The problem of nonadherence to drug therapy

Adherence to therapy generally means the patients’ ability to accurately follow their physician’s indications regarding times, frequency and assumption of medicine for the entire duration of therapy.

Lack of adherence to a medical prescription is directly correlated to an increase in healthcare interventions and an increase in mortality rates given that it renders therapy non-effective. There is usually greater adherence to therapy among patients affected by acute conditions compared to patients with chronic diseases.

Adherence to drug therapy in chronic patients has been shown to reduce drastically after the first six months of therapy, but the passing of time is not the only factor that causes patients to abandon drug therapy. After hospitalization, for example, patients tend not to immediately follow doctor recommendations upon discharge. In this historic moment, when the concept of the doctor-patient relationship is undergoing a transformation, making patients much more active in their own treatment plan, what are the solutions to this problem?

Improving adherence to therapy

There are many ways to improve adherence to drug therapy, of which the majority aim at overcoming all factors that can be attributed to patient responsibility. Nonetheless, the key to improvement is developing patient awareness about why drug therapy is needed and the effectiveness of adhering to it.

Patients need to comply with the suggestions and recommendations made by their physician. The success or failure of any type of therapy depends on patient adherence. Non-adherence renders therapy ineffective and generates an increase in all costs associated to the ill-management of the disease.  Through a series of interventions that educate patients about the usefulness of drug therapy, the consequences of scarce or non-adherence to therapy and, in general, increase patient knowledge about their disease, are all ways to help patients manage their patient journey.

The use of phone reminders, via text messages, Apps or the internet along with more informative talks, especially within PSPs, have proven effective means to improve patient adherence.

In order to guarantee adherence to drug therapy, the actions of all people involved in the patient journey need to be coordinated, from the physician to the pharmacist, the healthcare authorities and the patient’s family.

The first step in reducing non-adherence is to raise patient awareness on the importance of adhering to therapy, through improved communication and increased knowledge about the problem and by creating cultural initiatives on the topic of adherence to drug therapy, which are still not present in Italy.

Adherence to therapy

The majority of research concentrates on adherence to drug therapy, but the concept of adherence includes several other behaviors linked in various ways to health protection. For this reason, defining adhesion as “the level in which the patient follows medical instructions” may seem like a good place to start, but the term “medical” is insufficient to describe the entire spectrum of interventions needed in the treatment of chronic diseases.

Not even the term “instructions” is appropriate in that it appears the patient passively embraces an expert’s opinion when, in reality, the patient must actively collaborate with his or her own therapeutic process.

Improving adherence to therapy increases patient satisfaction. A large part of the treatments necessary for chronic conditions are based on the patient’s ability to autonomously manage the disease (often required in the presence of a complex combination of therapies), on the use of medical monitoring technologies and on lifestyles changes. Thus, if patients are not adequately supported by the healthcare system, they will face a great number of health risks.

Adherence to drug therapy and diabetes

Scarce adhesion to treatment for diabetics creates useless suffering for patients and added costs for the healthcare system. Scarce adhesion to treatment standards is the main cause of complications for diabetics and added costs for the individual, society and other expenses associated to the same. Furthermore, patients with diabetes have other comorbid conditions.

In particular, other diseases commonly associated to diabetes, such as hypertension, obesity and depression, are characterized by lack of adherence to treatment and thus also contribute to an increase in the possibility of a scarce therapeutic response.

The impact of diabetes in terms of economic and health terms is enormous and continues to rise.

How to measure adherence to therapy

The negative effects of scarce adherence to drug therapy on a patient’s health are well-known, but doctors are often unaware that scarce adherence is also the main cause of unsatisfactory results obtained by patients. Underestimating the role of scarce adherence to drug therapy, or the failure to recognize it, can lead to intensified treatments that may generate adverse effects that eventually convince the patient therapy is useless.

Estimating adherence to drug therapy in clinical practice is difficult. It can be done through direct methods that include the direct observation of the assumption of medicine or the extent of drug concentration. In any case, these methods are not practical on a mass or individual scale and, in economic terms, are too expensive.

On the other hand, the use of indirect methods such as questionnaires, pill counters, biological markers or medicine tracking notebooks may lower costs, but in some cases inevitably lead to a distortion of the truth (whether or not voluntarily). Physicians must thus contribute in playing a pro-active role as much as possible in order to overcome these problems, adapting treatment patterns and making the timing and number of administrations easier for the patient. This calls for communication between the doctor and the patient and a relationship of trust between the two.

Involving physicians

Improving adherence to drug therapy is a difficult process that requires continuous evolution. A lack of confrontation between a physician’s attempt to intervene and the patient’s response suggests that often treatments are prescribed by physicians, but patients are not ready to follow them.

Healthcare workers should be able, or rather, trained to gauge a patient’s readiness to adhere to therapy, providing advice and suggestions on how to follow a patient’s progress every time they meet. The involvement of healthcare professionals is becoming more and more necessary on the subject of adherence.

Healthcare professionals can have a significant impact in determining the risk of non-adherence and in recommending interventions aimed at optimizing the level of adhesion.

In order to transform this practice into reality, physicians should have access to specific training courses for adherence management. Additionally, the healthcare system should create and support assistance programs that comply with these objectives.

These training courses should provide education on different topics such as information regarding the concept of adherence, the process that leads to clinical decisions and behavioral tools for healthcare professionals.

Approaching the patient

Patients do not need to be blamed, they need support. Despite evidence to the contrary, there is still the tendency to focus attention on factors linked to the patient in identifying problems related to adherence instead of factors linked to the negligence of healthcare workers and the healthcare system. These last two have greater influence on adherence given that they shape the environment of the healthcare facility the patient receives assistance in.

Adherence is simultaneously influenced by different factors and, consequently, the ability of the patient to follow the treatment plan in the best way possible is often compromised by many obstacles frequently related to different aspects of the problem.

These aspects include: social and economic elements, the healthcare team and system, characteristics of the disease, type of therapy and specific case of the patient. Clarifying the problems related to each of these factors is thus necessary in order to improve the level of adherence to therapy.

There are no single intervention strategies or programs that have proven to be effective for all patients, situations and conditions. For this reason, interventions are aimed at the individuality of each patient and reaching adherence targets that are related to specific diseases and the patient’s own experience with the disease. To achieve this, the healthcare system and healthcare workers must develop instruments to accurately measure not only adherence to therapy, but even the factors that influence adherence.

Given that the majority of treatments necessary in the cases of chronic diseases are based on self-management of the disease by the patient (it is generally necessary to follow a complex multitherapy, undergo diagnostic tests and change of lifestyle), when indications received by the physician are not followed properly, several risks are involved. According to the Italian Observatory on Healthcare, 40% of the Italian population was affected by a chronic disease in 2019, or rather, 24 million people of which 12.5 million are affected by multi-chronicity. The projections on chronic diseases indicate that in 2028 the number of people affected by chronic diseases will rise to 25 million and those affected by multi-chronicity to 14 million. For this reason, improving the effectiveness of interventions aimed at increasing adherence to therapy can have a greater impact on the health of the population than any other progress realized for specific medical treatments.

© Domedica s.r.l. 

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