[132] Rethinking Medication Adherence

[132] Rethinking Medication Adherence

Vignette:

An 83 year old faces conflict between her own preference for a simpler medication regime and a specialist who emphasizes that she will “need” to take her 8 drugs (14 doses/day) “for the rest of her life.” She takes an NSAID regularly because it helps with pain, but not the bisphosphonate “pill for my bones”. She finds it hard to swallow and doubts that the small chance of preventing a fracture described by her family doctor/NP is worth the bother. Her family doctor/NP supports shared decision making. Wanting to avoid causing harm to her patient, she feels trapped between specialist advice and guidelines and her patient’s preferences. Can documenting a shared decision-making dialogue help resolve their dilemma?

Health professionals can find it challenging when patients do not follow well-intended advice. What was formerly called ‘non-compliance’ is now referred to as ‘non-adherence.’ This acknowledges the individual right to make one’s own health decisions as well as external factors such as price that determine access to medications.

There is a spectrum along which the importance of adherence to prescribed therapy varies. Sometimes it may be essential for safety or to achieve benefits important to a patient. Examples include vaccines, anticoagulation, contraception, seizure prevention, drug treatments of communicable diseases or treatment of microorganisms that select rapidly for drug resistance (e.g. TB, HIV). More often, we have no available evidence from randomized controlled trials (RCTs) as to how important perfect adherence may be for preventive therapies or symptom control.

Patients often find it difficult to access medications. A 2021 systematic review found that cost-related non-adherence to prescribed medications affects between 3.6% and 15% of Canadians.1 Challenges that clinicians can help overcome include: costs, no regular primary care provider to organize refills, medication stigma (e.g. antipsychotics, methadone) and time away from work or caregiving for follow-up.

Is medication adherence the right goal for all patients?

Discourse about adherence often assumes that patient “non-adherence” implies failure to achieve the benefits of pharmacotherapy. This approach ignores patient preferences and logistical barriers to adherence.2,3,4,5

Health benefits of improved adherence may appear self-evident, but understanding the available evidence is more challenging. For example, a 2006 meta-analysis suggested that increasing adherence to drugs prescribed for multiple chronic medical conditions reduces risk of premature death from all causes.6 However, this post-hoc analysis did not include RCTs specifically designed to test benefits/harms of increasing adherence, and may reflect a “healthy adherer” effect (the tendency of healthier people to follow medical instructions).

Three Cochrane systematic reviews assessed studies testing mixed interventions and reminder packaging specifically designed to increase medication adherence or medication-taking ability. Despite enhanced medication-taking ability or adherence, they found insufficient evidence of improved clinical outcomes important to patients.7,8,9

Pushing for improved adherence at any cost does not address informed, intentional non-adherence – a patient’s deliberate choice not to take medication. People who feel that a treatment benefit is not worth the burden or inconvenience may prefer not to follow the prescriber’s advice.10 This is more likely when people already take many drugs for multiple medical conditions.11

Prescriber recommendations often differ from a patient’s own preferences.12 One should not assume that a patient is willing to take medication regardless of the intended outcome, probability or magnitude of benefit, cost, duration of treatment, or risk of harm.10 For example, the 83 year-old in the vignette concludes that her chance to prevent a fracture does not warrant the nuisance of taking an additional daily pill.

Engaging in constructive dialogue

SHARE is one approach to exploring patient goals and possible reasons for non-adherence, promoted by the US Agency for Healthcare Research and Quality.13 (Table 1)

Table 1: SHARE Approach13

S

Seek your patient’s participation

H

Help your patient explore & compare treatment options

A

Assess your patient’s values and preferences

R

Reach a decision with your patient

E

Evaluate your patient’s decision

Before assessing medication adherence, this model recommends addressing all aspects of a shared decision-making approach. Was all the most relevant information shared between the clinician and patient? Does the patient understand short and long-term effects of the disease and treatment? With hypertension, for example, does the patient understand that a prescription drug’s purpose is not only to reduce blood pressure, but to avoid or delay long-term complications like heart disease or stroke? Based on best available evidence, is the proposed treatment likely to support the goals that a patient considers important? If so, is the expected magnitude of benefit meaningful, or marginal?

