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Medication Adherence

What is Medication Adherence?

The World Health Organization (WHO) defines adherence as “the degree to which a person’s behavior taking medications and following treatment therapies corresponds with the agreed recommendations from a health care provider”. Medication compliance/ adherence is a significant public health challenge and it is a key determinant to patient’s treatment success. Many patients are living with chronic diseases and require long term use of complex pharmacotherapy and multiple medication regimens. The efficacy of these medications has been proven in combating various chronic diseases, but patient non-compliance can limit their benefits leading to worsening of the diseases, affecting quality and length of life, increase healthcare costs and death. Approximately 50% of treatment failures have been attributed to non-adherence leading to 25% hospitalization and over 125,0000 deaths each year in the United States.

What are the reasons for Non-Adherence?

Many factors contribute to patient’s nonadherence to medications and some are listed below:

  • Poor communication between patient and provider: Various studies have shown that many patients misunderstood the direction given to them on how to take their medications or fail to correctly report the physician’s expectation of them after leaving the office.
  • Fear of medication side effects: All medications have side effects and physicians are vigilant for serious and life-threatening side effects, but they may be less attentive to side effects that can interfere with patient’s functional activities. Also, sometimes patients consider the desired effects of a medication as a side effect and this is specifically true for a patient taking diuretics for hypertension leading to sleep interruption at night due to frequent urination. Although changing the dosing schedule to morning may relieve the problem but may be challenging to the patient if they have limited access to the bathroom during the day.
  • Complex medication regimen: Patients with chronic diseases often take an average of 6 medications daily at a different time during the day. The complex medication regimen may affect adherence especially if the timing of medication administration conflicts with the patient’s job and daily life activities.
  • Low functional literacy and language barrier: An important contributor to medication non-adherence is low functional literacy and language barrier.  Older patients and immigrants with limited English proficiency can be vulnerable and a written word alone may not be sufficient for them to gain a clear understanding of the directions of their prescribed medication.
  • Patient’s Health Beliefs: Patient’s nonadherence may be due to beliefs in alternative or complementary medicine, religious beliefs, and the notion that they do not need to take any medication if they are not showing any symptoms which can all lead to poor treatment outcomes.
  • Low social and economic factors: A common reason for poor medication adherence is the cost. Many patients are not eligible for quality health insurance and those that are eligible have insurance that does not cover the cost of medications.  The high cost of medications has been a significant reason patients fail to fill their prescriptions or skip medication schedule doses so that it may last longer.

How to assess Medication Adherence?

  • Asking the patient if they miss their prescribed dosage at each office visit.
  • Asking the patient to bring all their medications to each office visit and calculate the medication possession ratio (PMR). 80% is needed for optimal therapeutic effects and indicates adherence.
  • Using a simple questionnaire and medication scale such as the Morisky Medication Adherence Scale (MMAS-4) is useful to estimate the likelihood of nonadherence.

What are methods to improve Medication Adherence?

  • A physician should simplify treatment regimens by reviewing medications regularly and identify those that are not effective and reducing the numbers of medications taken by the patients. A single pill combination should be offered so that fewer tablets are taking daily.
  • Collaborative planning between physician and patient to develop a dosing schedule that works for the patient to improve their adherence
  • The patient should be educated about the importance of medication adherence and how it can alter the course of their chronic medical conditions. It should be a repetitive effort to help the patient understand the benefits of taking their medications as prescribed.
  • Medication review visits should be implemented in patient treatment plan and this visit should focus exclusively on the proper administration of their medications and potential side effects.
  • Prescribing less expensive medication will limit financial burden and ensure patients have access to medication needed without cost barriers. 
  • The patient should be encouraged to use reminders such as apps or alarms on their smartphone to keep up with daily dosing that must be taken on a tight schedule.

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