Chapter 47 Patient adherence
Adherence refers to following advice given by health care professionals. This includes taking preventive action (e.g. reducing alcohol consumption), keeping medical appointments (e.g. screening or follow-up appointments), following self-care advice (e.g. caring for a wound after surgery) and taking medication as directed (e.g. in relation to dose and timing). Non-adherence is usually defined as a failure to follow advice, which will lead to a harmful effect on health or a decrease in medication effectiveness. Most medical interventions rely on patient adherence: ordinarily diagnosis and prescription only have an impact on patients’ health through their own action. The term ‘adherence’ is used instead of ‘compliance’ because the latter implies a need for patient obedience, rather than informed decision-making.
Patients’ reports, pill counts and analysis of blood or urine samples can be used to measure adherence. Patients consistently overestimate their adherence when self-report measures are compared to objective measures (Myers & Midence, 1998) but some simple self-report measures can provide good estimates of adherence (Morisky et al., 1986).
How good is patient adherence?
Adherence varies across behaviours but about 40–45% of patients are non-adherent (Ley, 1997). This implies that: (1) almost half of all prescribed medication has a reduced health impact; (2) doctors may only be effective with 55–60% of their patients; and (3) patients are becoming ill unnecessarily due to non-adherence. It has also been suggested that 10–25% of hospital admissions are due to non-adherence. Even when patients’ lives depend on taking medication as directed, as is the case with heart and liver transplant patients, between 5% and 33% of patients have been found to be non-adherent (Rovelli et al., 1989).
Why do patients not follow advice?
Patients may be non-adherent for different reasons and in different ways (Donovan & Blake, Some patients may intend to take recommended medication but forget to do so or find it difficult. Others may disagree with the diagnosis or the medication regimen and decide not to take the medication, or take more or less than was advised. In addition, as Conrad (1985) noted, patients may test their health or improvement by suspending medication or stop taking medication temporarily to avoid side-effects that could impinge on important social events. Others may be reluctant to take medication for fear of dependence.
How can doctors increase adherence?
Adherence is most likely when patients understand what they are being asked to do and why. Patients must remember what they are told if they are to act on it later and, finally, satisfaction with the doctor and the consultation makes adherence more likely (Fig. 1).
Patients are more likely to feel satisfied and to understand advice when doctors find out what they think is wrong and discuss this. The doctor should seek to reach an agreement with the patient about what is wrong and what should be done about it. The importance of such cooperation has been underlined by the proposal that, instead of encouraging adherence, doctors should seek to establish concordance
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