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Drugs don't work in patients who don't take them.

— C. Everett Koop, M.D.

Adherence to (or compliance with) a medication regimen is generally defined as the extent to which patients take medications as prescribed by their health care providers. The word "adherence" is preferred by many health care providers, because "compliance" suggests that the patient is passively following the doctor's orders and that the treatment plan is not based on a therapeutic alliance or contract established between the patient and the physician. Both terms are imperfect and uninformative descriptions of medication-taking behavior. Unfortunately, applying these terms to patients who do not consume every pill at the desired time can stigmatize these patients in their future relationships with health care providers. The language used to describe how patients take their medications needs to be reassessed, but these terms are still commonly used.¹ Regardless of which word is preferred, it is clear that the full benefit of the many effective medications that are available will be achieved only if patients follow prescribed treatment regimens reasonably closely.

Rates of adherence for individual patients are usually reported as the percentage of the prescribed doses of the medication actually taken by the patient over a specified period. Some investigators have further refined the definition of adherence to include data on dose taking (taking the prescribed number of pills each day) and the timing of doses (taking pills within a prescribed period). Adherence rates are typically higher among patients with acute conditions, as compared with those with chronic conditions; persistence among patients with chronic conditions is disappointingly low, dropping most dramatically after the first six months of therapy.^2,3,4 For example, approximately half of patients receiving hydroxymethylglutaryl–coenzyme A reductase inhibitor therapy will discontinue their medication within six months of starting the therapy.⁵

The average rates of adherence in clinical trials can be remarkably high, owing to the attention study patients receive and to selection of the patients, yet even clinical trials report average adherence rates of only 43 to 78 percent among patients receiving treatment for chronic conditions.^3,6,7 There is no consensual standard for what constitutes adequate adherence. Some trials consider rates of greater than 80 percent to be acceptable, whereas others consider rates of greater than 95 percent to be mandatory for adequate adherence, particularly among patients with serious conditions such as infection with the human immunodeficiency virus (HIV). Although data on adherence are often reported as dichotomous variables (adherence vs. nonadherence), adherence can vary along a continuum from 0 to more than 100 percent, since patients sometimes take more than the prescribed amount of medication.^8,9,10

The ability of physicians to recognize nonadherence is poor, and interventions to improve adherence have had mixed results. Furthermore, successful interventions generally are substantially complex and costly.^11,12,13,14 Poor adherence to medication regimens accounts for substantial worsening of disease, death, and increased health care costs in the United States.^{15,16,17,18,19} Of all medication-related hospital admissions in the United States, 33 to 69 percent are due to poor medication adherence, with a resultant cost of approximately $100 billion a year.^15,17,20,21 Participants in clinical trials who do not follow medication regimens or placebo regimens have a poorer prognosis than subjects in the respective groups who do.^22,23,24 Adherence to medication and placebo regimens, therefore, both predict better outcomes, and collecting adherence data from subjects is now considered an essential part of clinical trials.^25,26 Given the magnitude and importance of poor adherence to medication regimens, the World Health Organization has published an evidence-based guide for clinicians, health care managers, and policymakers to improve strategies of medication adherence.²⁷

Measures of Adherence

Adherence to medication regimens has been monitored since the time of Hippocrates, when the effects of various potions were recorded with notations of whether the patient had taken them or not. Even today, patients' self-reports can simply and effectively measure adherence.^28,29 The methods available for measuring adherence can be broken down into direct and indirect methods of measurement (Table 1). Each method has advantages and disadvantages, and no method is considered the gold standard.^30,31

View this table: [in this window] [in a new window]   Table 1. Methods of Measuring Adherence.

 
Directly observed therapy, measurement of concentrations of a drug or its metabolite in blood or urine, and detection or measurement in blood of a biologic marker added to the drug formulation are examples of direct methods of measures of adherence. Direct approaches are expensive, burdensome to the health care provider, and susceptible to distortion by the patient. However, for some drugs, measuring these levels is a good and commonly used means of assessing adherence. For instance, the serum concentration of antiepileptic drugs such as phenytoin or valproic acid will probably reflect adherence to regimens with these medications, and subtherapeutic levels will probably reflect poor adherence or suboptimal dose strengths.

