Optimizing Patient Adherence to
Pharmaceutical Care Plans
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Objectives
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Background
Burden of non-Adherence
Definitions
Factors affecting patient adherence
Interventions to detect and assess adherence/non-adherence
Consideration for special populations
Strategies to optimize adherence to pharmaceutical care plans
(prevention and resolving nonadherence)
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Lecture Resources
• Medication Adherence : Its Importance in Cardiovascular
Outcomes. Circulation. 2009;119:3028-3035
• Optimizing Adherence to Pharmaceutical Care Plans. J Am
Pharm Assoc. 2000;40(4). Accessed from:
http://www.medscape.com/viewarticle/406691_2
• Enhancing Prescription Medicine Adherence: A National
Action Plan (2007). Accessed from:
http://www.talkaboutrx.org/documents/enhancing_prescriptio
n_medicine_adherence.pdf
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Background
• Nonadherence has serious negative impact on patient’s and
health outcomes
• Considered as an "invisible epidemic”
• “America’s Other Drug Problem”
• It affect all age and ethnic groups
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Background
• About 69% of non-adherence to drug therapy is behavioral in
nature resulting from forgetfulness or procrastination
• Share many characteristics of medical disorders
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• Non-adherence rates are high among patients with
chronic diseases
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“Poor adherence to
treatment of chronic
diseases is a
worldwide problem of
striking magnitude.
Adherence to long-term
therapy for chronic
illnesses in developed
countries averages 50%.
(WHO 2003)
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“A worldwide problem of striking magnitude”
• In USA:
• Three out of every four American consumers report not always
taking their prescription medicine as directed*.
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Forgetfulness: 49%
Didn’t refill: 31%
Ran out of medicine: 29%
Took less dose than recommended: 24%
• About 33% to 69% of medication related hospital admissions
are due to poor adherence
* Survey conducted by National Community Pharmacists Association-2006
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“A worldwide problem of striking magnitude”
• In UK
• 20-30% don’t adhere to regimens that are curative or
relieve symptoms
• 30-40% fail to follow regimens designed to prevent health
problems
• 33-50% of newly prescribed medicines are subject to nonadherence
Survey by The New Medicines Service (NMS), a service commissioned by the Department
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of Health-UK
Nonadherence in Saudi Population
Data from Saudi Arabia
• Hypertensive patient has a compliance rate of 34.2%
Khalil et al. Journal of Hypertension, 1997, 15:561-565.
• Factors: organizational variables (time spent with the
doctor, continuity of care by the doctor, communication
style of the doctor and interpersonal style of the doctor)
Albaz RS. Journal of Social Sciences, 1997, 25:5-8.
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Nonadherence in Saudi Population
• Medication adherence among patients in a chronic disease
clinic
• Cross sectional study, n= 347
• Age and asthma were significantly associated with low
motivation
• Single status was the only independent predictor of low
adherence intention
Tourkmani, Saudi Med J. 2012 Dec;33(12):1278-84.
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“A worldwide problem of striking magnitude”
1. Adverse Heath outcomes:
 Decrease productivity
 Increase disease morbidity
 Increase physician office visits
 Hospital re/or-admissions
 Death
2. Pharmacies also lose revenue because patients often fail to
refill prescription medications, especially for chronic
diseases
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“A worldwide problem of striking magnitude”
3. Economic Burden:
• Data from USA:
• Annual deaths caused by non-adherence is estimated
to be 125,000
• Cost: nearly $300 billion annually in direct and
indirect costs
– Mostly due to readmissions
»70% of which are attributable to medication
non-compliance among the elderly
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What is the definition of nonadherence?
• “Drugs don't work in patients who don't take them”
- C. Everett Koop, M.D.
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The extent to which a person’s behavior – taking
medication, following a diet, and/or executing
lifestyle changes, corresponds with agreed
recommendations from a health care provider.
The definition best describes
Compliance
Adherence
Persistence
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Definitions
Compliance: the extent to which the patient’s
behavior matches the prescriber’s
recommendations’1
Adherence: ‘the extent to which the patient’s
behavior matches agreed upon recommendations from the
prescriber’
Medication persistence: “the length of time from initiation to
discontinuation of therapy”
16 2008;11:44–7.
Haynes R, et al 1979. Barofsky I. 1978, Cramer, Value Health
More than just medications….
