Editorial

  Pharmaceutical research has made major advances, but the medications can be effective only if patients would take them as prescribed. Taking less than 80% of the prescribed doses of a medication is considered non-adherence^[1]. Pharmaceutical non-adherence can be a serious obstacle in the way of achieving the desired treatment outcomes expected by the healthcare providers. A simple and good example is the non-adherence to the prescribed course of antibiotics which not only can result in treatment failure but also can be harmful if a prescribed dosage is not taken for the prescribed length of time.

  Generally it is estimated that 50 percent of the patients comply with the long-term medication therapies^[2]. The National Community Pharmacists Association^[3] conducted a telephone survey of 1,020 adults age 40 and older who took prescribed medications for a chronic medical condition. The average score reported on adherent behaviors of Americans was 79% (labeled as a C+ grade). Of all respondents, 30% reported they forgot to take the medicine, 22% reported taking a lower dose, 20% did not fill the prescription, and 14 % stopped taking the prescribed medication. The chief predictors of patient adherence were personal connection with someone at the pharmacy, low cost of the prescribed medication(s), a belief in the importance of following instructions, feeling informed about one’s health, and minimal side effects experienced.

  Non-adherence to prescribed medicines is not only a widespread patient behavior but also a problem that is difficult to manage by the healthcare providers. Recently a comprehensive review of 182 randomized controlled trials comparing groups “receiving” and “not receiving” an intervention to improve the adherence to their medication regimen was conducted. The general finding of the review was that the methods used for improving medication adherence by the patients with chronic health problems were found to be not very effective. The reviewers picked 17 studies of “the highest quality” and reported that the interventions were complex which included social support from family and friends, and professional support from allied professionals such as pharmacists. Only five of the studies showed improved pharmaceutical adherence, however, no common factors could be identified that were responsible for the improvement. Social support was also reported to be an important variable in relation to patient adherence by another review and meta-analysis of 122 studies published from 1948 to 2001^[6]. The reviewer concluded that the results of the meta-analysis provided “solid quantitative evidence” about the strong connection between social support and patient adherence.

  Despite all recommendations of many studies, the adherence rates have not improved much over the past six decades because many healthcare providers have done little to improve them^[4,5,6]. This suggests that doctor-patient communication might be an important moderating factor. In fact, the past research indicates that the quality of the doctor- patient relationship and patient health beliefs might be important factors. Another comprehensive review of the studies from 1975 to 1999 on patient adherence reported that over 200 variables were studied, but none of them consistently predicted adherence^[4]. Further, the reviewers found the research to be fragmented and difficult to integrate in order to make any definitive conclusions because of the possible interactions of the uniqueness of each case and each patient-doctor pair relationship.

  The comprehensive reviews and meta-analyses of past research have identified the following effective strategies to improve patient adherence: oral and clearly written instructions, simplified medication regimens, cues to signal the time for taking medicine, social and professional patient support, and patient-doctor communication/relationship^[1-6]. The benefits of increased patient adherence would be reduced cost and health risks associated with the problem of non-adherence in the United States^[3]. I agree with Vermeire et al^[4]. That the bottom line at this time is to move away from the “paternalistic” medical model to a doctor-patient collaborative approach. Healthcare providers should appropriately inform their patients about the medication regimen and convey to them that they are patients’ health partners in making shared decisions. This means that healthcare providers will have to spend more time with their patients and get to know their patients’ health goals, beliefs, and resources to design a “negotiated treatment plan” to which both patients and healthcare providers can adhere.

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