Encouraging adherence to
`long-term medication
`
`SUMMARY
`Non-adherence to medicines is common in patients with chronic disease and in those prescribed
`preventive medication. It can be intentional, unintentional, or both.
`
`Non-adherence reduces the effectiveness of prescribed medicines and may lead the prescriber to
`escalate treatment unnecessarily and potentially dangerously.
`
`Patient education, shared decision making, pharmacist support and motivational interviewing
`reduce intentional non-adherence.
`
`Interventions to reduce unintentional non-adherence address patient factors including
`misunderstanding, confusion or forgetfulness, and factors beyond the patient’s control such as cost.
`
`Patients should be asked about adherence at every consultation. A collaborative communication
`style is effective, using the patient’s own expressions and responding to their cues. Normalising
`non-adherence, and starting with open questions then following up with more specific probes,
`can also help.
`
`Electronic reminders, such as text messaging, have been shown to increase medication adherence.
`
`Tim Usherwood
`Professor of General
`Practice
`University of Sydney
`Honorary Professorial
`Fellow
`The George Institute for
`Global Health
`Sydney
`
`Keywords
`dose administration aids,
`medication reviews, patient
`adherence, polypharmacy
`
`Aust Prescr 2017;40:147–50
`https://doi.org/10.18773/
`austprescr.2017.050
`
`Introduction
`In developed countries approximately 50% of
`patients living with chronic disease do not adhere to
`treatment recommendations.1 A similar proportion
`do not take preventive medicines as prescribed.2
`Some patients do not start their prescribed drugs. Of
`those who do, many subsequently discontinue. Non-
`adherence is a major reason why treatments shown
`to be efficacious in trials are often less effective in
`clinical practice.
`Non-adherence can be classified as intentional or
`unintentional.3 Both reasons may contribute to non-
`adherence in an individual.
`
`Intentional non‑adherence
`Intentional non-adherence is when a patient actively
`decides not to take a drug or follow treatment
`recommendations. It is likely to reflect the patient’s
`attitudes to medicines in general, and their
`specific beliefs and concerns about the treatment
`recommended and the disease being treated.4 A
`study of 99 adults and young people living with
`asthma identified several themes that predicted
`adherence to preventer medication. These included
`the perceived necessity of treatment, safety concerns,
`acceptance of disease chronicity, beliefs about
`treatment effectiveness, ease of use and satisfaction
`with asthma management.5 The opinions of friends
`and family, concerns about adverse effects, and
`
`experience of adverse effects were particularly
`salient. Studies of intentional non-adherence to
`other types of medication for a wide range of
`diseases have shown similar results.6 These findings
`illustrate the importance of patients’ own experiences
`and the views of significant others in informing the
`decision to take medicines.
`
`Unintentional non‑adherence
`Unintentional non-adherence is unplanned by
`the patient. Causes include misunderstanding or
`forgetfulness, and factors beyond the patient’s
`control such as an inability to access prescribed
`treatment. Multiple studies have shown that
`treatment complexity, cognitive impairment,
`cost and other practical difficulties (e.g. opening
`medicine bottles or difficulty swallowing pills) may
`reduce adherence.1
`
`Detecting non‑adherence
`Non-adherence reduces the patient’s potential
`to benefit from treatment. It may also lead to
`unnecessary and potentially dangerous escalation
`of medicines.
`Clinicians are poor at detecting non-adherence. In a
`study of 1169 patients being treated for hypertension,
`their doctors recognised non-adherence in fewer
`than half of those whose pharmacy records indicated
`significant gaps in dispensing. Prescribers often
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`Encouraging adherence to long-term medication
`
`Patients should
`be asked about
`adherence at
`every consultation
`
`intensified treatment even when they suspected
`significant non-adherence.7 Patients should be asked
`about adherence at every consultation, and a poor
`response to treatment should always prompt detailed
`enquiry. A number of standardised questionnaires have
`been developed to measure adherence but they are not
`readily incorporated into routine clinical use and their
`psychometric properties are limited in that setting.8
`A small number of studies have
`examined different styles of
`questioning by prescribers for
`detecting non-adherence.9-11 Effective
`strategies include a collaborative
`style, using the patient’s own
`expressions in responding to their
`utterances and cues, normalising
`non-adherence, and starting with
`open questions then following up
`with more specific probes (see Box).
`In one study, questions that asked directly about
`missed doses were almost four times more likely to
`elicit disclosure of non-adherence than other question
`types.11 Disclosure can be followed up with a more
`detailed enquiry and discussion of ways to promote
`adherence and overcome barriers.
`
`Addressing intentional
`non‑adherence
`A systematic review explored patient-centred
`interventions to improve adherence, including patient
`education, shared decision making and pharmacist
`support.12 Many educational interventions resulted
`in better adherence and greater patient knowledge.