• Nonadherence encompass any of the following:
• Medications
• Recommended lifestyle changes: exercise or smoking cessation
• Prescribed non-pharmacologic interventions: physical therapy or
dietary plans
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Medication Nonadherence
• Can take many forms:
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Not having a prescription filled
Taking an incorrect dose
Taking medications at incorrect times
Forgetting to take doses
Stopping therapy before the recommended time
Drug Holiday
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What does the patient Really Say...
• “If I don’t put my pills on my plate 3 times a day, my wife will
put them for me, there is no question about that!”
• “I believe the doctor will know. He is trained regularly, he knows
the newest things. What do we know about it? I suppose that it
is necessary to take the medication.”
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What does the patient Really Say..
• “That is why I always ask for samples.. I take a lot of medicines and it
is very expensive.”
• “I never forget my medication, except for the one pill that I have to
take twice.”
• “I couldn’t make neither head or tail because in hospital they have
another name for the same tablet.”
• “I didn’t take my diuretics (metoprolol) because of my visit to HF
clinic.”
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What does the patient Really Say..
• “It is just a routine… I put the tablets on the breakfast table and
hope I take them.”
• “I suppose it is a built-in fear; if you don’t comply you will end
up back in the hospital again-and you don’t want that, do you?
• “When you so far gone as I am now, you will take them, you
have no choice.”
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Major Risk Factors for Non-Adherence
1. Asymptomatic conditions
2. Chronic conditions
3. Cognitive impairments, especially forgetfulness
4. Complex regimens
5. Multiple daily doses and polypharmacy
6. Patient fears and concerns related to medication effects
7. Poor communication
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Causes for Nonadherence
• Reasons for patient non-adherence are complex and
multidimensional
• Many internal and external factors
• The WHO define 5 dimensions for nonadherence:
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Social/economic factors
Provider-patient/health care system factors
Condition-related factors
Therapy-related factors
Patient-related factors
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Factors affecting Patient Adherence
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I. Social and economic factors
• Poor socioeconomic status and poverty
• Illiteracy, low level of education
• Unemployment
• Lack of effective social support networks
• Unstable living conditions (Wars)
• Long distance from treatment center
• High cost of transport; high cost of medication
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I. Social and economic factors
• Changing environmental situations
• Culture and lay beliefs about illness and
treatment
• Family dysfunction
• Race: cultural beliefs, social inequalities
• Age: Children, Adolescent, Elderly
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II. Health care team and system-related factors
• Poorly developed health services
• Poor medication distribution systems
• Lack of knowledge and training for health care
providers on managing chronic diseases,
overworked health care providers
• Lack of incentives and feedback on
performance
• Short consultations times
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II. Health care team and system-related factors
• Weak capacity of the system to educate
patients and provide follow-up
• Inability to establish community support
and self-management capacity
• Lack of knowledge on adherence and of
effective interventions for improving it
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III. Condition-related factors
• Severity of symptoms
• Level of disability (physical,
psychological, social and vocational)
• Rate of progression and severity of the
disease
• The availability of effective treatments
• Comorbidities: depression
• Substance of abuse
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IV. Therapy-related factors
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Complexity of the medical regimen
Duration of treatment
Previous treatment failures
Frequent changes in treatment
The immediacy of beneficial effects
Side-effects and the availability of medical
support to deal with them
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V. Patient-related factors
• Knowledge and beliefs about illness, motivation to
manage it
• Expectations regarding the outcome of treatment
and the consequences of poor adherence
• Inadequate knowledge and skill in managing the
disease symptoms and treatment
• Misunderstanding of treatment instructions
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V. Patient-related factors
• Negative beliefs regarding the efficacy
of the treatment
• Lack of perception of the health risk
related to the disease
• Lack of self-perceived need for
treatment
• Lack of perceived effect of treatment
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V. Patient-related factors
• Anxieties about possible adverse effects
• Low motivation
• Low attendance at follow up, or at counseling,
motivational, behavioral, or psychotherapy
classes
• Hopelessness and negative feelings
• Frustration with health care providers
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V. Patient-related factors
• Forgetfulness
• Psychosocial stress
• Misunderstanding and non-acceptance
of the disease
• Lack of acceptance of monitoring
• Disbelief in the diagnosis
• Low treatment expectations
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Patient-related factors
• Fear of dependence
• Anxiety over the complexity of the
drug regimen
• Perceived effect of treatment
• Feeling stigmatized by the disease
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Next Lecture
• Assessing Adherence
• Resolving adherence problem
• Preventing adherence
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