Periodic comprehensive medication reviews and prescription refills are opportunities for prescribers and pharmacists to engage patients in a respectful dialogue about their own values and preferences. If a non-adherent patient wishes to adhere more closely to recommended therapy, clinicans can offer helpful tools, including support for funding when needed.14,15 But when patients choose informed non-adherence, it is democratic, ethical and practical to respect their freedom of choice.

Document what you learn

Implementing a shared decision-making approach to drug therapy works best when clinicians clearly document their discussions and reasoning. As patients encounter other clinicians in their healthcare journeys, accessible and lucid records help everyone involved to make wise and mutually respectful decisions. Clinicians can leave an “intellectual footprint” by documenting specific patient preferences, by writing STOP orders to deprescribe medications, or by recording that the patient understands potential benefits and harms of a therapy and has chosen informed non-adherence.16 Incorporating the purpose of treatment into prescriptions (“indication-based prescribing”) adds clarity for patients and for others involved in their care.17

Table 2: Documenting an ‘intellectual footprint’ on a prescription or hospital order

Issue

Example of documentation

Indication-based
prescribing

Ramipril 10 mg/d to improve heart pumping. Supply 90 for 3 months. Renew 3 times.

Deprescribing

STOP glyburide (frequent hypoglycemia).

Patient preference for informed non-adherence

STOP hydralazine. We agreed to focus on drugs with best evidence for prevention of CV events & de-emphasize BP measurements.

Change in
therapeutic goals and strategy

STOP drugs 1,2,3,4,5. Reduce 6 to once/d. He now desires comfort care approach to diabetes, coronary artery disease, and CKD.

Patient preferences often change over time. Some may deem that medications used for decades are no longer appropriate to their current life goals. Communicating such changes clearly may prevent re-prescribing by subsequent clinicians, or other broken links in a chain of care. Good communication about pharmacotherapy is analogous to and just as important as ascertaining and documenting resuscitation preferences and “level of care” goals.

Conclusions

  • Non-adherence offers clinicians an opportunity to learn about patient goals and what makes treatment worthwhile for an individual.
  • A shared decision-making framework or structured questioning can facilitate meaningful dialogue and help clinicians understand patient preferences.
  • Informed non-adherence is an acceptable choice compatible with personal autonomy.
  • Documenting patient preferences can improve communication between clinicians and reduce confusion during transitions in care.
The draft of this Therapeutics Letter was submitted for review to over 100 experts and primary care physicians in order to correct any inaccuracies and to ensure that the information is concise and relevant to clinicians.
The Therapeutics Initiative is funded by the BC Ministry of Health. The Therapeutics Initiative provides evidence-based advice about drug therapy, and is not responsible for formulating or adjudicating provincial drug policies.
ISSN: 2369-8691 (Online) || ISSN: 2369-8683 (Print)
International Society of Drug Bulletin LogoThe Therapeutics Letter is a member of the International Society of Drug Bulletins (ISDB), a world-wide network of independent drug bulletins that aims to promote international exchange of quality information on drugs and therapeutics.

