It is a story as old as time. You write a prescription for a patient with a chronic condition such as asthma and later the patient reluctantly tells you that he or she only uses it a quarter of the time. Medication failure is an issue many clinicians will share with some frustrating anecdotes. In her presentation at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Heather De Keyser, MD, MS, assistant professor of pediatric pulmonology at the Breathing Institute, University of Colorado School of Medicine and Children’s Hospital in Aurora, discussed the impact and scope of non-compliance, which can affect compliance and ways to improve compliance.
Drug non-compliance is a frustrating issue, with global average adherence to chronic disease at around 50%. This adherence is costly, as 1 study of 43,156 children taking Medicaid and asthma found that if high adherence to inhaled steroids increased from the 33.35% seen in participants to just 40%, it would result in $ 8 million per year in cost savings and increasing compliance by 80% would result in savings of $57 million per year. Even with serious medical problems, adherence can be low, with 58% adherence in the 6 months following newly diagnosed epilepsy and the failure rate for organ transplantation ranging from 30% to 76%, with the worst adherence in adolescent patients.
A variety of factors can influence adherence to adherence, including poor access to care, caregiver’s poor knowledge of the formulary, patient-caregiver relationship, social determinants of health, stigma, medical beliefs leading to intentional non-compliance, forgetfulness, poor technique and responsibility for medication administration. De Keyser noted that if you take into account primary non-compliance, i.e. prescription filling, that is 14% to 20% for the first filling and 24% to 40% for subsequent fillings; secondary non-compliance, which means that the prescription has been filled but the medication has not been used, accounting for 30% to 70%; and poor device engineering, which accounts for 43% to 100%, true adherence to asthma medications is likely to be very small.
Ask any health care provider why a patient isn’t taking medication and the answer will likely be “if only they knew how important it was.” However, De Keyser emphasized that the reasons for non-compliance are complex. It can range from a prescription that is not filled because it needs to be refilled regularly, to parents who are not sure of the correct dose, to the child or parent who simply forgets the dose. She also shared a study looking at drug adherence to HIV medications. Barriers related to habit were reported by children and parents far more often than barriers related to education. Habit is indeed a strong driver of an action, thanks to the loop of cue, routine and reward. The habit loop was used to improve oral care when a toothpaste company, wanting to sell more products, encouraged people through an advertisement to run their tongues along their teeth and if they felt a film to brush their teeth, resulting in the reward of no more movie.
To improve adherence, she recommended asking all patients on chronic medications about adherence and verifying it with objective data, especially when the condition is not well controlled. When talking to patients and parents, it is best to speak clearly, use data and not judge. Based on a personal anecdote about how you don’t always stick to something that has to do with good health, De Keyser mentioned, for example, lack of flossing can put patients at ease and help them know that they are not alone. to be. She then recommended 4 techniques to improve adherence:
Place based cue – The patient places the medicine in a place where he or she will see it regularly throughout the day, such as the kitchen table or bathroom sink.
Time-based cue – The patient takes the medication at certain times of the day, such as right before school or during morning and evening meals.
Habit Stacking – The patient associates the use of the medication with another established habit, such as right after waking up or just before brushing their teeth.
Technology – The patient uses timers on his or her smartphone, other smartphone apps, or electronic health monitors. De Keyser recommends using smartphone times and reminders for medicines that only require a short course, because notifications are easy to ignore.
1. De Keyser H. It won’t work if you don’t take it: ways to improve adherence. American Academy of Pediatrics 2021 National Conference and Exhibition; virtual. Accessed October 10, 2021.