Compliance (medicine)

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

Patients may not accurately report back to healthcare workers because fear of possible embarrassment, being chastised, or seeming to be ungrateful for a 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 administration not clear
• Physical difficulty in complying (e.g. opening medicine containers, handling small tablets, swallowing difficulties, travel to place of treatment)
• Unattractive formulation, such as unpleasant taste
• Complicated regimen
• Cost of drugs

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Adherence

An estimated half of those for whom medicines are prescribed do not take them in the recommended way. Until recently this was termed "non-compliance", and 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 a patient has to take. However, there is no evidence that such measures are effective.

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 too easy for the prescriber to give out a prescription with little or no explanation. It also makes sense to reduce the frequency of taking medicine to once or twice a day: though again, there is no evidence that this tactic is effective.

Drug compliance

It is estimated that only 50% of patients suffering from chronic diseases in developed countries follow treatment recommendations.^[2] This may affect the health of the patient, as well as that of the wider society when resulting in complications from chronic diseases, formation of resistant infections, or untreated psychiatric illness. Compliance rates during closely monitored studies are usually far higher than in later real-world situations: for example, there may be up to 97% compliance in some studies on statins, but only about 50% of patients continue at six months.^[3] Again, the word “adherence” is preferred by many health care providers, because “compliance” suggests that the patient is passively following the doctor’s orders. Patients should not be passive: a treatment plan must be based on a therapeutic alliance or contract between the patient and the physician. Yet at least one reference implies that both terms are flawed, giving no meaningful information. ^[4]

Prescription collection and dispensing

In the past both doctor and patient expected that the end of a consultation should be marked by a prescription. However, many patients don't necessarily wish to commence a course of treatment, but merely seek reassurance as to the nature of their symptoms. It has been estimated that up to a third of prescriptions written by UK GPs do not go to the pharmacist. A third of all dispensed medication is not taken in accordance with the prescribing instructions.

Patients may simply forget to bring the prescription to a pharmacist. They may believe that the medication was not needed: the consultation provided reassurance, or pointed the way to self-care measures other than medication. Some patients may alternatively believe that their condition does not yet warrant starting treatment, but that the prescription is only in place should the problem fail to resolve spontaineously or deteriorate. Some of these patients are later unable to return to their doctor when their condition changes.

Conditions such as earache or sore throat do not automatically require a course of antibiotics. Evidence based medicine supports the increasingly common writing of deferred prescriptions. These are intentionally not to be dispensed for a specified period of time unless the patient feels that spontaneous recovery is not occurring. Only about a third of deferred prescriptions are used, which reduces unnecessary antibiotic use without antagonising patients.

Course completion

Once started, patients seldom take their medicines as often as they should^{[citation needed]}, and seldom complete the course of medication.^{[citation needed]} It is often practially difficult for a patient to remember to take medication several times a day.^{[citation needed]} He or she may forget^{[citation needed]}, not have the dose at hand, or have no water to help swallow tablets. If a course of treatment works, then the patient may feel that no more medication is needed^{[citation needed]} -- the symptoms are gone, after all -- and thus stop prematurely. Their cure is incomplete. He or she might stop medication prematurely after experiencing troublesome side effects, or after concerns of the long-term effects of a treatment^{[citation needed]}. Still others quit when medication be taken for a long time^{[citation needed]}. The risk of a patient quitting a long-term treatment grows greater when that treatment stablizes a condition, rather than giving relief from symptoms.

Patients who quit their medication take risks.^{[citation needed]} Some may relapse.^{[citation needed]} Others, who were taking antibiotics after an infection, thus make it possible for an infection to survive with antibiotic resistance. These patients also create risks for the rest of society:

• Communicable diseases such as tuberculosis or HIV may developstrains resistant to present treatments, thus becoming incurable.
• Patients with such psychiatric illnesses as schizophrenia or bipolar disorder may feel well while stabilised on medication, but are at risk of relapse should they then stop.^{[citation needed]}
• Patients taking certain antihypertensive medications may experience severe high blood pressure if they abruptly stop medication. This is known as rebound hypertension.
• Corticosteroids may require gradual reduction in dose if taken long-term. If the medication is discontinued abruptly, the body does not have sufficient time to adjust, and the patient may develop adrenal insufficiency.
• Anticonvulsant drugs can have unpleasant side effects, such as interfering with abstract thinking. This is not serious for the majority of people who do little abstract thinking. For some professionals, such as doctors, lawyers, and writers, this side effect makes it impossible to work. In some cases a patient will report that the drug makes him or her "feel stupid."^{[citation needed]} He or she then stops taking it: and typically, will subsequently have seizures.

Concordance

Concordance is a current UK NHS initiative to involve the patient in the treatment process and so improve compliance.^[5] The patient is informed about his or her condition and its various treatment options. He or she is involved with the treatment team in the decision as to which course of action to take, and partially responsible for monitoring and reporting back to the team. 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 fewer 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.)
• Simplifying dosage regimen, whether by selecting a different drug or using a sustained release preparation that needs fewer dosages during the day.^[6]
• Explanation of possible side effects and whether it is important to continue with the course of medication regardless of those side effects.
• Advice on minimising or coping with side effects, e.g. advice on whether to take a particular drug on an empty stomach or with food.
• Developing trust between patients and doctors so that the former will not fear 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

• Medical error
• Pill burden
• Polypharmacy
• Withdrawal

References