Practical Strategies to Improve Patient Adherence to Treatment Regimens

Imran Aslam, MD; Steven R. Feldman, MD, PhD

Disclosures

South Med J. 2015;108(6):325-331. 

In This Article

Abstract and Introduction

Introduction

Adherence is "the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen."[1] Poor adherence is ubiquitous in medicine, and its ramifications are far from trivial. Nonadherence costs the United States a staggering $300 billion in the form of emergency department use, hospitalizations, and diagnostic tests.[2] Nearly 50% of patients with chronic diseases do not take their medications regularly.[3] Furthermore, patients who are nonadherent to treatment are more likely to experience worsening medical conditions, unnecessary complications, and overall higher rates of morbidity and mortality.[2]

Adherence can be broken down further into three parts: initiation, implementation, and discontinuation. Initiation refers to when the patient takes the first dose of medication. Implementation is the extent to which a patient follows the treatment regimen. Discontinuation refers to when the patient reaches the end of the treatment regimen and stops taking medication.[4,5] Nonadherence also can be similarly conceptualized. When patients do not fill a prescription or do not "initiate" treatment, this is called primary nonadherence. Secondary nonadherence is when the prescription is received yet treatment is not "implemented" properly or is "discontinued" earlier than instructed.[6]

Compliance is another term that is synonymous with adherence. It once was used commonly; however, because of its negative connotations and suggestion of submission it has been replaced largely with the term adherence.[7] Adherence issues are manifold. Adherence is influenced by a wide variety of factors: patients' demographics, costs of medications, the number of medications taken by the patient, the type of intervention, and the nature of the medical condition, as well as by a host of other psychological and social factors.[8] Numerous approaches to improve adherence have been suggested, many targeted to the specific reasons that patients are nonadherent. To help organize these many approaches so that they can be presented in a coherent fashion, we turn to a model of adherence behavior, the health belief model.

The health belief model attempts to explain the rationale behind engaging in health behaviors. The model suggests that health-related decisions are based on five concepts: a patient's perceived susceptibility/severity to a particular condition; perceived benefits that the recommended action will reduce his or her risk of developing the condition; self-efficacy, which is a patient's belief that he or she is capable of taking the recommended action; perceived barriers to the recommended action (monetary and time costs); and cues to action, which are aids that teach or remind the patient about the recommended action.[9,10] These five concepts comprise the major factors that dictate health behaviors. To effectively manage adherence issues, strategies should aim to overcome the challenges posed by these principles. We conducted a PubMed search of "patient adherence" and identified interventions aimed at improving adherence. These interventions were then organized according to the principles of the health belief model (Table 1).

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