What is Medication Adherence

A seemingly simple behavior followed by every patient could save hundreds of thousands of lives each year: medication adherence, or the act of taking your medications as prescribed. 

Medication adherence – or medication compliance, by another name – is the extent to which patients take their medications as prescribed by their healthcare providers. 

Medication adherence includes filling prescriptions; taking medications at the right dose, at the right time; consistently.

This seemingly simple behavior may not be easy.  A 2012 literature review found that 50% of medications are not taken as prescribed; 20%-30% of new prescriptions are never filled, non-adherence costs the U.S. healthcare system as much as $300 billion per year and 125,000 people die annually as result of not taking their medicines correctly.  

Medication non-adherence affects everyone in the health system: 

  • Patients. Their lives, productivity, and quality of life are at stake. 
  • Health Systems & Providers. Getting and keeping patients healthy depends on medication adherence.
  • Health plans. Maintaining healthy members depends on medication adherence, and they want medications to be used effectively, not wasted.
  • Public health departments. Nonadherence can lead to antibiotic resistance and infectious disease outbreaks.

As a company dedicated to solving medication non-adherence, emocha wanted to share an overview of medication adherence; including accepted definitions of medication adherence, consequences of non-adherence, some reasons for non-adherence, and practices and technologies for improving medication adherence.

Benefits of medication adherence

Medication adherence is one of the most cost-effective ways to improve the health of individuals and populations. Providers, health plans, public health agencies, individual patients, their families and caregivers, and even the public at large all have a stake in ensuring patients take their medications as prescribed. 

Non-adherence remains a common problem, due to a variety of individual, social, economic, and systemic problems. Fortunately, technology paired with personal attention from health coaches can help patients overcome some barriers to adherence.

 

Definitions of medication adherence

To better understand medication adherence, let’s review how a few international and government agencies, clinical scientists, and clinical professional associations define the term.

 

The CDC defines medication adherence as:

the extent to which an individual’s behavior, including taking medications, corresponds to recommendations from a health care provider.

 

Cardiovascular experts, writing in the journal Circulation, use a similar definition, emphasizing the importance of patients continuing to take medication.

Medication adherence usually refers to whether patients take their medications as prescribed (eg, twice daily), as well as whether they continue to take a prescribed medication.
—“Medication Adherence – Its Importance in Cardiovascular Outcomes.” 

 

The World Health Organization takes a more holistic view, defining adherence as:

the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.

 

Finally, the American Medical Association takes a quantitative approach, stating:

A patient is considered adherent if they take 80 percent of their prescribed medicine(s). If patients take less than 80 percent of their prescribed medication(s), they are considered nonadherent.

 

Why medication adherence matters

Experts agree that poor adherence to medication regimens accounts for substantial worsening of disease, community disease spread, and increased health care costs. But, until recently, the clinical evidence base did not show just how much of an impact poor medication adherence can make on human health and the total cost of care. 

Patient impact of medication non-adherence

A 2012 literature review of many existing papers, studies, and reviews found that 20%-30% of new prescriptions are never filled.

Research published in The Annals of Pharmacotherapy in 2018 gave more detail. Today we know that non-optimized drug therapy results in 275,000 deaths per year and costs $528.4 billion in the year studied, equivalent to 16% of total U.S. healthcare expenditures in 2016.

Community impact of medication non-adherence

Medication non-adherence does not just affect individual patients, physicians, or payors.. It may also influence the spread of disease within communities.

When patients take less than the prescribed dose of antibiotics or stop taking their medications before their full course of treatment is completed, it contributes to the rise of antibiotic resistance. More drug resistance means fewer options to a community facing an outbreak and to individuals diagnosed with multi-drug resistant or extremely drug-resistant diseases such as tuberculosis. 

In other cases, treatment is prevention. For people with HIV, adherence to antiretroviral therapy suppresses an individual’s viral load and keeps them healthy, while also preventing the transmission of HIV to others.