References

  1. Holbrook AM, Wang M, Lee M, et al. Cost-related medication nonadherence in Canada: a systematic review of prevalence, predictors, and clinical impact. Systematic Reviews. 2021; 10(1):11. DOI: 10.1186/s13643-020-01558-5
  2. Bailo L, Vergani L, Pravettoni G. Patient Preferences as Guidance for Information Framing in a Medical Shared Decision-Making Approach: The Bridge Between Nudging and Patient Preferences. Patient Preference & Adherence 2019; 13:2225-31. DOI: 10.2147/PPA.S205819
  3. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clinic Proceedings 2011; 86(4):304-14. DOI: 10.4065/mcp.2010.0575
  4. De Geest S, Zullig LL, Dunbar-Jacob J, et al. ESPACOMP Medication Adherence Reporting Guideline (EMERGE). Annals of Internal Medicine 2018; 169(1):30-35. DOI: 10.7326/M18-0543
  5. World Health Organization‎. Adherence to long-term therapies: evidence for action / [‎edited by Eduardo Sabaté]‎. World Health Organization 2003; https://apps.who.int/iris/handle/10665/42682
  6. Simpson SH, Eurich DT, Majumdar SR, et al. A meta-analysis of the association between adherence to drug therapy and mortality. BMJ 2006; 333(7557):15. DOI: 10.1136/bmj.38875.675486.55
  7. Cross AJ, Elliott RA, Petrie K et al. Interventions for improving medication‐taking ability and adherence in older adults prescribed multiple medications. Cochrane Database of Systematic Reviews 2020, Issue 5. Art. No.: CD012419. DOI: 10.1002/14651858.CD012419.pub2
  8. Mahtani KR, Heneghan CJ, Glasziou PP, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD005025. DOI: 10.1002/14651858.CD005025.pub3
  9. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub4
  10. Fontana M, Asaria P, Moraldo M, et al. Patient-accessible tool for shared decision making in cardiovascular primary prevention: balancing longevity benefits against medication disutility. Circulation 2014; 129(24):2539-2546. DOI: 10.1161/CIRCULATIONAHA.113.007595
  11. Cheen MHH, Tan YZ, Oh LF, et al. Prevalence of and factors associated with primary medication non-adherence in chronic disease: A systematic review and meta-analysis. International Journal of Clinical Practice 2019; 73(6):e13350. DOI: 10.1111/ijcp.13350
  12. Harrison M, Milbers K, Hudson M, Bansback N. Do patients and health care providers have discordant preferences about which aspects of treatments matter most? Evidence from a systematic review of discrete choice experiments. BMJ Open 2017; 7(5):e014719. DOI: 10.1136/bmjopen-2016-014719
  13. Agency for Healthcare Research and Quality (AHRQ). The SHARE Approach: A Model for Shared Decision Making 2016; https://www.ahrq.gov/sites/default/files/publications/files/share-approach_factsheet.pdf
  14. Furmedge DS, Stevenson JM, Schiff R, Davies JG. Evidence and tips on the use of medication compliance aids. BMJ 2018; 362:k2801. DOI: 10.1136/bmj.k2801
  15. Persaud N, Bedard M, Boozary A, et al. Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial. PLoS Med 2021; 18(5):e1003590. DOI: 10.1371/journal.pmed.1003590
  16. CMPA. The intellectual footprint of your care. April 2021; https://www.cmpa-acpm.ca/en/education-events/good-practices/physician-patient/documentation-and-record-keeping
  17. Schiff GD, Seoane-Vazquez E, Wright A. Incorporating Indications into Medication Ordering–Time to Enter the Age of Reason. The New England Journal of Medicine. 2016; 375(4):306-9. DOI: 10.1056/NEJMp1603964
2 Comments
  • John MacIntyre
    Posted at 10:17h, 10 September Reply

    Adherence presupposes an agreement, in effect a social contract, concerning the nature of a health problem and its preferred treatment.

    Such agreement balances the limits of medicine (remember Illich?) with the limits of personal autonomy.

    The term ‘adherence’ as used in the article implies that the limits of medicine at some point constrain the limits of personal autonomy. If, however, ‘patient-centred care’ means that patient wishes are sovereign and that the patient retains veto power without apology, then the notion of patient adherence as deference to the medical model, is rendered meaningless.

    To the extent that the limits of medicine constrain the limits of patient autonomy where patient autonomy is meant to be the controlling interest, then the concepts of adherence and non-adherence are more aptly considered attributes of physician behaviour rather than patient behaviour.

    • Alan Cassels
      Posted at 14:06h, 23 September Reply

      Thank you for contributing to this discussion.
      cheers,
      Alan Cassels,
      Therapeutics Initiative

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