Elsevier

The Case Manager

Volume 16, Issue 2, March–April 2005, Pages 47-51
The Case Manager

Medication adherence: Factors influencing compliance with prescribed medication plans

https://doi.org/10.1016/j.casemgr.2005.01.009Get rights and content

Abstract

Adherence to medical therapy (the extent to which recommendations are followed as defined) is a complex and dynamic behavioral process that is strongly influenced by the patient, his or her support environment, practices of health care providers, and the characteristics of care delivery systems.1 Adherence, formerly referred to as compliance, is a patient-centered term. It suggests that patients carry out and maintain certain behaviors, such as taking medications, after making an informed choice in a supportive environment.

Section snippets

Adherence rates

For example, although the benefits of preventing and treating chronic conditions, such as hypertension and hypercholesterolemia, are clear, many patients fail to adhere to regimens repeatedly shown to slow the progression or even reverse the disease course and prevent morbidity and mortality.1, 2 For example, in a review of information for 5590 patients who experienced a first myocardial infarction (MI), those who had less than 80% adherence to statin therapy had a more than 4-fold increase in

Barriers to adherence

Poor adherence involves patient, medication, and prescriber factors.13, 14, 15 Race, marital status, current substance abuse, low literacy, poor understanding of the need for treatment, insufficient confidence in the clinician or medication, psychological problems, low motivation to change behavior, and low socioeconomic status are prominent patient factors that have a negative impact on adherence.15, 16, 17, 18 Medication factors include complexity of dosing regimen, pill burden, side effects,

New standards to assess and improve adherence

The scope of nonadherence and the variable and often modest impact of interventions to improve adherence20 are a result, at least in part, of a lack of consensus on what determines nonadherence and the absence of generally accepted standards for corrective approaches in the various settings in which health care is delivered, including the physician's office, the pharmacy, the home.21

Historically, interventional approaches have used the biomedical model of simply providing information from an

Patient factors

A large number of patient-centered characteristics influence adherence (Table 1).22 Recently, however, the WHO has made a strong case that medication adherence is based on three pillars: patient information, motivation, and behavioral skills (Figure 1).5 Of these, motivation may be the most critical. This view is consistent with global evaluations that identify motivation and readiness to change as fundamental to long-term alteration of behavior.23 The Case Management Society of America's

Patient population factors that may influence adherence

Elderly or aging patients may be more likely than their younger counterparts to have poor adherence to therapy.26 The cognitive declines of aging may place elders at particularly high risk for errors in self-medication. In a study of 70- to 97-year-old patients discharged after a hospital admission for heart failure, 27% were noncompliant after 30 days despite having received written instructions.27 Much of this failure was attributable to poor recollection of instructions. Among 75-year-olds,

Conclusion

Poor adherence to medical therapy may account for as much as $300 billion in unnecessary health care expenses each year. Nonadherence is a complicated interplay of patient, medication, and prescriber factors, but limitations in patients' medication knowledge and willingness to change behavior may be the greatest barriers to improving adherence. It is important for case managers to evaluate knowledge, motivation, and patient factors associated with adherence. These factors should be addressed as

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    Editor's note: This article is the first in a three-part series discussing case management's role in promoting medication adherence. This article provides a review of the literature on medication adherence, describes the extent and importance of the nonadherence problem, and describes patient characteristics and psychosocial factors that may present barriers. Article 2 will introduce evidence-based tools that case managers can use to formally assess medication adherence and patients' knowledge and motivation to modify behaviors. Article 3 will describe a national initiative under way by the Case Management Society of America to train case managers in psychosocial behavioral change and apply adherence interventions through a set of evidence-based guidelines called CMAG-1.

    1

    Jon J. Vlasnik, PharmD, BCPS, is the senior manager for clinical applications for Pfizer, Inc., in Cranberry Township, Pa.

    2

    Sherry L. Aliotta, RN, BSN, CCM, is president and CEO of S.A. Squared, Inc., and the 2004-2005 CMSA president.

    3

    Bonnie DeLor, PharmD, BCPS, is a clinical education consultant for Pfizer.

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