Compliance (medicine)

In medicine, compliance (also adherence or concordance) describes 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. Both the patient and the health-care provider affect compliance, and a positive physician-patient relationship is the most important factor in improving compliance, although the high cost of prescription medication also plays a major role.

Non-compliance is a major obstacle to the effective delivery of health care. Estimates from the World Health Organization indicate that only about 50% of patients with chronic diseases living in developed countries follow treatment recommendations. In particular, low rates of adherence to therapies for asthma, diabetes, and hypertension are thought to contribute substantially to the human and economic burden of those conditions. Compliance rates may be overestimated in the medical literature, as compliance is often high in the setting of a formal clinical trial but drops off in a "real-world" setting.

Major barriers to compliance are thought to include the complexity of modern medication regimens, poor "health literacy" and lack of comprehension of treatment benefits, the occurrence of undiscussed side effects, the cost of prescription medicine, and poor communication or lack of trust between the patient and his or her health-care provider. Efforts to improve compliance have been aimed at simplifying medication packaging, providing effective medication reminders, improving patient education, and limiting the number of medications prescribed simultaneously.

Terminology

An estimated half of those for whom treatment regimens are prescribed do not follow them as directed. Until recently, this was termed "non-compliance", which was sometimes regarded as meaning that not following the directions for treatment was due to irrational behavior or willful ignoring of instructions. Today, health care professionals more commonly use the terms "adherence" to or "concordance" with a regimen rather than "compliance", because these terms are thought to more accurately reflect the diverse reasons for patients not following treatment directions in part or in full. However, the preferred terminology remains a matter of debate. In some cases, concordance is used to refer specifically to patient adherence to a treatment regimen that is designed collaboratively by the patient and physician, to differentiate it from adherence to a physician only prescribed treatment regimen. Despite the ongoing debate, adherence is the preferred term for the World Health Organization, The American Pharmacists Association, and the U.S. National Institutes of Health Adherence Research Network.

Concordance also refers to a current UK NHS initiative to involve the patient in the treatment process to improve compliance. In this context, 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
• 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

Societal impact

A WHO study estimates that only 50% of patients suffering from chronic diseases in developed countries follow treatment recommendations. 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, one study reported a 97% compliance rate at the beginning of treatment with statins, but only about 50% of patients were still compliant after six months.

Compliance issues

Prescription fill rates

While a health care provider visit with a patient may result in a the patient leaving with a prescription for medication, not all patients will fill the prescription at a pharmacy. In the U.S., 20-30% of prescriptions are never filled at the pharmacy. There are many reasons patients do not fill prescriptions including the cost of the medication, doubting the need for medication, or preference for self-care measures other than medication. Cost is the most significant barrier to prescription drug adherence. A US nationwide survey of 1,010 adults in 2001 found that 22% chose not to fill prescriptions because of the price, which is similar to the 20-30% overall rate of unfilled prescriptions.

Course completion

Once started, patients seldom follow treatment regimens as directed, and seldom complete the course of treatment. Cost and poor understanding of the directions for the treatment (referred to as 'health literacy') are major barriers to completing treatments. As mentioend previously, the World Health Organization (WHO) has estimates that only 50% of people complete long-term therapy for chronic illnesses as they were prescribed, which puts patient health at risk.

A wide variety of packaging approaches have been proposed to help patients complete prescribed treatments. These approaches include formats that increase the ease of remembering the dosage regimen as well as different labels for increasing patient understanding of directions. For example, medications are sometimes packed with reminder systems for the day and/or time of the week to take the medicine. With the objective to support patient adherence to medicinal therapy, a not-for-profit organization (Healthcare Compliance Packaging Council of Europe/HCPC-Europe) [1] 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 by this collaboration to aid in patient compliance.

The failure to complete treatment regimens as prescribed has significant negative health impacts worldwide. Examples of the rate and consequences of non-compliance for selected medical disorders is as follows:

• Diabetes non-compliance (98% in US) is the principal cause of complications related to diabetes including nerve damage and kidney failure
• Hypertension non-compliance (93% in US, 70% in UK) is the main cause of uncontrolled hypertension-associated heart attack and stroke
• Asthma non-compliance (28-70% worldwide) increase the risk of severe asthma attacks requiring hospitalization

See also

• Pill burden
• Polypharmacy
• Withdrawal

External links

• Adherence to Long-Term Therapies, a report from the World Health Organizationar:امتثال (طب)

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