`However, their impact on adherence typically
`decreased over time. Shared decision making
`(including the use of decision aids) increased patient
`
`Box Asking about adherence to medicines during
`a consultation
`
`Doctor: How are you going with taking your pills?
`
`[Open question using the patient’s usual name for their tablets]
`Patient: Yes, good
`
`Doctor: Remembering to take them regularly?
`
`[Gentle probe question]
`Patient: Yes, usually
`
`Doctor: Many people forget to take their pills occasionally
`
`[Normalising statement responding to patient’s answer to the probe question]
`Patient: Hmm
`
`Doctor: Just thinking about the last couple of weeks – have you missed taking your pills on
`any occasion?
`[Specific probe asking directly about missed doses]
`
`
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`knowledge, but adherence improved in only two
`out of four studies.12 Adherence also improved with
`interventions by pharmacy staff, when they were
`tailored to patient needs, often involving both face-to-
`face and telephone encounters.
`Motivational interviewing is a patient-centred
`counselling technique that aims to encourage
`behaviour change by reinforcing positive intentions
`and challenging negative ideas. It has been shown to
`improve adherence in a variety of settings.13,14 However,
`not all studies show benefit and the time pressures of
`routine clinical practice can limit applicability.15
`
`Reducing unintentional
`non‑adherence
`Interventions that address unintentional non-
`adherence seek to reduce barriers and improve the
`patient’s ability to take medicines as prescribed.
`A wide range of strategies has been studied.
`
`Cost
`Out-of-pocket cost is a well-recognised barrier
`to accessing medicines.16 In a recent survey, the
`Australian Bureau of Statistics reported that
`7.6% of patients who had received a prescription
`delayed getting the medicine, or did not get it at
`all, due to cost. The proportion was even higher
`in areas of disadvantage.17 Prescribers may be
`able to reduce the impact of cost by, for example,
`prescribing generic or lower cost medicines when
`appropriate. Pharmacists may also assist patients by
`recommending lower cost brands.
`
`Drug regimen
`Patients can be confused by the number and variety
`of medicines they need to take. Adherence has long
`been known to be inversely associated with the
`complexity of the regimen.18 Prescribers should aim
`to simplify this as much as possible. Discussion with
`a pharmacist may assist, particularly with tailoring
`appropriate preparations, formulations and packaging
`for the individual (e.g. people with an inability to
`swallow).19 These consultations may be rebatable in
`Australia using the Medicare medication management
`review items. It may be possible to reduce the
`frequency of administration, introduce combination
`medicines, or even deprescribe in some instances.20
`It is good practice to provide patients with a printed
`list of their medicines and the times of day when they
`should be administered. Alternatively, the patient
`may be encouraged to use a smartphone app such
`as the NPS MedicineWise MedicineList+. The patient’s
`understanding of their regimen should be checked.
`For patients with cognitive impairment, the support
`of a carer to encourage or assist with administration
`is essential.
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`Brand swapping when medicines are dispensed may
`cause confusion and impair adherence. Pharmacists
`have a responsibility to educate patients if they swap
`brands, and prescribers should explain to patients and
`carers when they may be offered a choice.
`Fixed-dose combinations can be helpful for patients
`on multiple medicines, and have been shown to
`improve adherence in some circumstances.21 Starting
`treatment with combination medicines has a strong
`evidence base in the management of HIV and other
`infections. For conditions such as hypertension, the
`evidence for starting with more than one medicine is
`mixed, but the strategy should be considered.22
`
`Patient reminders
`Reminder packaging, which incorporates a date or
`time for a medicine to be taken, is an effective way
`of promoting adherence and has been shown to
`improve biological outcomes in type 2 diabetes and
`hypertension.23 Drug administration aids are a form of
`reminder packaging and may be particularly helpful for
`patients prescribed multiple medicines. However, they
`are not suitable in all circumstances.24 The stability of
`some drugs may be compromised by repackaging.25
`Patients with impaired cognition, eyesight or dexterity
`often have difficulty using them. Repackaging by the
`pharmacist may increase the cost to the patient and
`filling a compartmentalised box at home can lead to
`errors. Also, such boxes are rarely childproof.26
`There is strong evidence that regular reminders are
`an effective strategy for increasing adherence.27
`Electronic devices can assist with this. In a
`randomised controlled trial, 143 adults with asthma
`
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`used combination fluticasone propionate/salmeterol
`inhalers with attached electronic monitoring devices.
`The device recorded inhaler activation and provided
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`
`Conclusion
`
`Medicines do not work if they are not administered.
`Non-adherence, whether by intent or due to cost,
`complexity, or forgetfulness, is a major cause of
`reduced effectiveness and hence of preventable
`morbidity and mortality. Evidence-based strategies
`are available to address both intentional and
`unintentional non-adherence.
`
`Tim Usherwood is a member of the Editorial Executive
`Committee of Australian Prescriber.
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