Reasons for medication non-adherence

Although taking medications as prescribed seems simple, there are many reasons why patients don’t or can’t take their medicines every day. 

Experts group reasons for non-adherence into three categories:

 

1. Behavioral challenges

  • Skepticism about the medication’s benefits; 
  • Forgetfulness;
  • Don’t feel engaged in the care plan;
  • Don’t understand the dosing regimen or how to use the medication dispenser;
  • Lack of time to take the medication;
  • No longer seeing the need for treatment because they are feeling better; 
  • Have cognitive, substance use or behavioral challenges;
  • Advice from family or friends who tell them to stop taking the medication; 
  • Not wanting to be reminded that they are ill; and/or
  • Lack of routines or disrupted routines. 

 

2. Medication challenges

  • No or low tolerance of the medication’s side effects;
  • Difficulty correctly administering the medication;
  • Uses medication incorrectly (dose timing, incorrect storage, incorrect technique, wrong dose); and/or
  • Medication possession issues (e.g. lost medication, out of refills, not covered by insurance).

 

3. Social determinants

  • Can’t afford their prescriptions and are trying to save money;
  • Can’t make it to the pharmacy;
  • Hunger;
  • Lack of child care;
  • Exposure to environmental triggers (e.g. smoke, indoor allergens like mold); and/or
  • Have too many other life stressors.

 

Research has shown the greater the number of medications one takes, the less likely you are to follow medication instructions precisely.  What’s more, if you have a short-term, acute illness, you are more likely to be adherent than if you have a chronic condition that calls for taking medication every day for the rest of your life. 

A 2013 telephonic survey of 1,020  Americans aged 40+ who were prescribed medication for a chronic condition found that certain factors correlate with higher adherence. Seeing the same physician consistently, being over age 50, and finding medications relatively affordable predicted greater adherence. 

Regardless of the cause,  non-adherence is a behavior that takes place outside of healthcare practitioners’ offices, which makes it difficult to address without a comprehensive medication adherence program.

 

Practices and technologies to support medication adherence

A wide variety of interpersonal, technological, and automated solutions are available to support patients with medication adherence.  Each addresses at least one challenge, and some help patients holistically in supporting adherence. 

A comprehensive medication review (CMR), an encounter conducted face-to-face between a patient and pharmacist, is one tool to increase medication adherence.  The pharmacist collects patient-specific information, identifies any patient-specific barriers, and creates a plan to resolve them with the patient. Overall, a CMR is the first step to empowering a patient to take ownership of his or her health.  

Positive and supportive healthcare provider dialogue also is important. Clinicians are trained to assume medication non-adherence is not a patient’s fault, thereby creating a shame- and blame-free environment in which to talk about barriers to adherence. Providers can use motivational interviewing to understand how patients feel about taking medication.

Specific technology tools also can help patients remember to take their medication. These tools include:

    • Reminders, like alarms and text messages sent to patients
    • “Smart” pill packaging, boxes, and bottles to detect if patients are opening their dispensers
    • Mobile reminder-only apps

Directly observed therapy (DOT) has long been considered the gold standard of medication adherence support. In fact, it is the standard of care delivered in hospitals in order to prevent medication errors.  During DOT, a healthcare provider watches a patient take each dose of medication in person every day, The World Health Organization and the U.S. Centers for Disease Control both endorse DOT for the treatment of tuberculosis.  

Video DOT takes the same approach as in-person DOT, but asks patients to capture a video of each medication dose, enabling objective remote monitoring of adherence. Video DOT can be less stigmatizing for patients, less costly for health systems, more convenient for patients and health workers, and may even be safer for both patients and providers during COVID.

In contrast to other medication adherence solutions, Video DOT can be used with patients for weeks or longer, each day checking patient response to medication, timing, and technique via video recordings made by the patient or a caregiver on a smartphone or tablet. The care team responds using a variety of means, escalating up to live contact with the primary care doctor if the situation warrants it.