Impact on treatment recommendations

Patient adherence with prescribed treatments has become an area of increasing interest and concern over the last few decades. Studies have shown that non-adherence is a significant issue that causes serious problems for the health care system: Among the statistics:

  • Most studies show that between 25 and 50 percent of patients are non-adherent.
  • Some studies show non-adherence rates as high as 93 percent.
  • Most health care professionals underestimate the prevalence of non-adherence.

Alarmingly, despite significant advances in disease prevention and health care, many Americans continue to die of conditions that could have been prevented or treated. Although health risks for a number of serious diseases are known, millions of people continue to engage in unhealthy behaviors such as tobacco use, excessive alcohol consumption, a sedentary lifestyle, and poor dietary habits. Assuming that the patient’s condition has been accurately diagnosed and the appropriate treatment prescribed, the only way that recommended therapeutic or preventative regimens could be effective is for patients to follow advice given them. It is widely accepted that this does not occur in many instances.

Non-adherence has a profound effect on the individual patient’s health status, on individual health care professionals, and also on the health care system. Huge amounts of health care dollars are wasted when medications are not taken correctly, when medical equipment is misused, when patients are re-admitted to hospital care for preventable problems, and when a large percent of the public continue to practice health habits that inevitably lead to serious disease. Patient non-adherence can take many forms, including missing health care appointments, not taking medications as directed, or not following recommended dietary or other lifestyle changes. A patient’s failure to keep an appointment is costly. It can have serious health consequences for the patient and contributes to increasing health care costs by wasting the time resources of health care professionals. Appointments for follow-up on a previously treated condition can also be a source of non-adherence, especially for patients who have no longer have troublesome symptoms. An example is the patient who seeks medical care, is prescribed antibiotics for a urinary tract infection, and is scheduled for a follow-up appointment for another urine culture to make sure her infection has been resolved. When the antibiotics are completed, the patient sees no reason to make the follow-up appointment and does not seek medical help until weeks later, when she experienced chills, fever, and flank pain-symptoms of a kidney infection, a much more serious problem than the original cystitis. Teaching patients about how to use their medications effectively is a significant challenge in our health care system. An estimated $100 billion is spent each year on problems caused by noncompliance with medication regimens. Table 18 outlines the basics of what patients must know in order to adhere to a medication prescription.

Non-adherence involving medication use occurs in many ways. Patients may never have the prescription filled or may alter the prescribed dose-taking either too much or too little of the medication, or changing the time interval at which the medication is given. It is not uncommon for patients to save up drugs that should have been completely used, increasing the possibility that they or others may use the drugs inappropriately later. In cases in which medication is a continual, ongoing part of controlling the disease itself, such as with hypertension or diabetes, failure to adhere can have life-threatening consequences. Patients who err on the side of excess run the risk of drug interactions, drug toxicity, and a variety of other impairments from misuse or overuse of prescribed, therapeutic medications.

Non-adherence also affects dietary and other lifestyle changes suggested as part of treatment, sometimes with serious consequences. For example, a patient had circulatory problems in his lower extremities due to arteriosclerosis. When his foot became infected, he was instructed to soak it several times a day, followed by a heat lamp treatment. Unfortunately, the patient adhered only sporadically and eventually had a below-the-knee amputation.

Problems with potential non-adherence are considered a major factor in developing new forms of medications and treatments. Many advertisements by drug companies claim that their produce will „improve compliance.“ Various techniques have been used to assess adherence with treatments, especially drug therapy, including technical methods such as checking blood concentration and serum levels of drugs, and urine screening for drug metabolites or other biochemical markers. Other simpler methods are pill counts, checking whether prescriptions are dispensed, and direct questioning of patients. There are problems with all these methods. Blood and urine screening are affected by individual variations in metabolic and absorption rates. Pill counts may be unreliable, and direct questioning may impair the relationship between clinician and patient. In addition, none of these methods gives an indication of adherence to the treatment schedule.

Patient non-adherence also has a negative impact on health professionals. We have the best of intentions in helping patients learn how to care for themselves and become discouraged and even angry when patients ignore our advice. Non-adherent behavior violates the professional beliefs, norms, and expectations we have about the relationship between patients and health care professionals. Not only do nurses and other health care professionals tend to underestimate the extent of non-adherence, but we may also have misconceptions about who is at risk for non-adherent behavior. We may assume that patients who are uneducated or from lower socioeconomic groups are less likely to follow recommendations; however, research has shown this not to be true. Amazingly, although it seems logical that patients with the most serious health care problems would be the most adherent, this has not been found to be true. One study found that patients with less severe medical problems were actually more likely to follow through with medical advice than those with a more severe illness. In addition, patients with asymptomatic disease conditions such as hypertension often have problems with adherence. It is thought that the level of perceived threat to health for asymptomatic patients is not enough to motivate a person to adhere to treatment recommendations, while very high levels of perceived threat cause such fear that the patient is unable to act.

Table 18

What Patients Must Know About Their Medications

  • The name of the medication and what it is for
  • The dosage, route of administration, and how long to take the drug
  • Any special directions or precautions about how to prepare the drug or take the drug
  • Common severe side effects or interactions that may occur with other drugs or food, how to avoid such interactions, and what to do if they occur
  • When to call the physician about problems with the drug
  • How to store the drugs
  • Prescription refill information
  • Actions to be taken if a dose is missed
SOURCE: Adapted from Kramer, E.J. (1999). „Health promotion and disease prevention.“ In: Bateman, W.B., Kramer, E.J., & Glassman, K.S. (Eds.) Patient and Family Education in Managed Care and Beyond. New York: Springer Publishing Co., 100.

Causes of non-adherence