Strategies to Enhance Patient Adherence: Making it Simple

Ashish Atreja, MD, MPH; Naresh Bellam, MD, MPH; Susan R. Levy, PhD


A Conceptual Framework to Address Patient Nonadherence

The aforementioned strategies have been proven to enhance patient adherence in multiple studies and can have huge implications for cost-savings and improved patient outcomes.[42] The average unweighted effect size for such interventions has been calculated to be around .23.[21] In terms of binomial effect-size display, this difference of 23% may be interpreted as a "success rate" of 62% in intervention subjects vs 38% in control subjects. Although these results are encouraging, the challenge still remains over how to implement and operationalize these strategies in a modern-day busy practice where clinicians are constrained by limited time and budget. To compound this problem, there is no single intervention strategy that has been shown to be effective across all conditions and settings, and hence a combination of the above strategies is often required to make a meaningful difference to patients' adherence[21,43] (see Table 1 ). To bridge this gap between research and clinical reality, we propose a conceptual framework based on our literature review and the recommendations adopted by some of the leading organizations.[8,44,45] This framework is based on a multidisciplinary approach, which looks at the strategies in the context of healthcare team and system-related factors to help reduce the time and cost involved with implementing these strategies (see Figure 1). The framework considers patient adherence not as a patient or physician issue but as a systems problem and helps integrate the strategies at the systems level. In the framework nurses, pharmacists, case managers, health educators, and others involved in patient care are aware of one another's responsibilities and have an important role to play. For example, understanding and accepting the role that a pharmacist plays in imparting medication-related knowledge to patients may help clinicians to focus on other aspects of the treatment plan. The community pharmacist can help increase adherence to drug regimens by providing patients with additional information about individual drugs, identifying potential adverse drug reactions and interactions, and supplying appropriate drug containers or compliance aids.[46] Similarly, interventions, such as mailing appointment reminders and patient-education materials, may be accomplished by nurses or other healthcare staff. The framework also implies that adherence is a dynamic process that needs to be extensively evaluated. Closing the feedback loop relies on good evaluation, which in turn entails defining specific criteria to measure adherence as well as assessing both the processes and outcomes of an initiative. Developing institutional-wide committees to plan and operationalize the strategies would help incorporate the guidelines smoothly into the existing systems and make them a part of continuous quality-improvement initiatives.