Improving Patient Compliance, an impressive challenge and a costly task.


By Xavier Tello

One of the most important [not so] hidden costs of therapeutics and health care, is patients’ lack of adherence to treatment.

According to several authors, including a review of the Cochrane Collaboration, the “desertion” index could go up to more than 50% of doses amongst patients.

“People who are prescribed self-administered medications typically take less than half the prescribed doses,” R.B. Haynes

While this problem has been addressed by scholars, physicians, health authorities and the Pharmaceutical Industry, it appears that neither an effective nor adequate solution exists. Worst of all, the proper diagnosis of this issue, has been established just a decade ago, at (almost) the same time that tougher regulatory, ethical and compliance codes have emerged, restricting the range of action of some instances like Industry-supported patient-groups or direct to patient initiatives.

As the demographical curve is directing towards a more elder population and epidemiological information indicates that chronic illnesses such as Diabetes and Cardiovascular disease, Cancer, Alzheimer, Depression, etc, will have a major impact in health and general economics; a big discussion is starting to emerge regarding the kind of interventional measures that have to be taken, as well as who has to take them, to improve patient compliance.

What should be done?

In an ideal world, all patients would follow their prescription ad integrum with no dose skipped or treatment dropout at all. However, there are motivations (some of them very strong) for patients to abandon their therapies.

These reasons, which are very well described, are:

Economical.- Patients who have no resources, insurance or healthcare system; or medications that are rather expensive.

Educational.- When patients don’t understand the implications of their disease and the importance of following an adequate treatment.

Technical.- Attributed to the medication itself. Difficult or unfriendly pharmacological forms like big or distasteful pills or painful injections; or complicated dosages like: five-times-a-day.

Cultural.- A phenomenon well identified in third world countries (like México), where challenging the physicians knowledge (or authority) happens frequently. In these scenarios, a lot of desertion occurs while patients look for friends or family “counseling”; and other forms of therapies emerge such as alternative medicine.

We are not mentioning religion here as a cause of low treatment adherence, as it should be detected by the physician while diagnosing and determining the best treatment option for the patient.

With these factors in mind, it would be obvious to think about addressing adequate countermeasures to avoid specific causes of treatment desertion.

In a 2007 paper published in the BMC Health Services Research (BMC Health Services Research 2007, 7:55) a team lead by Dr. Sandra van Dulmen, from the Netherlands Institute for Health Services Research, analyzed different forms of interventions towards a better adherence.

The first and perhaps more important conclusion, is that the most adequate interventions are effective in short term treatments, while efficacy of actions during chronic therapies has to be further investigated.

It is important to mention that there were different levels of efficacy while addressing to different types of intervention:

Technical Interventions, like modifying packaging characteristics or dosing prove to be very effective, but it has to be considered that benefits are better noted in patients complaining for these particular reasons.

“Behavioral” Interventions like reminders (newsletters, phone calls, or even personal paging) or rewards also were detected as very useful and cost-effective. Whereas these incentives have to be in kind (actual product rebates) or in cash (yes, cash…) has yet to be determined.

Educational Interventions are very difficult to evaluate, since there’s not an appropriate method of measuring the impact. If a patient doesn’t know or if he or she is simply not interested is always difficult issue to be solved.

Social support interventions proved to have the strongest relationship with adherence. Apparently, social or “common cause” bonding has really big implications when talking about changing treatment fulfillment attitudes, just like AA does to alcoholics.

Structural interventions, which are defined as specific programs created to “push” adherence within non-adherent patients could be as twice as effective as “general ones”.This programs could include specially trained nurses for administer treatment or at place of work programs.

Who has to be responsible for provide this interventions?

There has been lots of discussion regarding the actual implications of the involvement on these actions.

While it’s clear that something has to be done in order to improve adherence rates amongst patients, it’s more difficult to determine who has the moral / ethical authority to do so.

Governments could play an important role in this matter; however, it is inarguable that it implies a huge amount of resources in cash, headcount, logistics and informatics. In an age where a tough economical crisis is being faced worldwide, allocating resources to improve patient adherence will require in-depth pharmaco-economical studies.

Pharmaceutical Companies have traditionally embraced this quest, due to two obvious factors:

  • The serious concern of their products not been associated with poor efficacy (due to treatment dropouts) and
  • The economical benefits of doubling or multiplying the total number of units sold for each treatment-span.

The active intervention of the Biopharmaceutical Industry has been challenged by regulatory authorities, as it’s always seen as a proactive communication with and influence to the patient, in order to assure re-purchase of an specific brand.

The Financial Times published today an article about Roche been censored by UK’s Prescriptions Medicines Code of Practice auto-regulatory Authority, for giving ₤10 Toys-R-Us vouchers to persuade children of taking Pulmozime® to prevent pulmonary infections in cystic fibrosis cases.

At first sight, such a determination looks like nonsense; however the line that separates a real and plausible preoccupation for patient compliance from an open effort of pushing sales of a brand, is very thin.

With the recent outcome of the new PhRMA Code of ethics, a more difficult task is been faced: How to really help to improve patient compliance and adherence to treatment while moving within ethical limits.

Is patient education the only way?

