MedCity Influencers, BioPharma

Let’s focus on patient compliance as the problem, not adherence

The change in terminology from “compliance” to “adherence” is based on unfounded and untenable foundations. It conflates cause and effect, and a shift in language and mindsets can help reframe and better tackle the core problem: patient failure to take medications as prescribed.

As young pharmacists, my colleagues and I wrestled with the thorny and puzzling phenomenon of why people refused to take medications as prescribed—acting ostensibly against their self-interest, and considered how we could get them back on track. We quickly learned that this issue, which we referred to as “patient non-compliance to medications,” was a complex one. Fast forward a couple of decades, and we see that the issue of compliance has been renamed “medication adherence,” a sterile, uncomplicated phrase deemed a better label for the issue, or to some, an interchangeable term.

I am proposing, in this article, reasons why this change from the term “compliance” to “adherence” is based on unfounded and untenable foundations, how it conflates cause and effect, and why a shift in language and mindsets can help reframe and better tackle the core problem: patient failure to take medications as prescribed.

Why nonadherence is a problem

Patients just don’t take medications in the doses prescribed, at the times prescribed, and for the durations prescribed. The magnitude of the problem, termed nonadherence, is well known, severe and widespread. Poor adherence has been reported for patients on antihypertensives, antihyperglycemics, anticoagulants, and is even more severe for topical medications commonly used for dermatological ailments.

Besides contributing to poor patient outcomes, nonadherence leads to well-documented financial effects downstream, including higher hospitalization costs, unnecessary emergency room visits, and other avoidable treatment costs, as well as significant losses to the pharmaceutical industry. An entire ecosystem of firms has evolved over the years to assist healthcare providers in overcoming the challenge, through engagement solutions, electronic adherence monitoring, financial incentives, and even high-touch solutions involving multi-disciplinary care teams.

I suggest that these technological advances will synergistically benefit from a similarly strong focus on patient compliance, the behavioral foundation of medication adherence.

Transition from “compliance” to “adherence”: A poorly justified change 

Little support to suggest that compliance is seen as negative or pejorative

Other than speculation, there is sparse, if any, research that supports the notion that patients find compliance to be a negative word, or that they take umbrage at being asked to be compliant. Some research even suggests that patients were unconcerned about either phrase being used. Similarly, even as providers deliver care in an increasingly collaborative and consumerized manner, there is little research or even an opinion suggesting that they regard the phrase adherence more positively in comparison to the phrase compliance.

Patients routinely comply with clinician recommendations and requirements terms

Patients seeking care for a variety of transient and chronic conditions seek out advice from competent care providers — and then comply with this advice to the best of their ability. Take patients undergoing physical therapy following an orthopedic procedure or patients prescribed dietary and lifestyle changes following cardiovascular interventions. With the belief that competent advice from a caring provider can help them recover and return to good health, patients (and their caregivers) comply with the advice of providers.

The words adherence and prescription can be viewed as equally offensive 

Even a cursory epistemological examination shows that if the word compliance somehow appears to demand actions from patients or come across as paternalistic, so could the word adherence, and the word prescription. A dictionary definition of adherence brings up attachment, fealty, and fidelity. And the meaning of prescription includes authoritative direction and orders. If these terms carry negative connotations for patients, then using “adherence” makes little practical sense.

Conflating cause and effect: compliance is a key driver of adherence

Financial metrics for any company in the consumer product market depend on purchases of their products. However, the focus of most consumer driven businesses has shifted to the causal driver of purchases, i.e., consumer loyalty, a behavioral, affective and cognitively defined concept.  Analogically, medication adherence is the objective act of a medication being taken at a certain time, in certain doses, for a certain duration etc. Patient compliance, or the desire to comply, is a major driver of adherence. Adherence and compliance are not the same, and not just terms to be substituted based on their putative acceptability.

Compliance:  A behaviorally networked & actionable concept

Compliance, like loyalty, is imbued with cognitive and affective dimensions 

The suggestions that compliance is a passive act, would assume that it is based on mindlessly following rules or taking orders. Instead, like the desire to be loyal to a brand or a firm, (intentional) compliance or the desire to be compliant, is an active decision that relies on a cognitive cost-benefit calculus in some cases, or an affect laden response in other cases. The resulting desire to be compliant is a volitional drive state, and not just a passive response. Unveiling the complexity of compliance (and noncompliance) toward specific therapies, or among specific patient segments, can provide insights that merely monitoring adherence cannot.

Patient-provider relationships are a strong driver of patient adherence, via compliance  

Research tells us the patient-provider relationship and trust are strong drivers of adherence; patient compliance mediates this relationship. Research into patient adherence in a wide range of areas including highly active antiretroviral therapy, antihypertensive medications, and topical therapies for psoriasis has found that strong patient-provider relationships lead to improvement in adherence. In the end, trust in the provider trust, and relational strength all drive adherence. But they do this via (through) their impact on the patient’s willingness to comply with their prescribed medication regimen. Patients that trust their providers want to do what they recommend – and as a result of that desire, they take their medications as instructed.

Actionable drivers of patient compliance come into play – affecting downstream adherence 

Compliance fits a nomological network – or a causal map of related constructs – that can suggest behavioral drivers of adherence. Patient trust, patient satisfaction, cost-benefit assessments of therapeutic value (possibly flawed) and a host of cognitive judgements directly drive the patient’s compliance. A focus on these drivers, or antecedents, will uncover systematic patterns underlying compliance (or noncompliance), promote further examination of secondary drivers and provide clinicians and care-teams with better insight into managing poor medication taking habits.

Looking at the issue of suboptimal patient medication management from this perspective and focusing on the drivers of compliance listed above are a more effective way of improving it. The shift in language from “compliance” to “adherence” not only lacks a strong justification, but it also misidentifies the relationship between the two and moves the conversation away from the underlying causes of compliance. Embracing and understanding the term “compliance” could be an important step towards improving medication adherence, and ultimately patient outcomes.

Photo: Stas_V, Getty Images


Avatar photo
Avatar photo

Deepak Sirdeshmukh

Deepak Sirdeshmukh, MS, Ph.D., is Co-founder and CEO of Sensal Health, offering groundbreaking hardware and software solutions to empower clinical research organizations, pharma companies, and healthcare providers to manage patient medication compliance to complex dosage regimen. Drawing on his expertise as a pharmacist and deep understanding of behavioral modification strategies, Deepak’s passion lies in helping drive transformative change and contribute to improved patient outcomes. At Sensal Health, Deepak has spearheaded the development of MyAide a pioneering patented solution for complex oral dosage regimen, and MyAide Derm for topical dermatology. He received his MS in Pharmaceutical Administration and Ph.D. in Marketing from the Ohio State University. Deepak’s recent research has appeared in the Journal of the American Academy of Dermatology and Journal of Dermatological Treatment. He has also published in the Journal of Marketing, Journal of Marketing Research, Journal of Consumer Research, the Journal of Consumer Psychology among others.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.

Shares0
Shares0