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At the heart of general practice since 1960

Non-compliance with prescribed medication

Professor Hugh McGavock examines why many patients fail to take their medications correctly and offers some strategies that GPs can adopt to help improve compliance

The term 'non-compliance' is useful in that it means the wilful or inadvertent failure of a patient to take medication as directed, thus depriving him or herself of the possible benefits. Nowadays we tend to talk in terms of concordance rather than adherence or even compliance.

In the limited time available during the average eight-minute NHS GP consultation there is very little opportunity to negotiate concordance, but all GPs should be aware of the extent of the problem, of the known causes of non-compliance and how compliance may be improved.

The size of the problem

More than 90 per cent of all deaths due to rejection of transplanted hearts, kidneys and other organs are a result of non-compliance with the immunosuppressive medication. Of greater relevance to most GPs is the fact that 70 per cent of blindness in patients with glaucoma is due to non-compliance. Between 40 and 60 per cent of all end-stage diabetes (renal, retinal and vascular complications) and 50 per cent of end-stage hypertension is due to non-compliance.

It does not matter which country you survey, the figures in the US, the UK and the rest of Europe are fairly similar. This indicates self-harm on a massive scale, wasting individual health and life, unnecessary hospital treatment, wasting the investment by the NHS in prophylactic drugs, wasting the economic benefits of good health and wasting the GP's scarce time.

It is doubtful there would be any NHS bed shortage if these statistics were rectified.

Overall about 20 per cent of your patients will take their medication as prescribed, with remarkable precision and regardless of side-effects. These are the highly dependent people with a positive attitude to authority who are also generally well-organised in all aspects of their lives.

A further 40 per cent of patients will comply reasonably well when they remember and with positive intentions.

Such people achieve at least a proportion of the intended benefit from their medicines.

The reason for this article is that the remaining 40 per cent of your patients will comply so badly that they will achieve no benefit, in the short- or long-term, from your efforts ­ this includes the 15 per cent of patients who will not even have their prescription dispensed.

Reasons for non-compliance

Research in the US, Canada and the UK suggests various reasons for non-compliance. The reasons for unintentional non-compliance are obvious:

 · Forgetfulness, particularly in the elderly.

 · Failing to understand the doctor's or pharmacist's instructions.

 · Inability to read the label (medication labels are usually in very small type).

 · Failing to understand the need to persevere with long-term therapy.

 · A regimen comprising more than three drugs greatly increases the likelihood of unintentional poor compliance.

 · A regimen requiring more than thrice-daily dosage is also strongly associated with reduced compliance.

The reasons for intentional non-compliance are as complex and varied as human personalities. Sociological techniques have revealed the following reasons and a patient may show evidence of more than one:

 · Autonomy ­ the dislike of feeling dependent on drugs.

 · A false concept of immunity ­ some patients believe their medicine will slowly become ineffectual if taken continuously.

 · Many patients fear drugs as 'artificial chemicals'.

 · A desire for control ­ some patients alter their medication up or down in a quasi-experimental fashion, often giving themselves 'drug holidays' lasting days or even weeks.

 · Scare stories from neighbours and the media. The grossly overloaded legally driven PILS (patient information leaflets) have actually added to patients' worries.

 · Unpleasant side-effects ­ this may be a rational reason for non-compliance, however, it often results in a reduction of the dose to sub-therapeutic levels.

 · No perception of improvement often leads to disillusionment with treatment ­ patients may not realise that antihypertensive medication has only long-term benefits. Failure to 'notice an improvement' often leads to the dangerous non-compliance of increasing the dose.

What can be done?

Research, particularly in the US, has clearly shown almost any intervention to improve compliance will do so, for as long as it is continued.

 · By far the strongest compliance improver is regular contact with GPs, nurses and pharmacists. Pharmacists have a particular role here and now look on compliance improvement as a primary part of their work. Speak to your pharmacists and try to develop a joint strategy, preferably with feedback as to those patients who may not be complying.

 · Repeat the compliance message every time you review a patient on long-term maintenance treatment.

 · Speak to the pharmacist about regular mailshots for long-term patients; telephone reminders (which are often very effective at low cost); dosage aids which most community pharmacists now stock; and for

more literate patients, medication diaries.

 · For the frail, elderly and forgetful, your compliance strategy must be targeted at the carer, remembering that the carer may also exhibit unintentional and/or intentional reasons for non-compliance.

 · Whenever you perceive treatment failure where you would have expected substantial improvement, consider that non-compliance may be the reason rather than your diagnosis or treatment regimen.

 · At a personal level, you will develop your own techniques for encouraging medication compliance, which will be slightly different from your colleagues'. Just as patients are all individuals, so are GPs. The 'right way' is the way that works and it will have to be sensitively adapted for each individual patient.

 · Finally, in this age of monitoring, don't forget that a practice compliance improvement policy would look very well in your appraisal declaration. You could think about designing simple patient compliance leaflets for your own practice or group of practices.

Hugh McGavock is visiting professor of prescribing science, University of Ulster, and course organiser for GPs' continuing medical education, Northern Ireland Council for Postgraduate Medical and Dental Education, Belfast

Royal Pharmaceutical Society of GB. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of GB, 1997

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