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Enhancing Medical Adherence

      SEE RELATED ARTICLES pp. 882 and 888
      Adherence to a medical regimen is defined as the extent to which a patient takes a prescribed medication. The term “adherence” is often used interchangeably with “compliance,” but adherence is currently the preferred term because it implies a responsibility that is shared by both the patient and the healthcare provider.
      • Osterberg L.
      • Blaschke T.
      Adherence to medication.
      • Burnier M.
      Medication adherence and persistence as the cornerstone of effective antihypertensive therapy.
      Many barriers to appropriate medication adherence have been described in the past, including problems when treating asymptomatic conditions such as hypertension and hyperlipidemia, the cost of medication, the side effects of medications, and the complexity of medication dosing regimens. Other issues that could affect adherence to drug therapy are summarized in Table 1.
      • Dhanuka P.K.
      • Brown M.W.
      • Lee W.N.
      • Peterson S.J.
      • Frishman W.H.
      Compliance with cardiovascular drug treatment.
      Table 1Characteristics That Influence Medication Adherence
      Reprinted with permission from Dhanuka PK, Brown MW, Lee WN, Peterson SJ, Frishman WH. Compliance with cardiovascular drug treatment. In: Frishman WH, Sonnenblick EH, Sica DA, eds. Cardiovascular Pharmacotherapeutics. 2nd ed. New York: McGraw Hill; 2003:27.
      Patient's sociodemographic characteristics:
      AgeGender
      Educational levelSocioeconomic status
      Occupational statusLiving status (alone vs not alone)
      Family stability and level of supportMental stability; level of forgetfulness
      Race and ethnicityReligious beliefs
      State of knowledge of disease process orStrength of belief in treatment value
       consequences and medication regimenHistory of adherence
      General attitude toward health careAppropriateness of health beliefs
      Expectations of prescribed regimenAppointment attendance
      Characteristics of health care provider:
      Length of time between start of problem andPatient level of satisfaction with initial contact with provider
       referral of patient to providerAbility level of provider to assess patient adherence and potential barriers
      Interviewing and listening ability of providerLength of waiting time for provider services
      Length of time between contacts between providerLength of time provider spends with patient
       and patientLevel of support, empathy, and feedback that provider gives to the
      Provider's ability to keep appointments patient
      Continuity of care with providerQuality of instruction given for taking prescribed regimen
      Degree and ease of access to the patient by provider
      Medication characteristics:
      Type of medicationDuration of therapy
      Complexity of dosing scheduleNo. of prescribed medications
      Medication packagingSide effects
      Degree of lifestyle changes required to adhere to  prescribed medication regimenCost
      Disease characteristics:
      SymptomatologySeverity of illness
      Duration of illnessHistory of disease
      Previous hospitalizationLevel of disability caused by disease process
      In this issue of The American Journal of Medicine, Naderi et al
      • Naderi S.H.
      • Bestwick J.P.
      • Wald D.S.
      Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients.
      report on the findings of their meta-analysis of studies of 376,162 patients involving adherence to drugs that are used to prevent cardiovascular disease. These authors found that drug adherence is poor for preventive treatment and is not related to the class of drugs used, suggesting that adverse effects are not the main cause of poor adherence. They observed that approximately one third of patients who have a myocardial infarction and approximately one half of patients who do not have a myocardial infarction adhere to effective cardiovascular preventive drug therapy. Strategies to improve patient adherence need to be generalized and comprehensive. They concluded that the frequency of the interaction between patient and prescriber and the level of patient education may be important in improving adherence.
      There have been multiple strategies used to improve patient adherence, including once-daily treatment regimens,
      • Frishman W.H.
      Importance of medication adherence in cardiovascular disease and the value of once-daily treatment regimens.
      peer monitoring,
      • Long J.A.
      • Jahnie E.C.
      • Richardson D.M.
      • et al.
      Peer mentoring and financial incentives to improve glucose control in African American veterans.
      positive affect interventions,
      • Ogedegbe G.O.
      • Boutin-Foster C.
      • Wells M.T.
      • et al.
      A randomized controlled trial of positive-affect intervention and medical adherence in hypertensive African Americans.
      and financial incentives
      • Choudhry N.K.
      • Avorn J.
      • Glynn R.J.
      • et al.
      for the Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial.
      • Petry N.M.
      • Rash C.J.
      • Byrne S.
      • et al.
      Financial reinforcers for improving medication adherence: findings from a meta-analysis.
      (Table 2).
      Table 2Innovative Strategies for Improving Patient Adherence
      Adapted with permission from Dhanuka PK, Brown MW, Lee WN, Peterson SJ, Frishman WH. Compliance with cardiovascular drug treatment. In: Frishman WH, Sonnenblick EH, Sica DA, eds. Cardiovascular Pharmacotherapeutics. 2nd ed. New York: McGraw Hill; 2003:27.
      Electronic monitoring devices
      Pill containers with daily compartment for medication
      Phone call/text message and iPhone refill reminders from pharmacies
      Augmented medication counseling by pharmacists at time prescription is filled
      Computerized lay-language medication instructions written by manufacturer for distribution at local pharmacies
      Computerized dosage-schedule charts from pharmacies incorporating medication interactions of a prescribed regimen in over-the-counter medications and food products
      Contact with pharmaceutical companies to provide medications for economically needy patients
      Contact with pharmaceutical companies who offer adherence reminder programs
      Community-based programs for patients by health care providers at schools and community centers
      Adherence programs educating patients to be resourceful health care consumers
      Adherence teams within health care facilities to educate and monitor patient adherence
      Continuing education programs for health care providers on ways to increase patient adherence
      Peer mentoring
      Financial incentives
      Also in this issue of the Journal, another meta-analysis was performed looking at studies addressing the impact of financial incentives and adherence
      • Petry N.M.
      • Rash C.J.
      • Byrne S.
      • et al.
      Financial reinforcers for improving medication adherence: findings from a meta-analysis.
      beyond giving medications for free. The authors concluded that financial reinforcement interventions are beneficial for improving medication adherence. They do, however, conclude that there are ethical and logistic issues that need to be addressed before making broad-based recommendations regarding this type of strategy.
      Adherence to a prescribed drug regimen is critical to effective treatment. Despite the great advances made in the pharmacotherapy of disease in recent years, many patients, for multiple reasons, do not avail themselves of this benefit. Adherence strategies will always need to be individualized, with the focus of these strategies based around the relationship of the patient with his/her physician.

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