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Patient adherence to drug regimens

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VOL: 102, ISSUE: 26, PAGE NO: 52

Ann Shuttleworth

The extent to which patients follow prescribed regimens for medication is difficult to ascertain, but it has been s...

The extent to which patients follow prescribed regimens for medication is difficult to ascertain, but it has been suggested that as many as 80% may not adhere to their regimen (Dunbar-Jacob and Mortimer Stephens, 2001), although this figure varies between patient groups and illnesses.

The potential harm to patients' health and the waste of NHS resources make non-adherence a critical issue. As nurses take increasing responsibility for the prescribing as well as the administering of medications, it is an issue the profession needs to address.

In discussions on patients' adherence to prescribed regimens, the words 'compliance' and 'concordance' are often used interchangeably. In fact they have very different meanings that reflect different approaches to care provision:

- Compliance relates specifically to patient behaviour - the extent to which patients take medicines as prescribed by a healthcare professional (Carter et al, 2005);

- Concordance is based on a partnership between patient and healthcare professional and focuses on shared decision-making (Cox et al, 2004; Weiss and Britten, 2003).

Compliance puts the onus on the patient to 'obey' instructions, but many compliance studies fail to assess whether patients understand or agree with their prescribed regimen, and simply compare their behaviour with the 'ideal' models.

Concordance advocates the sharing of power between patient and professional so that patients can make informed choices for themselves. Non-concordance is the failure of both parties to reach an understanding on how to proceed.

Although it has not been ascertained whether or not the taking on of an approach that encourages concordance increases adherence rates (Weiss and Britten, 2003), a review of adherence to prescribed regimens (Haynes et al, 2001) concluded that the full benefits of medication cannot be realised on current levels of adherence. This suggests that the paternalistic compliance approach is ineffective.

Carter et al (2005) concluded that a number of factors increased patient non-compliance. Some of these may be difficult to change, such as complexity of the regimen, side-effects and cognitive or physical problems in the patient. However, compliance is also reduced by less tangible factors. These include:

- Patients' beliefs about their illness and how to live with it conflicting with those of the prescriber;

- Patients seeing medicines as having a preventive rather than a curative or short-term distress-relieving role;

- Patients counterbalancing the health benefits of a medication with possible negative social and psychological considerations.

In taking an approach that encourages concordance, healthcare professionals will discuss patients' beliefs about their illness with them and the benefits of the medication in relation to any negative effects. They will also ensure patients understand why particular medications have been suggested before a regimen is agreed. Because this approach also involves ensuring patients are able to make informed choices, it may reduce non-adherence to a regimen because of its complexity or its side-effects.

Concordance requires that healthcare professionals ensure patients understand their regimen or have appropriate support or aids to help them to adhere to it. Furthermore, problems with side-effects can be discussed and patients can decide whether these are outweighed by the benefits of the medication.

Further information about concordance and compliance

- The Medicines Partnership

A DH-funded initiative aimed at enabling patients to get the most out of medicines by involving them as partners. The partnership publishes information for professionals and patients and provides professional updating and training.

- NHS Service Delivery and Organisation Programme

The Service Delivery and Organisation Programme has commissioned a scoping exercise on concordance, compliance and adherence in medicine-taking, with two main aims: to produce a conceptual map of the area, and to make proposals for future research. Its final report is available in draft format.

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