The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow

Disclosures

January 16, 2014

In This Article

Why Research Hasn't Been More Helpful

Advances in medicine generally stem from peer-reviewed studies that produce statistically compelling, evidence-based data for doing one thing or another. The more studies, the better and more refined the evidence, or so one would think.

This has not, by and large, been the case with compliance. The ocean of data on the subject has stubbornly resisted attempts at synthesis into a statistically compelling, evidence-based, systematized plan or plans of action for overcoming barriers to compliance across a range of patients, drugs, and diseases.

A 2007 Cochrane review of interventions for enhancing medication compliance didn't mince words: "With the astonishing advances in medical therapeutics during the past two decades, one would think that studies of the nature of non-adherence and the effectiveness of strategies to help patients overcome it would flourish," the authors wrote.[40] "On the contrary, the literature concerning interventions to improve adherence with medications remains surprisingly weak."

"There probably is a set of general principles that might emerge from the literature," suspects Kaiser Permanente's John Steiner, "but they're not intuitively evident because of the way the studies are designed and carried out."

Even the definition of compliance is subject to debate. Is compliance mainly taking one's medications as instructed, a narrow definition adopted by most researchers because it simplifies research to study only one variable at a time, even if it sacrifices environmental complexity? Or should the definition be broader: "the extent to which a person's behavior -- taking medication, following a diet, and/or executing lifestyle changes -- corresponds with the agreed recommendations from a health care provider," as WHO maintains?[25]

Steiner tells of his 93-year-old father, who embodies this definitional dilemma. "He discovered to his great delight that as long as he took his statin, he could eat anything he wanted," Steiner says. "By being adherent with his medication, he didn't need to be adherent with his diet. Those are different adherence behaviors, but in his case, one trumps the other."

"The problem is with the way the scientific literature evolves," Steiner reflects. "It's reductionistic. You want to do a study on adherence with antihypertensive drugs, for example, and you disregard the 6 other drugs that the patient is taking.

"That can make the literature seem fragmented," he says. "We don't tackle the adherence problem at the patient level. We tackle it at the drug or disease level. It's easier to study at that level. Measurements are easier. Costs are lower."

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