Indirect methods of measurement of adherence include asking the patient about how easy it is for him or her to take prescribed medication, assessing clinical response, performing pill counts, ascertaining rates of refilling prescriptions, collecting patient questionnaires, using electronic medication monitors, measuring physiologic markers, asking the patient to keep a medication diary, and assessing children's adherence by asking the help of a caregiver, school nurse, or teacher. Questioning the patient (or using a questionnaire), patient diaries, and assessment of clinical response are all methods that are relatively easy to use, but questioning the patient can be susceptible to misrepresentation and tends to result in the health care provider's overestimating the patient's adherence.

The use of a patient's clinical response as a measure is confounded by many factors other than adherence to a medication regimen that can account for clinical outcome. The most common method used to measure adherence, other than patient questioning, has been pill counts (i.e., counting the number of pills that remain in the patient's medication bottles or vials). Although the simplicity and empiric nature of this method are attractive to many investigators, the method is subject to many problems, because patients can switch medicines between bottles and may discard pills before visits in order to appear to be following the regimen. For these reasons, pill counts should not be assumed to be a good measure of adherence.^8,9,32 In addition, this method provides no information on other aspects of taking medications, such as dose timing and drug holidays (i.e., omission of medication on three or more sequential days), both of which may be important in determining clinical outcomes.

Rates of refilling prescriptions are an accurate measure of overall adherence in a closed pharmacy system (e.g., health maintenance organizations, the Department of Veterans Affairs Health Care System, or countries with universal drug coverage), provided that the refills are measured at several points in time.^33,34,35 A medical system that uses electronic medical records and a closed pharmacy can provide the clinician or research scientist with readily available objective information on rates of refilling prescriptions that can be used to assess whether a patient is adhering to the regimen and to corroborate the patient's responses to direct questions or on questionnaires.

Electronic monitors capable of recording and stamping the time of opening bottles, dispensing drops (as in the case of glaucoma), or activating a canister (as in the case of asthma) on multiple occasions have been used for approximately 30 years.^32,36,37,38 Rather than providing weekly or monthly averages, these devices provide precise and detailed insights into patients' behavior in taking medication, but they are still indirect methods of measuring adherence; they do not document whether the patient actually ingested the correct drug or correct dose. Patients may open a container and not take the medication, take the wrong amount of medication, or invalidate the data by placing the medication into another container or taking multiple doses out of the container at the same time. The cost of electronic monitoring is not covered by insurance, and thus these devices are not in routine use. However, this approach provides the most accurate and valuable data on adherence in difficult clinical situations and in the setting of clinical trials and adherence research^10,39 and has advanced our knowledge of medication-taking behavior.⁴⁰ Although certain methods of measuring adherence may be preferred in specific clinical or research settings, a combination of measures maximizes accuracy.^10,41,42

Epidemiology of Medication-Taking Behavior

Electronic medication-monitoring devices have provided very detailed information about the patterns of medication-taking behavior. Most deviations in medication taking occur as omissions of doses (rather than additions) or delays in the timing of doses.^11,43 Patients commonly improve their medication-taking behavior in the 5 days before and after an appointment with the health care provider, as compared with 30 days after, in a phenomenon known as "white-coat adherence."^44,45 Studies using these monitors have shown six general patterns of taking medication among patients treated for chronic illnesses who continue to take their medications. Approximately one sixth come close to perfect adherence to a regimen; one sixth take nearly all doses, but with some timing irregularity; one sixth miss an occasional single day's dose and have some timing inconsistency; one sixth take drug holidays three to four times a year, with occasional omissions of doses; one sixth have a drug holiday monthly or more often, with frequent omissions of doses; and one sixth take few or no doses while giving the impression of good adherence.^40,46

Simple dosing (one pill, once daily) helps to maximize adherence, particularly when combined with frequent reinforcing visits, despite the fact that 10 to 40 percent of patients taking these simple regimens continue to have imperfect dosing.^47,48 In a large systematic review of 76 trials in which electronic monitors were used, Claxton and colleagues⁷ found that adherence was inversely proportional to frequency of dose (Figure 1), and patients taking medication on a schedule of four times daily achieved average adherence rates of about 50 percent (range, 31 to 71 percent).

View larger version (15K): [in this window] [in a new window]   Figure 1. Adherence to Medication According to Frequency of Doses. Vertical lines represent 1 SD on either side of the mean rate of adherence (horizontal bars). Data are from Claxton et al.7

 
Identifying Poor Adherence

Indicators of poor adherence to a medication regimen are a useful resource for physicians to help identify patients who are most in need of interventions to improve adherence.^5,49,50 Table 2 lists major predictors associated with poor adherence. Race, sex, and socioeconomic status have not been consistently associated with levels of adherence.^59,61 When these predictors, listed in Table 2, are present, physicians should have a heightened awareness of the possibility of poor adherence, but even patients in whom these indicators are absent miss taking medications as prescribed. Thus, poor adherence should always be considered when a patient's condition is not responding to therapy.

