Adherence Report Card: Is Patient Tutoring Needed?

Gayle Nicholas Scott, PharmD


July 19, 2013


How do I recognize patients most at risk for nonadherence and what can I do to help them be more adherent?

Response from Gayle Nicholas Scott, PharmD
Assistant Professor, Eastern Virginia Medical School, Norfolk, Virginia

Medication adherence is an area of growing concern. A search of "medication adherence" on PubMed reveals that more than 80% of the articles cited have been published within the past 5 years, and the number of articles on the subject has increased each year.

Medication adherence is also receiving attention from the Centers for Medicare & Medicaid Services (CMS). CMS is rolling out quality measures that include adherence to oral hypoglycemics, and some antihypertensives and lipid-lowering drugs. Adherence will be evaluated by prescription refill records. To receive a top rating of 5 stars, healthcare plans must achieve an 80% medication refill rate by at least 75% of beneficiaries[1] -- a challenging requirement.

Nonadherence to medication is a frequent and expensive problem. The estimated preventable cost incurred by the approximately 30%-50% of US adults who are nonadherent to long-term medications is more than $300 billion annually.[2,3] Less than one half of patients prescribed a new drug for diabetes, hypertension, or hyperlipidemia persist in taking the medication for even 1 year.[4,5]

Medication nonadherence was formerly called "noncompliance," but the terminology was changed to reflect the participatory responsibility of the patient. The etiology of this growing problem is multifaceted.[6]

Results were recently released of a survey on medication adherence conducted in early 2013 that was commissioned by the National Community Pharmacists Association.[7] A national sample of 1020 adults aged 40 years and older who were prescribed medication for a chronic medical condition, most commonly hypertension or hypercholesterolemia, formed the basis for the first national report card on medication adherence. On average, Americans earn only a C+ for taking medication as prescribed, and 1 in 7 receive a failing grade.

Survey questions focused on nonadherent behaviors, including failing to fill or refill a prescription, missing a dose, taking a lower or higher dose than prescribed, stopping a prescription early, taking an old medication for a new problem without consulting a provider, taking someone else's medication, or forgetting whether they had taken a medication. Surveyors also asked about participants' relationships with healthcare providers and about their attitudes toward their health and prescription medications.

Level of adherence was based on a scale of 0 (no adherence) to 100 (complete adherence). Only 24% of participants received an A grade (complete adherence), 24% received a B grade (largely adherent), with an average of 1 nonadherent behavior; 20% received a C grade for an average of 2 nonadherent behaviors; 16% received a D grade for an average of 3 nonadherent behaviors; and 15% received an F grade (largely nonadherent), with an average of 4 or more nonadherent behaviors. More than one half of participants (57%) reported missing a dose of medication, and 30% reported forgetting whether they had taken their medication. Failing to fill a new prescription (20%) or failing to refill a prescription on time (28%) were reported nonadherent behaviors. Some participants (22%) reported taking a lower dose of medication than instructed.

The Table summarizes the most common reasons given for nonadherence.

Table. Most Common Reasons for Nonadherence to Medication

Nonadherent Behavior Participants Reporting Behavior
Forgetting to take medication 42%
Running out of medication 34%
Being away from home 27%
Attempting to save money 22%
Unpleasant side effects 21%
Being too busy 17%
Feeling that the medication was not working 17%
Believing that medication was not needed 16%
Disliking taking medication 12%

Survey analysts found 6 important predictors of adherence:

  • Personal connection with the participant's pharmacist or pharmacy staff;

  • Affordability of medications;

  • Level of continuity in healthcare (ie, seeing the same healthcare provider for each office visit);

  • Participant's sense of the importance of taking medication exactly as prescribed;

  • Participant's feeling of being well informed about their health; and

  • Degree of unpleasant side effects of the medication.

These predictors suggest that pharmacists and pharmacy staff can improve adherence by fostering a strong personal connection with patients. Pharmacists can further improve adherence by educating patients about their medical condition and emphasizing the importance of adherence to medication and other related behaviors, such as blood pressure monitoring and salt restriction. Pharmacists should encourage patients to report side effects so that medication adjustments can be made (in conference with the prescriber as appropriate) to avoid nonadherence.

Improved adherence requires coordinated care on the part of the prescriber, medical office staff, pharmacist, and pharmacy staff.[8] This survey underscores the need for a personal connection between the patient and each care provider to improve adherence. Increased personal interaction with patients offers the opportunity to educate patients about their health and to stress the importance of taking medications exactly as prescribed.