The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow

Disclosures

January 16, 2014

In This Article

Patient Beliefs and Behaviors Are Often Barriers

Patients with chronic conditions may spend only a few hours a year in your office, but they spend roughly 5000 waking hours each year living the rest of their lives.[17] During that time, out of touch with their doctors and generally unmonitored by the healthcare system, many are allowed to quietly, invisibly slip off their regimens.

In 2009, a team of researchers at Kaiser Permanente combed through much of the vast literature on compliance and distilled the sea of data down to several important patient-related barriers.[18] They include forgetfulness; lack of knowledge about the medication and its use; cultural, health, and/or religious beliefs about the medication; denial or ambivalence regarding the state of their health; financial challenges; lack of health literacy; and lack of social support.

Forgetfulness is the number-one barrier to compliance, experts believe, although a survey of 10,000 patients found that only 24% ascribed noncompliance to forgetfulness.[16] Up to 20% failed to take medications because of perceived side effects, 17% had cost issues, and 14% didn't feel the need to take medication; they believed it would have little or no effect on their disease.

Among patients with chronic conditions, such as high blood pressure and high cholesterol, noncompliance tends to be highest if symptoms aren't experienced.[5]

Myopic? Perhaps. But when doctors are patients, they tend to act just like everyone else. Steiner likes to ask an audience of physicians for a show of hands of who has ever taken an antibiotic. Many hands are raised. He then asks how many doctors took the full course of antibiotics even after their symptoms abated. Many hands go down.

Even the Sickest Patients May Not Take Their Drugs

Noncompliance is plentiful in patients who exhibit symptoms too -- even for life-threatening conditions. Not even a brush with death is enough to get some patients to stick to their regimens. According to one study, after hospitalization for acute MI, about 24% of patients still had not filled their cardiac medication prescription a week after being discharged.[19]

In another study, among patients discharged with prescriptions for aspirin, statins, and beta-blockers after an episode of acute MI, about 34% stopped at least 1 medication and 12% stopped all 3 medications within a month.[20]

A third study found that only about 40% of patients were still taking statins 2 years after hospitalization for acute coronary syndrome.[21] Compliance was even lower for patients taking statins for chronic coronary artery disease.[21]

A major reason why many patients go off-regimen is the cost of drugs. But even when patients are given drugs gratis, compliance improves only slightly. One much-discussed study looked at 2845 Aetna health plan members discharged from the hospital after an acute MI episode who were given all of their drugs -- statins, beta-blockers, ACE inhibitors, ARBs -- for free, comparing them with 3020 Aetna enrollees who had the usual prescription coverage.[22] In the usual-coverage group, compliance rates were 36%-49%. But without the cost barrier, the rates were only 4%-6% higher.

What could account for this underwhelming result? Could depression play a role? Although the investigators noted cardiac-related comorbidities of patients at baseline, they didn't ask about depression. Yet a meta-analysis of 31 studies that collectively included 18,000 people found that depressed patients with a variety of chronic illnesses, including diabetes and heart disease, had 76% greater odds of being noncompliant compared with patients who weren't depressed.[23]

At least you can understand why depressed patients may lack the motivation to stay on regimen, but, confoundingly, so do many patients who aren't depressed. As Shrank and cardiologist Lisa Rosenbaum, MD, noted in a 2013 paper:

Though patients may be forthcoming about the more practical challenges [to adherence], the psychological barriers are tougher to identify and articulate. Patients don't generally tell their physicians, 'Every time I look at that pill bottle, it reminds me that I'm ill' or 'I tend to discount future benefits as long as I feel well today.' Such underlying psychological mechanisms probably contribute to nonadherence far more than we realize and help explain why existing interventions have brought only modest improvements.[24]

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