Treatment compliance

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Treatment compliance or Adherence to treatmentis not to be assumed just because people seek help.

It has been estimated that half of those for whom medicines are prescribed do not take them in the recommended way. Until recently this was termed “non-compliance”, which was sometimes regarded as a manifestation of irrational behavior or wilful failure to observe instructions, although forgetfulness is probably a more common reason. But today, healthcare professionals prefer to talk about “adherence” to a therapeutic contract rather than “compliance”.

Adherence in medicine

Compliance (or Adherence) in a medical context refers to a patient both agreeing to and then undergoing some part of their treatment program as advised by their doctor or other healthcare worker. Most commonly it is whether a patient takes their medication (Drug compliance), but may also apply to use of surgical appliances (e.g. compression stockings), chronic wound care, self-directed physiotherapy exercises, or attending for a course of therapy (e.g. counselling).

A patient may or may not accurately report back to their healthcare workers whether they have been compliant because of possible embarrassment, fear of being chastised or for seeming to be ungrateful for their doctor's care.

Causes for poor compliance include:

• Forgetfulness
• Prescription not collected or not dispensed
• Purpose of treatment not clear
• Perceived lack of effect
• Real or perceived side-effects
• Instructions for administering not clear
• Physical difficulty in complying (e.g. with opening medicine containers, handling small tablets or swallowing difficulties, travel to place of treatment)
• Unattractive formulation (e.g. unpleasant taste)
• Complicated regimen
• cost of drugs.

Drug compliance

It has been estimated that in developed countries only 50% of patients who suffer from chronic diseases adhere to treatment recommendations. This may affect the patient's own immediate health or have implications for the wider society (e.g. failure to prevent complications from chronic diseases, formation of resistant infections or untreated psychiatric illness). There are also important implications when assessing reports from research into treatment efficacy rates, given that compliance rates during closely monitored studies are usually far higher than in later real-world situations (e.g. up to 97% compliance in some studies on statins, but only about 50% of patients continue at six months). Special attention should be paid to the fact that the word “adherence” is preferred by many health care providers, because “compliance” suggests that the patient is passively following the doctor’s orders and that the treatment plan is not based on a therapeutic alliance or contract established between the patient and the physician. According to some, both terms are imperfect and uninformative descriptions of medication-taking behavior.

Prescription collection and dispensing

In the past there was an expectation, by both doctors and patients, that the end of consultation should be marked by prescribing some form of medication to treat the problem. However many patients merely seek reassurance as to the nature of their symptoms, rather than necessarily wishing to commence a course of treatment. It has been estimated that up to a third of prescriptions written by UK GPs are not later presented to a pharmacist for dispensing. Likewise a similar fraction of all medication dispensed is not taken in accordance with the prescribing instructions.

Failure to present a prescription for dispensing may reflect forgetfulness by a patient, or belief that reassurance or some other self-care measures rather than medication was required. Alternatively a patient may believe that their condition does not yet warrant starting treatment but that they now have a prescription ready should the problem either deteriorate or fail to resolve spontaneously. This last point is particularly important for those unable to return to their doctor should their condition change; whether through difficulty taking time off from work to revisit their doctor, it being just prior to a weekend when their doctor's surgery may be closed, or prior to undertaking long journeys away from home.

For conditions such as earache or sore throat that Evidence based medicine suggests do not automatically require a course of antibiotics, it is becoming increasingly common for doctors to issue deferred prescriptions. These are intentionally not to be dispensed for a specified period of time unless the patient feels that spontaneous recovery is not occurring. It has been estimated that only about a third of deferred prescriptions are made use of, and this provides a useful means of reducing unnecessary antibiotic prescribing without antagonising patients in the western world who through cultural, the wider media and past medical practices may have unrealistic expectations on the value of antibiotics for minor common illness.

Course completion

Once started, patients often fail to adhere to the original prescribing instructions either over dosage frequency or completion of the course. Medication that must be taken several times a day causes practical difficulties for patients including remembering to take, having to carry around the medication with them, availability of water to help swallow tablets. If a course of treatment proves effective, then the imperative to continue with the effort of taking the medication in order to relieve symptoms is lost and many patients therefore stop at this point. This may result in only an incomplete cure being achieved with a risk of relapse or, in the case of treating infections, lead to the development of antibiotic resistance. Failure to comply with completion is more likely if the patient experiences troublesome side effects, has concerns for the long-term effects of their treatment, or if medication must be taken for a protracted period. This is a greater problem therefore with any long-term treatment particularly if the medication merely stabilises a condition rather than gives relief from symptoms. Furthermore there are wider implications to society if a patient fails to comply with treatment for a number of conditions:

• Communicable diseases such as tuberculosis or HIV present a risk to society should a patient fail to comply with treatment thus resulting in the development of resistant strains, that may prove incurable.
• Patients with some psychiatric illness, such as schizophrenia or bipolar disorder, may feel entirely well whilst stabilised on medication, but are at risk of relapse should they discontinue.
• Patients taking certain antihypertensive medications may experience severe high blood pressure if they discontinue the medication abruptly. This is known as rebound hypertension.
• Corticosteroids may require a 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 as a result.

Concordance

Concordance is an approach at involving the patient in the treatment process to improve compliance and is a current UK NHS initiative. The patient, being informed about the condition and the various treatment options, is jointly involved in the decision as to which course of action to take and partially responsible for the monitoring and reporting back to others involved in their care. 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 concerns for long-term use
• Prescribing the minimum number of different medications, e.g. prescribing for someone with two concurrent infections a single antibiotic that addresses the sensitivities of both likely bacteria, rather than two separate courses of antibiotics. However, this also raises the spectre of developing antibiotic resistant species in the wider scenario.
• Simplifying dosage regimen, whether by selecting a different drug or using a sustained release preparations that need less frequent dosages during the day.
• Explanation of possible side effects and whether important to continue with the course of medication none-the-less.
• Advice on minimising or otherwise coping with side effects, e.g. advice on whether to take a particular drug on an empty stomach or with food.
• Developing trust between the patient and their doctor such that patients do not feel they will be embarrassed or seen as ungrateful if they are unable to take a particular drug, thus allowing a better tolerated alternative preparation to be tried.

See also

• Medical error
• Pill burden
• Polypharmacy
• Withdrawal

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