View this table: [in this window] [in a new window]   Table 2. Major Predictors of Poor Adherence to Medication, According to Studies of Predictors.

 
The simplest and most practical suggestion for physicians is to ask patients nonjudgmentally how often they miss doses. Patients generally want to please their physicians and will often say what they think their doctor wants to hear. It can be reassuring to the patient when the physician tells them, "I know it must be difficult to take all your medications regularly. How often do you miss taking them?" This approach makes most patients feel comfortable in telling the truth and facilitates the identification of poor adherence. A patient who admits to poor adherence is generally being candid.^29,62 Patients should also be asked whether they are having any side effects of their medications, whether they know why they are taking their medications, and what the benefits of taking them are, since these questions can often expose poor adherence to a regimen.⁶³

Barriers to Adherence

Research on adherence has typically focused on the barriers patients face in taking their medications. Common barriers to adherence are under the patient's control, so that attention to them is a necessary and important step in improving adherence. In responses to a questionnaire, typical reasons cited by patients for not taking their medications included forgetfulness (30 percent), other priorities (16 percent), decision to omit doses (11 percent), lack of information (9 percent), and emotional factors (7 percent); 27 percent of the respondents did not provide a reason for poor adherence to a regimen.⁶⁴ Physicians contribute to patients' poor adherence by prescribing complex regimens, failing to explain the benefits and side effects of a medication adequately, not giving consideration to the patient's lifestyle or the cost of the medications, and having poor therapeutic relationships with their patients.^49,65,66,67

More broadly, health care systems create barriers to adherence by limiting access to health care, using a restricted formulary, switching to a different formulary, and having prohibitively high costs for drugs, copayments, or both.^60,68,69 To improve the patient's ability to follow a medication regimen, all potential barriers to adherence need to be considered. An expanded view that takes into account factors under the patient's control as well as interactions between the patient and the health care provider and between the patient and the health care system will have the greatest effect on improving medication adherence (Figure 2).^70,71

View larger version (38K): [in this window] [in a new window]   Figure 2. Barriers to Adherence. The interactions among the patient, health care provider, and health care system depicted are those that can have a negative effect on the patient's ability to follow a medication regimen.

 
Interventions

Methods that can be used to improve adherence can be grouped into four general categories: patient education; improved dosing schedules; increased hours when the clinic is open (including evening hours), and therefore shorter wait times; and improved communication between physicians and patients. Educational interventions involving patients, their family members, or both can be effective in improving adherence.^72,73 Strategies to improve dosing schedules include the use of pillboxes to organize daily doses, simplifying the regimen to daily dosing, and cues to remind patients to take medications. Patients who miss appointments are often those who need the most help to improve their ability to adhere to a medication regimen; such patients will often benefit from assistance in clinic scheduling and what is called "cue-dose training" to optimize their adherence. Clinic-scheduling strategies to improve adherence include making follow-up visits convenient and efficient for the patient. Delays in seeing patients and problems with transportation and parking can undermine a patient's willingness to comply with a medication regimen and to keep follow-up appointments. Interventions that enlist ancillary health care providers such as pharmacists, behavioral specialists, and nursing staff can improve adherence.^12,74,75 Finally, enhancing communication between the physician and the patient is a key and effective strategy in boosting the patient's ability to follow a medication regimen.^11,18,76,77

Most methods of improving adherence have involved combinations of behavioral interventions and reinforcements in addition to increasing the convenience of care, providing educational information about the patient's condition and the treatment, and other forms of supervision or attention.^12,78,79,80 Successful methods are complex and labor intensive, and innovative strategies will need to be developed that are practical for routine clinical use.¹² Given the many factors contributing to poor adherence to medication, a multifactorial approach is required, since a single approach will not be effective for all patients.^81,82 Table 3 lists some simple strategies for optimizing a patient's ability to follow a medication regimen.

View this table: [in this window] [in a new window]   Table 3. Strategies for Improving Adherence to a Medication Regimen.

