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Independents' Day

Tackling poor compliance

Professor Hugh McGavock continues his series on common problems in primary care prescribing by discussing difficulties with compliance and strategies to overcome them

Professor Hugh McGavock continues his series on common problems in primary care prescribing by discussing difficulties with compliance and strategies to overcome them

Twenty years of drug use research have shown consistent and worrying evidence of the extent of non-compliance (or non-adherence) of patients with their prescribed medication – both short-term courses and long-term regimens.

About 20% of patients take their treatment (and medicate their dependents) with remarkable precision. A further 40% take their medicines with varying degrees of imperfection – but well enough to derive some therapeutic benefit. The remaining 40% do not take their prescribed medicines at all, or they take them so badly that they get no benefit whatsoever. Of this last group, 15% do not even get their prescriptions dispensed.

The ultimate evidence of the effects of non-compliance is the observation that over 90% of organ transplant rejection (and death) is due to non-compliance with the immunosuppressant regimen. And it has often been reported that up to 70% of asthmatic children admitted to A&E with acute, severe asthma have not been receiving their preventive steroid inhalations regularly.

Non-compliance involves waste. Quite apart from the waste of the doctors' and pharmacists' time and expertise, and of the NHS budget, non-compliant patients face serious adverse outcomes. It is impossible to be precise, but it is estimated that at least £10bn is wasted each year in the UK by non-compliance.

Compliance-enhancing techniques

Much can be done for the majority of non-compliers. Most strategies have been proven to work for most patients and to improve outcomes, but only for as long as the intervention continues. When the intervention is stopped, patients often revert to their previous behaviour.

Many techniques involve extra workload for the prescribing doctor, the nurse, the pharmacist, the carer, or several of them. But most would agree that this is a price worth paying. The following are proven and practicable compliance-enhancing methods.

Recognise the problem

If there is no clinical response, reconsider your diagnosis. If the diagnosis is firm, do not automatically increase drug dose. Ask the patient whether they have any problem in taking the medicines, and to tell you how and how often each drug is taken.

Remember that many patients have been shown to lie about their compliance (often to avoid offending their doctor), and check on your computer system to see if prescriptions have been issued and with their pharmacist to see if they have been dispensed and collected.

Ascertain the reason for non-compliance

There are a number of possibilities:

• Side-effects? Explain that these will often slowly decrease and could even disappear.

• Unsure of the dose frequency? Explain, write it out and rehearse at every review.

• Unable to open the pill bottles? The pharmacist can supply containers with easy-opening caps. But blister packs remain a problem for many.

• Unable to swallow larger tablets or capsules? This is a common problem. Select smaller presentations or prescribe in a liquid form.

• Unable to remember the regimen? Simplify the regimen as far as possible, and ask the pharmacist to make up a weekly supply in one of the several good dosage aids – this is especially useful for carers.

Educate at every opportunity, and ask nurses and pharmacists to reinforce the message

Try to do this in the context of a ‘therapeutic contract' between the patient and yourself – a ‘concordance'. Use the mantra: ‘We can do together what neither of us can do alone' – it is a part of the process of teaching and conditioning health behaviour.

Try getting the patient to keep a drug diary

This should be completed daily and brought to you regularly – but it will not suit all patients.

Consider telephone reminders for at-risk patients

This can prove very effective in selected patients – whether by you, the nurse, the pharmacist or the reception staff who deal with repeat prescriptions. Many housebound patients welcome this contact with the outside world.

Reassure patients that they will not become addicted to or dependent on their medications

This is a major worry for many intelligent lay people.

Reassure patients that the drugs you prescribe are much more effective and usually safer than herbal extracts

Herbal treatments vary greatly in dose and may contain dangerous impurities such as pesticides used on the plant, which are potentially toxic.

Achievable outcomes

Patients will give a number of explanations for non compliance (see box below). All are amenable to repeated, reasoned education in an atmosphere of trust and co-operation. In many cases, the outcome of improved well-being will reinforce compliant behaviour. A significant improvement in self-medication in 50% of non-compliant patients would be a reasonable aspiration.

Professor Hugh McGavock is visiting professor of prescribing science, department of nursing studies, University of Ulster and course organiser, GP Continuing Clinical Education, Northern Ireland Medical and Dental Training Agency

This is an extract from Pitfalls in Prescribing and How to Avoid Them. Pulse readers can buy the book at the specially discounted price of £15.00 plus P&P (usual price £18.99 plus P&P) directly from . To claim the discount enter the discount code PPLSE9 at the checkout. Alternatively, please order via 01235 528820 quoting the same code. Offer ends 28 August 2009.

Intentional non-compliance: 10 common patient perspectives Intentional non-compliance: 10 common patient perspectives

1 Some believe that their bodies will self-cure, and do not realise that for most chronic diseases this is not the case
2 Some doubt the efficacy of modern medicines
3 Some fear that they will become addicted to their drugs
4 Some believe that their bodies will develop immunity to long-term treatment
5 Some dislike handing over control of their bodies and/or minds to medicines (and clinicians) – ‘loss of autonomy'
6 Many imagine that a short course of medicine will cure them of hypertension, diabetes and so on
7 Many do not comprehend the long-term benefits of maintenance medication, or the risks of having no treatment
8 Some are worried about side-effects, often with good reason
9 Some fear ‘unnatural, synthetic chemicals', preferring ‘natural remedies' without realising the risks of herbal treatments
10 Some have a completely anti-drug attitude, even to the vaccination of their children

Tackling poor compliance

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