Clin Hypertens (Greenwich). 10 (5): 348–54. doi:10.1111/j.1751-7176.2008.07572.x. PMC 2562622. PMID 18453793.
  11. ↑ McHorney CA (2009). "The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease". Curr Med Res Opin. 25 (1): 215–38. doi:10.1185/03007990802619425. PMID 19210154.
  12. ↑ "Not to be taken as directed - Putting concordance for taking medicines into practice" BMJ. 2003;326:348-349 ( 15 February ) Editorial.
  13. ↑ "Dosing and compliance?" Bandolier 117 Nov 2003 Report (see Figure 1)

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