 
Examples of Challenges to Adherence

HIV Infection

In the treatment of patients with HIV infection or the acquired immunodeficiency syndrome, it is essential to achieve more than 95 percent adherence to highly active antiretroviral therapy (HAART) in order to suppress viral replication and avoid the emergence of resistance.^84,85 Achieving such high rates of adherence is very challenging to such patients, because their regimens include multiple, often expensive medications that have complex dosing schedules and may cause food interactions and side effects that result in poor tolerability. In addition, lifestyle factors and issues in the patient–provider relationship may make adherence difficult.⁸⁵

Promising strategies for improving adherence to HAART that have been studied in randomized clinical trials include pharmacist-led individualized interventions, cognitive–behavioral educational interventions based on self-efficacy theory, and cue-dose training in combination with monetary reinforcement.^75,79 Cognitive–behavioral approaches have resulted in more than 90 percent of patients achieving 95 percent adherence, but these approaches require considerable resources, and adherence is typically not sustained after the intervention is withdrawn.^86,87 Federally funded trials of strategies to improve patients' ability to follow treatment regimens are ongoing, including the use of handheld devices, two-way pagers, medication vials equipped with alarms, and the enhancement of social and emotional support.⁷⁵

Hypertension

Consistent control of blood pressure requires that patients with hypertension follow medication and dietary regimens. However, antihypertensive therapy may have untoward side effects and result in little symptomatic relief, since hypertension often causes no symptoms. No matter how effectively the clinician communicates the benefits of antihypertensive therapy, patients are still ultimately responsible for taking their medications. Since adherence is enhanced when patients are involved in medical decisions about their care and in monitoring their care, the traditional model of the authoritarian provider should be replaced by the more useful dynamic of shared decision making by the health care provider and the patient.^78,88,89 The patient must actively participate in the selection and adjustment of drug treatment and in changes in lifestyle in order to maximize the usefulness of the therapeutic regimen. When feasible, self-monitoring of blood pressure can also enhance adherence.^78,90 Simplifying instructions to the patient and medication schedules is essential, and minimizing the total number of daily doses has been found to be more important in promoting adherence than minimizing the total number of medications.^48,91

When inadequate adherence to medication has been identified and the available strategies for improving adherence have not achieved the target level of blood pressure, selecting "more forgiving" antihypertensive agents that either do not depend on half-life or have a longer half-life — drugs whose efficacy will not be affected by delayed or missed doses — will probably help to maintain a more stable blood pressure, despite imperfect adherence.^40,46 When choosing among the major classes of antihypertensive agents — calcium-channel blockers, angiotensin-converting–enzyme inhibitors, angiotensin II type 1–receptor antagonists, alpha blockers, and direct vasodilators — the practitioner should consider selecting the agent with the longest half-life in each class. The antihypertensive effect of some drugs, such as the thiazide diuretics, is not related to plasma concentrations or drug half-life, and for these drugs, timing doses and short lapses in adherence are probably clinically unimportant. The most forgiving medications, such as the thiazides or modified formulations such as the transdermal clonidine patch, are more likely than less forgiving drugs to achieve an acceptable therapeutic outcome if they are otherwise tolerated.

Another strategy used by Burnier and colleagues⁹² in a study of a highly selected group of patients with refractory hypertension was to monitor adherence objectively with the use of microelectronic monitors. In more than 30 percent of patients initially identified as having refractory hypertension, blood pressure became controlled merely as a result of monitoring, and an additional 20 percent of patients were identified as having lapsed adherence. Further control of blood pressure was achieved in a subgroup of subjects with poor adherence who agreed to continued monitoring and adjustment of their medications.⁹²

Psychiatric Illness

Patients with psychiatric illness typically have great difficulty following a medication regimen, but they also have the greatest potential for benefiting from adherence.^80,93 Half of patients with major depression for whom antidepressants are prescribed will not be taking the drugs three months after the initiation of therapy.⁹⁴ Rates of adherence among patients with schizophrenia are between 50 and 60 percent, and among those with bipolar affective disorder the rates are as low as 35 percent.^56,57,95 In a systematic review by Cramer and Rosenheck, among patients with physical disorders, the mean rate of medication adherence was 76 percent (range, 40 to 90 percent), whereas among those with psychoses the mean rate was 58 percent (range, 24 to 90 percent) and among those with depression the mean rate was 65 percent (range, 58 to 90 percent).⁹⁶

A number of interventions to improve adherence to medication regimens among patients with psychiatric illnesses have been tried. Successful approaches include a combination of educational interventions (involving both patient and family), cognitive–supportive interventions, and the periodic use of reinforcement techniques.^73,89,97,98 Educational approaches appear to be most effective when they are combined with behavioral techniques and supportive services.⁸⁰ Reinforcements include a wide variety of techniques, such as monetary rewards or vouchers, frequent contact with the patient, and other types of personalized reminders.^{79,99,100,101} Unfortunately, these interventions require trained personnel and repeated sessions if increased adherence is to be maintained; without these resources, adherence falls with time.

