This site is intended for health professionals only

Patient noncompliance: a costly issue in healthcare

Iun Grayston
BPharm MRPharmS
PCG Pharmaceutical Advisor
Wandsworth PCT
Wandsworth
London

Noncompliance is universal, and has potentially life- threatening repercussions.(3,4) One study has shown that neglecting to take immunosuppressive drugs is the most common cause of kidney transplant failure.(5) Another study found that patients frequently failed to adhere to their antihypertensive drug regimens, with well-recognised consequences.(4)

What is noncompliance?
There is no generally recognised and accepted defination of noncompliance.(4) Noncompliance implies that the patient does not use a medicine according to medical advice.(4) The term compliance has long been criticised as denoting obedience - following the prescriber's orders.(6) Lately, medication concordance is a term used to signify that the doctor or nurse and patient have come to a shared agreement about therapeutic goals. Efforts to improve compliance have not had sustained success. A therapeutic alliance between patient and prescriber may be the way forward.(7)
A wide range of patients factors lead to poor adherence, which can be broadly categorised as intentional or unintentional. Unintentional poor adherence may arise simply from deterioration in mental or physical competence, often associated with ageing, or from a misunderstanding between the patient and prescriber. Intentional poor adherence involves rationality and decision-making on the part of the patient - when the patient either rejects the prescriber's diagnosis or the prescriber's recommended treatment, or does not cash in a presription.(4)
Noncompliance is multifactorial. Table 1 lists some of the common factors that influence compliance.

[[NIP05_table1_26]]

What have we learned so far?
There are good reasons for suggesting that older people are more susceptible to failures of compliance.(1,4) Studies have indicated that 25-50% of particular groups of elderly patients do not, or cannot, take all their medications as prescribed.(4) One reason for this is that the number of different medications prescribed often increases with age, as the number of disease processes increases with age.(1,4) Another reason is that the elderly are more susceptible to adverse drug reactions, and this discourages compliance.(4) The elderly may also find it difficult to read and understand the labelling on medications.(4)
Brief counselling can improve this. A study found that patients who were given the opportunity to discuss the most convenient times in their daily routine when medication could be taken, and then given a leaflet with the times written down, were significantly more compliant.(4) Reviews of the literature tend to support the importance of helping patients find ways to integrate medication-taking into their daily routine.(4)
Research suggests that while patient leaflets can improve patient satisfaction and knowledge, they have little effect on compliance. A number of reminders have been demonstrated to improve compliance, such as telephone or postcard reminders, individualised reminder charts, diaries, and engaging family members and carers to provide reminders.(4)
The effects of frequency of dose have also been studied. Regimens that involve taking medication once or twice daily are associated with better compliance than those that involve taking medication three or four times daily.(3)
Patients vary individually in their confidence that a given drug will alleviate their symptoms and normalise their life.(4) A number of studies suggest that patients have many fears and powerful negative images of medicines.(4,8) One study has shown that ideas about side-effects and not wanting a prescription are two of the most common issues that are not raised by patients in a consultation, and often lead to specific problem outcomes, such as unwanted prescriptions, non-use of prescriptions, and nonadherence to treatment.(10)
The quality of interactions between prescriber and patient can have a major influence on health outcomes. Some studies, although not directly concerned with compliance, point to considerable improvements in healthcare outcomes consequent on achieving a richer and more cooperative interaction between prescriber and patient.(4)
Interventions that resulted in improvement in compliance all showed rapid deterioration if the intervention was not repeated regularly.(4) No single method of improving compliance appears to be inherently superior,(6) and combined strategies work better than single ones.(3)

Strategies for improvement
Healthcare professionals must communicate better with their patients, not only about diagnosis, treatment and possible side-effects, but also about prognosis and frequency of follow-up, and the reasoning behind what is proposed.(3) 
Describing the treatment and its effects in ways that patients will understand is the essence of patient education. With the informed approach, patients are accorded a more active role in both defining the problem for which they want help and in determining appropriate treatment. The patients are provided with relevant research information about treatment options, their benefits and risks, so that they can make an informed decision.(9) Patients can be informed about dosing options and asked what would work best for them.(6) Treating the patient as a decision-maker is a fundamental step towards the concordance model (see Tables 2 and 3).(6)

