The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow

Disclosures

January 16, 2014

In This Article

An Epidemic of Noncompliance

If you're baffled by how many of your patients, particularly those with chronic conditions, don't take their medications as prescribed -- if at all -- you're not alone. Doctors from coast to coast feel frustrated by the same thing.

In 2011, Consumer Reports published a survey of 660 primary care physicians, "What Doctors Wish Their Patients Knew."[1] The number-one complaint by far: Patients didn't take the doctors' advice or otherwise follow treatment recommendations.

"Most of the doctors we surveyed said it affected their ability to provide optimal care," the editors wrote.[1] "Thirty-seven percent said it did so 'a lot.'"

In fact, the number of patients who are noncompliant has reached epidemic proportions, and doctors' inability to provide optimal care as a result has mushroomed into one of the most pressing problems in healthcare today.

In the United States, some 3.8 billion prescriptions are written every year,[2] yet over 50% of them are taken incorrectly or not at all.[3]

In a survey of 1000 patients, nearly 75% admitted to not always taking their medications as directed.[4]

A study of over 75,000 commercially insured patients found that 30% failed to fill a new prescription, and new prescriptions for chronic conditions such as high blood pressure, diabetes, and high cholesterol were not filled 20%-22% of the time.[5]

Even among chronically ill patients who regularly fill their prescriptions, only about half the doses taken are taken as their physicians intend.[6]

Poor compliance accounts for 33%-69% of drug-related adverse events that result in hospital admissions.[3]

Poor compliance with medication regimens is associated with up to 40% of nursing home admissions.[7]

In a study of over 8400 senior health plan enrollees, only 1 in 3 of those who began treatment with concurrent antihypertensive and lipid-lowering drugs were taking both medications as directed or at all at 6 months.[8]

In a study of over 240,000 patients who were given a new prescription for an antidepressant, less than 30% were still taking the medication 6 months later.[9]

Compared with patients who follow instructions, patients who don't take their medications as intended have a risk for hospitalization, rehospitalization, and premature death that is 5.4 times higher if they have hypertension, 2.8 times higher if they have dyslipidemia, and 1.5 times higher if they have heart disease.[10]

The number of patients with serious cardiac conditions who don't take their medications is especially baffling and problematic. In a study of 34,501 patients age 65 or older, only 26% of those who began a statin regimen to reduce the risk for coronary heart disease maintained a high level of use 5 years later; the greatest decline occurred during the first 6 months of treatment.[11]

Even after a life-threatening event, compliance with medication regimens remains surprisingly poor. Within 2 years of initiating therapy, only half of patients hospitalized for acute myocardial infarction (MI) were still taking their prescribed statins, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs).[12]

One upshot: Poor medication compliance is implicated in over 125,000 US deaths per year.[3]

Yet compliance -- which is used interchangeably with the term "adherence," although the latter is gaining ground -- has been exhaustively studied. More than 40,000 peer-reviewed papers on the subject have been published,[13] "yet the rates of poor adherence have not changed significantly over the past several decades and continue to remain at an unacceptable level," observes URAC, a healthcare accreditation organization, in a white paper prepared for industry leaders.[13]

Or, as former Surgeon General C. Everett Koop once put it with his customary forthrightness, "Drugs don't work in people who don't take them."[3]

The $290-billion question -- $290 billion being how much poor compliance is estimated to cost the US healthcare system each year[14] -- is, why?

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