The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow

Disclosures

January 16, 2014

In This Article

An Unbelievably Complicated Problem

One reason noncompliance has been such a tough nut to crack is its daunting complexity. Patients don't take their medications for a multitude of reasons, many of them emanating from the murky depths of human psychology, and which the patients (not to mention medical researchers) may not fully understand.

To complicate matters, these reasons vary from patient to patient. That rules out a one-size-fits-all solution. Internist William Shrank, MD, MSHS, Chief Scientific Officer and Chief Medical Officer of Provider Innovation and Analytics at CVS Caremark, has served as lead author or coauthor in over 100 studies on patient compliance with medication. His conclusion: "There is no silver bullet."

Researchers have analyzed the steps involved in compliance to better understand where the process breaks down.[15] First the patient must receive the right prescription from a doctor or other provider. The new prescription must then be filled, the seemingly simple act of which can be a major barrier to compliance. The patient must then make it through the first 6 months on the medication, when the risk for noncompliance is highest. If the medication is for a chronic condition, it must then be taken as intended -- indefinitely.

"'Adherence is the result of getting through these four steps successfully," notes the RAND Corporation, a nonprofit research organization, in a report aimed at policymakers in Washington, "and a single policy option is not going to address each of these challenges to adherence."[15]

To thicken the plot, a patient's unique cluster of reasons for not complying at any given time isn't stable. With the loss of a job, for example, medications may become unaffordable, so the patient stops taking them, or cuts the pills in half to make them last longer, or skips some doses.

After a divorce, job loss, or any traumatic event, depression may set in; taking medication as directed may then be the last thing on the patient's mind.

Or a compliant patient may suffer a medication-related adverse event. As a result, she may stop taking her pills, as up to 20% of patients do because of perceived side effects.[16]

Does the patient tell the doctor? Probably not. Why? The doctor is so busy; she doesn't want to be a bother. Or she doesn't like the doctor, so this is how she retaliates. Or she decides that her ill effects are a sign that she's taking too many drugs, so she goes off-regimen. Or she consults with a friend on a social networking Website for patients with similar chronic conditions, and the friend advises her to try alternative medicine instead.

"Is it widely known that adherence is a cluster of behaviors and not a single construct?" asks internist John F. Steiner, MD, MPH, Research Director at Kaiser Permanente's Institute for Health Research in Denver, and a thought leader on medication compliance issues. "No, that's actually a radical claim."

It may be radical, but researchers are putting patients, doctors, and the healthcare system itself under a microscope to better understand this ever-shifting cluster of behaviors and why it so often results in noncompliance. While many questions remain unanswered, here's what has been learned to date.

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