To understand the impact on patient adherence (or compliance) we must first define it. When people talk about patient adherence they are referring to an individual’s ability to follow a prescribed regimen or therapy plan. The plan will vary depending on the nature of the illness: most people see it as the taking of specific medicines during a given period. In reality it covers a wide spectrum of treatments including:
1. Physiotherapy exercises.
2. Following a specific diet plan.
3. Radiotherapy for cancer.
Studies have shown that the adherence to long term therapies is only 50% for the developed world (Fleming, W). Such a poor performance has an associated cost:
1. Treatment plans or therapies are designed to facilitate the recovery of the patient. This in turn increases the quality of life of the individual, their caregivers and family.
2. Patient adherence will reduce the financial burden on society. The lack of adherence is attributed to 10% of the USA’s hospitals admissions costing an estimated $100 billion each year (Peterson, M).
3. Finally there is the financial impact to the medical companies (pharma, medical devices, nutriceutical, etc): maximum compliance means maximum sales.
Cynics may argue that the last factor should not be considered. The pragmatist would say that the work that companies do on improving compliance would benefit all. Either way, the key question is still: “how can we get patients to be more compliant?”
The answer is inextricably linked to people’s behaviours and emotions. Social psychologists have spent many hours researching the actions and motivations of individuals. There are many theories that we could probably point to non-compliance, too many for this blog unfortunately. The overriding factor is we all behave differently, which means that a number of different strategies are needed if medical adherence is to increase globally. Let us look at some of the issues that need to be addressed when developing such strategies:
The vast arena of medicinal drugs can be consumed in a variety of formats. A good example is the peroral option: delivery through the mouth. This can be done using pills, capsules, pastes, liquids or solutions. The taste, size, quantity will have an impact on adherence. An individual, particularly if they are a child, is unlikely to comply well if they do not like the taste. Another aspect to consider is the patient’s life style. The best way to explain this concept is with an example: last winter I was prescribed an antibiotic for a chest infection. I was given an oral suspension (liquid) that need to be kept below a certain temperature. Now, as someone who travels a great deal for business I found it very difficult to complete the regimen. I had to go back to the GP and ask for the drug in a capsule format!
Packaging can also have a profound impact on adherence. The packaging will create psychological and supportive factors. The supporting aspect can be as simple having a calendar guide on the packaging: this will remind the individual of their requirements. The psychological aspect is a little more complicated and is best explained with an example: children with PKU have to take their protein supplements every day; compliance was identified to be worse at lunch time (while the child was at school). Compliance increased dramatically when the packaging was change to look like a sports rehydration drink.
Patient’s Physiological and Psychological Attributes.
The patient’s physiological and psychological will dictate much of their quality of life, or to put it bluntly how they cope with the everyday simple things that most of us take for granted. The loss of vision or hearing may result in that individual being unable to understand the instructions for a particular regimen. Dementia, depression or other psychological problems can also reduce compliance.
Behavioural and Religious Beliefs.
The strong behavioural or religious beliefs of individuals can cause them to ignore medical advice and look for other solutions. As an example, Jehovah Witnesses will refuse blood transfusions. There are also individuals who will only go for homeopathic options.
Education / Awareness.
Education and awareness plays an important part in compliance and patient adherence. It will even help capture those individuals who have not been diagnosed yet. The healthcare professional will have a big part to play here. It is their interaction with the patient (or even their caregiver) that will dictate the success of the regimen: the way they explain the treatment plan will help increase the desire to complete the regimen to its full course.
Cost of Treatment.
The cost of treatment is most significant in those countries using an insurance based healthcare infrastructure. Individuals will purchase insurance plans based on their income, this may restrict certain treatments.
Self Monitoring / Tests.
Providing a means for the patient or caregiver to self monitor is another ideal way to increase adherence. There is evidence to support the effectiveness of self-monitoring in achieving a desired behaviour change.
Pharmacies are unable to store every single drug. Most utilise wholesalers who provide daily if not twice daily deliveries. Unfortunately there are still occasions when supply cannot be fulfilled. This may be due to stock-outs or even the patient forgetting about the repeat prescription. A number of companies now provide home delivery services to support the patients, it includes the management of prescriptions.
All the points above demonstrate the complexity of the subject. It is by no means a definitive list of reasons for non compliance, but it covers most of the important ones. Clearly no one factor can be attributed as the underlying cause. Ultimately strategies need to be integrated, linking the healthcare professionals, the medical manufactures and the patients together.
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