[[NIP05_table2_28]]

[[NIP05_table3_28]]

Compliance cannot be assumed.(3) Patients may be compliant in attitude but not in behaviour, and vice versa.(3) With coaching and a nonjudgmental attitude from the prescriber, patients are more likely to describe their drug-taking truthfully.(6) It may be that those who state their noncompliance when questioned about it are more likely to respond to efforts to improve compliance.(3) 
It should also not be assumed that medicines are an acceptable form of treatment in every situation.(8) Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agendas.(9,10) At consultation, it is worthwhile exploring whether medicine taking is problematic or whether the patient has any fears about it.(8) If there are fears, the patient should be encouraged to express them, and then the implications for adherence can be sympathetically discussed.(8)
Patients can be asked about their social life to establish if work or leisure commitments are going to affect adherence.(8) An exploration of these issues should help assess the appropriateness of the proposed treatment.(8)

Monitoring responses
There are many monitoring systems available, but they may not be practical in all therapeutic settings. Realistic steps to monitor response include:

  • Watching for nonattendance at follow-up appointment. Patients who do not attend clinic are far more likely to be noncompliant.(3)
  • Watching for lack of responsiveness to a usually or previously adequate dosage.(3)
  • Carefully questioning-a nonjudgmental, nonthreatening approach is essential.(3)

Conclusion
Many patients do not take their medication to best effect and so do not derive the optimum benefits of treatment. The personal cost in avoiding continuing illness and premature death and the public cost in terms of economic loss and increased health services expenditure are vast.(4)
Patients fail to take their medications for a variety of reasons. There are various methods to remind patients to take the medicines. However, some patients seem to consciously modify their medications rather than simply forget.(11) A hypothesis has arisen that compliance is related to the failure to negotiate a therapeutic goal that is understood and owned by the patient and the prescriber.(4) Concordance is the new approach to the prescribing and taking of medicines. It is an agreement reached after negotiation between a patient and a healthcare professional that respects the beliefs and wishes of the patient in determining whether, when and how medicines are to be taken. 
The "compliance problem" may be getting a new name, and with it a new view of the patient's role in the prescriber- patient relationship. The change in terminology will have an impact only if the culture change that is advocated succeeds and clinicians take a more egalitarian view of the relationship between prescribing and medicine-taking, and between patient and prescriber. 
This model may require a radical change in consulting styles and a deeper understanding of the patient's health beliefs. An education and training agenda that includes improving consultation and communication skills as part of the training of prescribers may be the way forward.

References

  1. Corlett AJ. Caring for older people: aids to compliance with medication. BMJ 1996;313:926-9.
  2. Beardon PH, et al. Primary non-compliance with prescribed medication in primary care. BMJ 1993;307:846-8.
  3. Wright EC. Non-compliance - or how many aunts has Matilda? Lancet 1993;342:909-13.
  4. Royal Pharmaceutical Society of Great Britain. From compliance to concordance: achieving shared goals in
  5. medicine taking. London: RPSGB; 1997.
  6. Marshall M. Personal paper: Writing prescriptions is easy. BMJ 1997;314:747-8.
  7. Editorial. Compliance becomes concordance. BMJ 1997;314:691.
  8. Collier J, Hilton S. Doctors and patients should sign prescriptions. BMJ 1998;317:951.
  9. Britten N. Patients' ideas about medicines: a qualitative study in a general practice population. Br J Gen Pract
  10. 1994;44:465-8.
  11. Charles C, Gafni A, Whelan T. How to improve communication between doctors and patients. Learning more about the decision-making context is important. BMJ 2000;320:1220-1.
  12. Barry C, et al. Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320:1246-50.
  13. Chen J. Medication concordance (letter). BMJ 1998; 28 Oct 1998.

Further reading
Royal Pharmaceutical Society of Great Britain. From compliance to concordance: achieving shared goals in medicine taking. London RPSGB; 1997.
Charles C, et al. How to improve communication between doctors and patients. Learning more about the decision-making context is important. BMJ  2000;320: 1220-1