New antidepressant drugs and antipsychotic agents generally have fewer side effects than do older medications, and, consequently, their use results in reduced rates of discontinuation.^{57,102,103,104,105} New agents may be preferred to older agents for a variety of reasons, but factors such as cost and efficacy may be more important for some patients in achieving optimal adherence. Depot neuroleptic agents are often the treatment of choice for patients with schizophrenia who are not adhering to a regimen of oral agents.^106,107 The recent development of atypical depot neuroleptic drugs has the potential to improve adherence, since these agents combine the better efficacy and tolerability of the atypical agents with the reliability of the depot formulation.^106,108

Illness in Pediatric Patients

Anyone who has seen a child with clenched teeth and a caregiver struggling desperately to administer the next dose of a medication understands the challenge of adherence to a medication regimen in the treatment of children. Achieving full adherence in pediatric patients requires not only the child's cooperation but also a devoted, persistent, and adherent parent or caregiver. Adolescent patients create even more challenges, given the unique developmental, psychosocial, and lifestyle issues implicit in adolescence.^{109,110,111,112} Although the factors that contribute to poor adherence in children and adolescents are similar to those affecting adults, an added dimension of the situation is the involvement of patients' families.^113,114,115 Rates of adherence to medication regimens among children with chronic diseases are similar to those among adults with chronic diseases, averaging about 50 percent, with decrements in adherence occurring with time.^116,117,118

Many interventions to improve adherence have been tried in pediatric patients but have had limited success. Most of the successful interventions in patients with chronic childhood illnesses have used behavioral interventions or a combination of behavioral and other interventions. The most common intervention is the token reinforcement system,^{119,120,121,122} which involves motivating adherence by providing tokens or other rewards for taking medications successfully. The tokens can be used to obtain privileges, access to certain activities, or other rewards. Behavioral strategies often require resources and trained staff, yet simple reinforcement systems are practical for use by parents or other caregivers. The use of a more palatable medication than was initially prescribed has met with some success in improving adherence,^123,124 and the involvement of family members, schools, and other social supports are valuable strategies for maximizing children's ability to adhere to medication regimens.^113,115

Conclusions

Poor adherence to medication regimens is common, contributing to substantial worsening of disease, death, and increased health care costs. Practitioners should always look for poor adherence and can enhance adherence by emphasizing the value of a patient's regimen, making the regimen simple, and customizing the regimen to the patient's lifestyle. Asking patients nonjudgmentally about medication-taking behavior is a practical strategy for identifying poor adherence. A collaborative approach to care augments adherence. Patients who have difficulty maintaining adequate adherence need more intensive strategies than do patients who have less difficulty with adherence, a more forgiving medication regimen, or both. Innovative methods of managing chronic diseases have had some success in improving adherence when a regimen has been difficult to follow.^{99,125,126,127} New technologies such as reminders through cell phones and personal digital assistants and pillboxes with paging systems may be needed to help patients who have the most difficulty meeting the goals of a regimen.

Dr. Blaschke reports having received consulting fees from Jazz Pharmaceuticals, Portola Pharmaceuticals, Gilead Sciences, Aerogen, Depomed, Kai Pharmaceuticals, and Pharsight, and reports having shares in Johnson & Johnson and Procter & Gamble.

Source Information

From the General Medicine Division, Veterans Affairs Palo Alto Health Care System, Palo Alto (L.O.); and the Division of Clinical Pharmacology, Stanford University Medical Center, Stanford (T.B.) — both in California.

Address reprint requests to Dr. Osterberg at the VA Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, CA 94304, or at larso{at}stanford.edu.

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Adherence to Medication
Campbell R. J. Jr., Krienke R., Lippman A., Treharne G. J., Lyons A. C., Kitas G. D., Osterberg L., Blaschke T.
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N Engl J Med 2005; 353:1972-1974, Nov 3, 2005. Correspondence

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