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Introduction

If you thought you were alone in forgetting to take your medicines or simply skipping doses when you felt you’re getting better, guess what? You’re not alone. This phenomenon is medically referred to as non-adherence, which is a combination of “compliance” (% pills taken as instructed) + “persistence” (duration of time medicines are taken for). And, according to research studies, medicine non-adherence – the act of not taking medications as prescribed/instructed – is actually what happens in 50% medical cases; this percentage shoots up to nearly 90% of mental health patients. According to a 2017 article published in the Journal of Medical Society, a research study indicates 56% respondents with hypertension are not taking their regular medication - in fact, 16% of hypertensive respondents aren't taking ANY anti-hypertensive medication, at all!

The Centers for Disease Control & Prevention (CDC) even goes as far as to point out that 20-30% new prescriptions aren’t ever even filled at pharmacies, and hardly 51% of patients on high blood pressure actually bother to take their medication during long-term treatment plans.

Why People Don’t Adhere To Medicine Regimens

Often, non-adherence is unintentional where a patient is simply forgetful or careless, in general – many times, patients are barely able to list out the number of medicines they are supposed to take and what the real purpose of each medicine even is. Other times, it is intentional where a patient weighs out what they perceive to be the pros and cons of deviating from a medicine regimen and dismiss instructions prescribed to them by a healthcare provider. While many factors come into play in determining why a patient does or does not adhere to their medicine regimen, according to the World Health Organization (WHO), these are five key reasons –

1) Issues With Healthcare Systems
A patient might be suffering from a poor relationship with their healthcare provider and/or isn’t engaging in clear communication with them. Or, there might be lack of healthcare access to begin with.

2) Unique Medical Conditions
Patients who have an asymptomatic chronic disease may not even be aware of the severity of their condition since there are no physical symptoms – they might incorrectly assume they are getting a lot better and skip/reduce/terminate medication, without professional inputs. Likewise, patients suffering from depression may not be aware of what’s actually manifesting in their mind/body since they cannot pinpoint things. In essence, both of these issues stem from a much deeper problem – lack of awareness / insight into illness and lack of conviction/understanding regarding the benefit of thorough treatment.

3) Patient-Related Barriers
Patients who are minors might not have actual control over adherence to medication if they are dependent on someone else, such as a parent or guardian. And, patients who are suffering from a physical / cognitive / psychological / behavioral impairment might also have issues in following through on medicine adherence, which can be unintentional in such cases.

4) Complex Treatment
Sometimes patients who are undergoing complex therapy have difficulties in adhering to their medicine regimen because it is too complex. Or, in some instances, the adverse side-effects of treatment instils fear so much so that patients fail to comply with their medicine regimen out of lack of understanding of the long-term implications of not taking medicine due to short-term side effects. The Journal of Medical Society's 2017 article also backs this notion.

5) Socioeconomic Conditions
Sometimes, patients skip doses of medication to cut costs. For example, there have been many recent reports of diabetes patients in the US stretching their medication over a longer period of time to lower costs if they don’t have health insurance. Low literacy and poor social support are additional factors that lend itself to higher non-adherence. According to a systemic review and meta-analysis study published in the Journal of Human Hypertension in 2017, the percentage of adherence is hardly 36.65% among hypertensives of low and middle-income countries whereas it is 51% in a high-income country like the United States. In India, adherence reported ranged from 30% - 73% in separate studies conducted in places like Kolkata (73%), Mumbai (63.7%), Hyderabad (39.4%) and Delhi (30%). Research studies in other developing countries like Brazil and Nigeria have indicated adherence levels of 43.1% and 42.9%, respectively. Even though there is wide range in rates of adherence, the numbers clearly indicate adherence is a global public health problem.

In addition to the above 5 adherence roadblocks WHO has identified, we’ve observed two more issues that come in the way of adherence –

a) Keeping Track Of Multiple Meds Is Tricky
Nearly 50% of polypharmacy patients – people on four or more medications – fail to adhere to their medication regimens as prescribed by their healthcare provider. In fact, studies indicate each additional daily dose of medicine results in a 10% decrease in adherence. Organizing medication regimens can be challenging for those taking a variety of doses.

b) Lack Of Accountability
Patients who lack a support system that holds them accountable for taking meds have a higher chance of not adhering to their prescription schedule. Studies indicate patients with accountability at the hands of a caregiver are 40% less likely to deviate from their medicine regimen.

Issues In Detecting Non-Adherence

If you thought non-adherence in and of itself was a problem, here is another pain-point – it’s extremely tricky to detect.

Although there are several tools to measure adherence – tracking pharmacy fill rates; pill counts; electronic monitoring; closely monitoring someone in-person; measuring medicine levels through blood tests – each of these methods has pitfalls. For example, even if someone’s pill count result seems good, they could be dumping pills before the test. Or, they could be taking the medicine at the wrong time!