Unfortunately our opinion is no. Although patient education looks fancy and could be the most regulatory / ethically correct, patient education is a difficult and rather risky subject.

First of all, a proper situational diagnosis has to be made. When someone (like a government health authority) addresses education as the only or most important factor around poor adherence; it is not recognizing that in many cases, other limitations exist such as the economical ones.

Economical constraints could not be an issue in Canada or Europe but in México and plenty of other countries, medicines are bought almost totally out of the pocket.

A recent poll conducted by Strategic Consulting within Mexican population, showed that 40% of patients abandoned their treatment because it was expensive, as 50% agreed that a “special price” or direct offer from the laboratory would put them back on track.

In the USA this phenomenon happens with people that only have basic coverage or not insurance at all.

As mentioned, patient groups seem to be a rather effective way to improve compliance, but someone with the appropriate resources should cover the costs of launching and properly operating them.

At this point, the only realistic means for correctly maintaining an effective patient compliance program should come from the Bio-pharmaceutical Industry.

More flexible and well-thought rules have to be designed in order to assure patients a better environment to maintain their medication regimes.

However, if these companies don’t understand well the responsibility that comes with a direct-communication to the patient, the whole intention of such a maneuver could be jeopardized and the reputation of the Sector would suffer more damage.

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5 Responses to Improving Patient Compliance, an impressive challenge and a costly task.

  1. Nat Bourre says:

    Thank you for such a thorough analysis of patient compliance. From my canadian experience, I believe that patient education as well as patient management are the key factors to improving compliance.

    In Canada, we also see very quick drops in patient adherence, even with drugs that are paid for by the government. By taking out the economic factor, one would assume that patients either need more education about their disease and treatment, or they need reminders.

    The tricky part for the pharma industry in Canada is that we are not allowed to do any direct-to-consumer (DTC) advertising. Therefore, the pharma industry in Canada is providing some disease information directly to patients and consumers – these are completely unbranded, no products get mentioned in this type of information. However, we are allowed to provide the physicians with product information (from the product monograph), and the physicians can then provide this to their patients themselves (direct-to-patient, DTP).

    Some pharmacies are also taking the initiative to provide reminders to patients to refill their prescriptions. For example, when I was visiting my parents just recently, they received an automated phone call reminding them to go to the drugstore to talk to their pharmacist about a long-term prescription that they have not picked up yet, which is probably overdue.

  2. Vidhu Ohri says:

    An excellent article on patient compliance.
    I have worked as a retail pharmacist and have seen each of those reasons mentioned play a part in non-compliance. Constant reminders, small incentives, convenience of pick-up and other interventions do not seem to work at times.

    As an in-patient pharmacists’ observation, an ambulatory patient however seems to be well educated about the medications that are being provided to him. But again, as mentioned in the article – “People who are prescribed self-administered medications typically take less than half the prescribed doses, R.B. Haynes”.

    A very true and apt statement.

  3. Priti Majali says:

    I am a Pharmacist who specializes in Medication Therapy Management in Geriatric patients.
    The issues stated in this article are more pronounced in the elderly and I have made interventions to eliminate duplicate therapy, drug drug interactions and maintain compliance which have resulted in financial returns and better care for the patients.
    A very good article..people are definitely inclined to take less than half the medications if they are prescribed the number of medications as we see today ( average 9 in geriatrics).

  4. Chris says:

    Greta article. I think that it raises some interesting points, which have been ongoing for a number of years. Having worked as a packaging specialist in the healthcare and pharmacy industries for over 25 years I have seen a number of attempts to resolve this non-compliance issue with packaging technology in the form of a variety of devices that:
    (1) beep, blip or blurt when it is time to take your medication.

    (2) track the number of times a dosage has been removed from the medication pack. Data collected is then downloaded at doctor’s surgery or pharmacy to check compliance statistics.

    (3) can remind patient to take medications & confirm they have taken it by pressing button to send data.

    BUT a weakness of all of these is that they can never guarantee that the patients have taken the correct medicine or taken it at the right time.

    A new intelligent packaging technology has been developed and tested in clinical trials which has the potential to dramatically impact the therapy compliance rates for individuals. OtCM™ (Objective therapy Compliance Measurement) is all about Improving Patient Adherence by using the ‘real-time’ registration & correlation of medical events.

    The system consists of:
    Smart medication blisters, Reading devices & Database with web portal using leading edge technology in the form of Radio Frequency Identification (RFID), Near Field Communication (NFC) & the internet.

    The system enables:
    • Single unit dose event registration
    • Registering the event of patients removing their medication from the package,
    • Correlation of that data with diagnostic data from vital body signs,
    • Provision of feedback to patients, their health professional +/or family, via….website, mobile phone +/or call centre

    You can find out more in the following article:

    Kind regards
    Chris Penfold

  5. This is a good article on patient compliance and the comments on using patient management and education to improve compliance is a key factor.

    I work for a company called Patient Reminders and we work with Pharmaceutical companies trying to improve compliance and adherence, we send optimally timed SMS, email, IVR or iCAL messages in the local language/font to remind patients when to take there medication. We also help patients who need motivation and education on knowing the risks and benefits.
    or call me (Bernie) to schedule a meeting with one of our medication compliance experts +44 141 416 0074

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