Adherence and Compliance: You Say Tomato, I Say ToMAHto

When prescribers give patients a fistful of prescriptions, how many are actually filled?

About 33% of new prescriptions never make their way to a pharmacy. In addition, patients who do fill prescriptions frequently do not follow the directions. Experts estimate that, globally, adherence hovers at or below 50%.^1-3 The problem is most worrisome among individuals with chronic diseases. The table^4,5 describes the outcomes associated with nonadherence.

Adherence statistics have been stagnant for many years, despite widespread knowledge of this problem. Many studies have proposed solutions, but so far, change is elusive. Increasing adherence (or compliance) rates is critical. Health care professionals tend to use adherence and compliance interchangeably,⁶ but the words have subtle differences. For the most part, the difference is important only to organizations that track how closely patients follow their recommended medication regimens. However, the words we choose to describe people and their actions have meaning, and increasingly, people are trying to select words that are more descriptive and less offensive. Compliance is the older term. It describes the extent to which patient behavior matches the prescriber’s directives. Note that when using this term, one considers the provider’s intent and assigns blame to patients who are noncompliant. For this reason, clinicians now prefer to use adherence. Adherence is the extent to which patient behavior aligns with mutually agreeable clinical decisions. In this case, patients and providers collaborate, and patients are free to adhere or not without blame.⁶

RESEARCH FINDINGS ARE INFORMATIVE

Many studies have looked at various interventions to improve adherence. Unfortunately, many studies are plagued by inadequate descriptions of interventions, insufficient numbers of enrollees, and poor design. Some recent publications have tried to tease out the most effective interventions.

For example, a systematic review has summarized evidence from multiple systematic reviews to differentiate interventions.⁷ It found that dose simplification was consistently the most effective intervention to increase adherence. Others that were associated with positive results were comprehensive patient educa- tion, electronic reminders, and reduced cost-sharing or financial incentives.⁷

A randomized clinical trial that enrolled individuals (N = 805) with an elevated risk of cardiovascular disease and suboptimal cholesterol levels looked at financial incentives.⁸ The investigators were interested in determining if a financial reward would create durable, that is, long-lasting, adherence. They monitored adherence using a wireless pill bottle that notified them when the patient removed the cap. Patients could earn up to $200 as they completed study milestones over 1 year. The investigators found that financial incentives improved adherence, but they did not improve low-density lipoprotein cholesterol (LDL-C) levels. That created a conundrum: How could high adherence be associated with such poor outcomes? They hypothesized that study participants were at very high risk and had extremely high LDL-C levels. It is possible that the dose was insufficiently intensified. The investigators concluded that financial incentives might be useful in patients with lower degrees of health engagement.⁸

CLARIFYING REASON FOR USE

Throughout the years, many people who are involved with health systems have talked about the value of adding a reason for use (RFU) to each prescription vial.^9-11 For example, a prescription for lisinopril might be marked thus: “Take 1 tablet every morning for high blood pressure.” Investigators conducted interviews with 20 patients to determine if including an RFU on the label would increase adherence. All patients considered the RFU to be important and an educational enhancement. Previous study results showed that pharmacists believed an RFU would increase patient safety, and physicians indicated that it would decrease the number of calls from pharmacists to physicians to clarify the reason for the prescription. Patients want RFUs written in lay language and indicated that it would provide them with more information to determine whether to continue taking a medication.¹² Thus, including an RFU would address adherence as opposed to compliance.^6,12

CONCLUSION

A final study looked at pharmacist beliefs about adherence monitoring. Previous research has indicated that pharmacists are generally positive about the subject.^13,14 In this newer study, however, the investigators found that pharmacists perceive prescribers to be less than enthusiastic about pharmacy-based adherence monitoring.¹⁵ They also found that pharmacists’ beliefs translate into action or, in some cases, lack of action. Pharmacists who could see the value in adherence monitoring were more likely to perform that function. Many pharmacists questioned the suitability of a community pharmacy setting for adherence monitoring.

Pharmacists who are interested in increasing adherence for patients should remember that dose simplification appears to be the most effective intervention. Educating patients and expressing an interest in improved adherence at every visit could be the difference between good disease control and progressive disease.

Jeannette Y. Wick, RPh, MBA, FASCP, is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

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