The most common method used across the globe is the Morisky Medication Adherence Scale. Earlier, it only contained 4 questions. Today, it consists of 8 behavioral questions that gauge if patients are forgetting to take meds and/or are discontinuing prescriptions without any medical guidance. Now, while it is easy to administer this test anywhere (even online) and isn’t costly, this method has quite a few pitfalls, too –

1) Patients sometimes overestimate their adherence (they might face difficulty in remembering information correctly),
2) Patients sometimes give “correct” answers to get a positive response from their healthcare provider, rather than an honest one.

According to experts, clinicians are only accurate in detecting non-adherence in 10% patients. Yikes! What about the remaining 90% non-adherence cases going undetected?

Consequences Of Non-Adherence To Medicine Regimen

As mentioned earlier, nearly 50% of patients are assumed to not be adhering to their medicine regimen, and only 10% of non-adherence cases are detectable by clinicians. The reason this is so alarming is because non-adherence has many consequences –

1) No Treatment Without “Treatment”
As former US Surgeon General, C. Everett Koop, once said, “Drugs don’t work in patients who don’t take them.” The truth is you cannot get better fully if you are not even giving medicine a chance to work its magic on your system.

According to research reports, cardiovascular patients, in particular, are at high risk for non-adherence. Nearly 1/4th of patients didn’t even fill their cardiac medications by the time one week had passed since discharge. 34% patients stopped at least 1 crucial medication within 1 month of discharge, and 12% terminated all their medication within 1 month of discharge. 60% of patients, who faced hospitalization for acute coronary syndrome, weren’t even taking statin medications when they were followed-up with after 2 years.

2) Increased Risk Of Morbidity & Mortality
Not taking your medication properly can put you at risk for prolonged illness, additional illnesses and even death. This is especially true for patients facing cardiovascular issues or diabetes. Studies indicate that failure to adherence to cardio-protective medications (β-blockers, statins / angiotensin-converting enzyme inhibitors) can result up to 40% increased risk of hospitalizations and up to 80% increased risk of mortality! Falling ill repeatedly and checking into the hospital again and again, simply because of non-adherence to medication, really isn’t worth it!

3) Decreased Treatment Effectiveness
Terminating medicine mid-way, skipping doses or altering the timing of medication can reduce the effectiveness of therapies/treatment. In essence, you aren’t fully nipping the problem in the bud with comprehensive treatment, which could lead to long-term adverse effects.

4) Economic Implications
Not adhering to your medicine regimen also results in financial consequences – it becomes more expensive to not adhere to medicine regimens than adhering to it. A 2015 research study that looked at non-adherence across 14 disease groups around the world indicated higher overall costs. The annual adjusted disease-specific economic cost of non-adherence ranged between $949-$44190 per person! In the United States, annual costings of non-adherence is estimated to be between $100-290 billion, and approximately €1.25 billion in Europe. In a developing country like India, the financial burden is usually borne by the patient itself, not the healthcare system! Patients suffering from diabetes, cancer, osteoporosis, cardiovascular disease, epilepsy, Parkinson’s disease, musculoskeletal issues, mental health and HIV/AIDS especially face immense financial burden linked to non-adherence related consequences.

In short, the total healthcare cost, pharmacy cost, inpatient/outpatient cost, emergency department visit(s) cost, medical costs, hospital/re-hospitalization costs are at a risk of increasing the less you adhere to your treatment plan. This puts strain not just on a patient, but on the healthcare system, overall. Studies indicate 10% of hospitalizations in elderly patients is linked to non-adherence – non-adherent patients are estimated to require three additional medical visits annually than medicine regimen-adhering patients; medical practitioners are already struggling to cope with the number of patients that exist as it is, and add to it patients who require attention simply because they failed to follow through on instructions given earlier.

Improving Adherence

If you are wondering how you can improve your own adherence or want to help another patient you care about adhere to their medicine regimen, there are a few effective tactics –

1) Clear Communication With Your Doctor And Pharmacist
Ask your doctor or pharmacist to clearly explain a) why you are taking each medicine that has been prescribed, b) what the side effects are, c) how to handle the side effects, d) when to expect various symptoms to improve, e) consequences of non-adherence. Having enough information will enable you to stay motivated to adhere to a particular regimen.

2) Ask For 1-2 Doses/Day
Simplification always helps. When patients only have to take one dose a day, it is easier for them to remember and adhere to a set pattern. In some instances, doctors can prescribe a once-a-day or twice-a-day alternative dose, so ask!

3) Make Adherence Convenient
A 2009-based research study indicated 76% people when adhere to medicine regimens when it is convenient. Whether you need a reminder system friends/family are involved in, an easy-to-use organized pill box, SMART phone reminders/alarms or a customized service like Kaleido, be proactive in creating a system that works for your particular needs so you can actually stick to it.

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