Compliance (or adherence) is a medical term that means the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication, or drug compliance, but may also mean use of medical appliances such as compression stockings, chronic wound care, self-directed physiotherapy exercises, or attending counseling or other courses of therapy. The most effective way for a doctor to improve patient compliance is through a positive physician-patient relationship.

Other factors that increase compliance include:

• Patient feeling ill
• Limitations of patients activities due to disease state
• Written instructions for taking medication
• Acute illness
• Simple treatment schedule
• Short time spent in waiting room
• Physician recommending one change at a time
• Benefits of care outweigh costs
• Peer support

Patients may not accurately report back to health care 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
• Poor rapport with physician
• Few symptoms
• Chronic illness
• 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

Contents 1 Adherence 2 Drug compliance 2.1 Prescription collection and dispensing 2.2 Course completion 3 Concordance 4 See also 5 References

[edit] Adherence

An estimated half of those for whom medicines are prescribed do not take them correctly. Until recently, this was termed "non-compliance", and was sometimes regarded as irrational behavior or willful ignoring of instructions, although forgetfulness is probably a more common reason. 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.

[edit] Drug compliance

A WHO study estimates that only 50% of patients suffering from chronic diseases in developed countries follow treatment recommendations.^[2] This may affect patient health, and affect the wider society when it causes 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]

[edit] 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.^{[citation needed]} A third of all dispensed medication is not taken in accordance with instructions.^{[citation needed]}

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 spontaneously 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. Doctors intend these not to be dispensed for a specified period of time, unless the patient feels spontaneous recovery is not occurring. Patients use only about a third of deferred prescriptions, which reduces unnecessary antibiotic use.

[edit] Course completion

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Once started, patients seldom take medicines as often as they should^{[citation needed]}, and seldom complete the course of medication.^{[citation needed]} It is often practically difficult for a patient to remember to take medication several times a day.^{[citation needed]} They may forget^{[citation needed]}, not have the dose at hand, or not have water to swallow tablets with. People often miss taking prescribed medication, because of forgetfulness, changing medication schedules or busy lifestyles. It is estimated that between 40% and 60% of people do not take medication as prescribed, which can lead to worse outcomes. Packaging of medication with reminder systems for the day and/or time of the week is an attempt to help people take long-term medications... Reminder packaging for certain individuals may represent a simple method for improving the taking of medications." (Heneghan CJ, Glasziou P, Perera R The Cochrane Library, ISSN 1464-780X) [2]. "Combination pills and unit-of-use packaging are likely to improve adherence in a range of clinical conditions and settings. ..." archives.who.int/icium/icium2004/resources/ppt/AC016.ppt

With the objective to support patients' adherence to medicinal therapy, a not-for-profit organization (Healthcare Compliance Packaging Council of Europe/HCPC-Europe) [3] was set up between the pharmaceutical industry, the packaging industry and representatives of European patients organizations. The mission of HCPC-Europe is to assist and to educate the healthcare sector in the improvement of patient compliance through the use of packaging solutions.

A variety of packaging solutions have been developed to aid in patient compliance. Most are based on the use of a solid dose blister as the primary package. Many material and component suppliers as well as pharmaceutical contract packagers have worked to develop proprietary packaging formats. The automation of the packaging process for these package formats can be very difficult, as many do not use standard packaging equipment. Some examples of specialty compliance packaging equipment can be found at [4].

If a course of treatment works, the patient may feel that no more medication is needed^{[citation needed]} -- the symptoms are gone, after all -- and thus stop before their cure is incomplete. They 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 is to be taken for a long time^{[citation needed]}. The risk of a patient quitting a long-term treatment grows greater when that treatment stabilizes 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 develop strains resistant to present treatments, thus becoming incurable.
• Patients with such psychiatric illnesses as schizophrenia or bipolar disorder may feel well while stabilized 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 reports that the drug makes them "feel stupid."^{[citation needed]} They stop taking it may subsequently have seizures.

[edit] 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 their condition and treatment options. They are 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 a single antibiotic that addresses two concurrent infections (though risking contributing to antibiotic resistant species development)
• Simplifying dosage regimen by selecting a different drug or using a sustained release preparation that needs fewer doses during the day^[6]
• Discussing possible side effects, and whether it is important to continue medication regardless of those effects
• Advice on minimising or coping with side effects, e.g., whether to take a particular drug on an empty stomach or with food
• Developing trust so patients don't fear embarrassment or anger if unable to take a particular drug, allowing the doctor to try a better tolerated alternative

[edit] See also

• Good hospital practice
• GxP
• Medical error
• Pill burden
• Polypharmacy
• Withdrawal

[edit] References