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Non-adherencetoPrescribedTherapy:APersistentContributortotheCareGap

TerrenceMontague,CM,CD,MD,Lori-JeanManness,BScPharm,BonnieCochrane,RN,MSc,AmédéGogovor,MSc,JohnAylen,MA,LesliMartin,BA,JoannaNemis-White,BSc,PMPAbstractComparisonsofthescope,causesandsuccessfulinterventionstoimproveadherencetomedicaltherapyoverthelastdecadedonotrevealsignificantadvancesinimprovementofpatientcareandoutcomes.Rather,patients’adherencetoprescribedtherapiesremainssub-optimal;and,notbyasmalldegree.Inthe2016HealthCareinCanadasurvey,amongthe43percentofCanadianadultsprescribedanaverageof3.4medicationsperperson,perday,morethan50percentreportedsomeformofnon-adherencetotheprescribedtherapy.Theadherencedeficitspansallmajorchronicdiseasesandinvolvesmultiplepatterns,particularlytakingmedicationslessfrequentlythanprescribed,butoccasionally,morefrequently;and,athigher,orlower,doses.Patients’mostcommonlyreportedreasonsfornon-adherenceareforgetfulness;and,aninclinationtomakeongoingtreatmentdecisionswithinaconstructofhowtheyfeelinthemoment–apparentlyirrespectiveofexistingevidence.Therapeuticcosts,concernforsideeffectsanddisbeliefinefficacyareuncommonorminimalfears.Rather,patients’reportedunderstandingoftheirmedications’scientifically-basedefficacyandrationale,theirhoped-foroutcomes;and,how/whentotaketheirprescriptionsrangefrom77to91percent.Thesefindingsareverycompatiblewithhealthprofessionals’reportedtransmissionofthesameknowledgetopatients,aspartoftheirrecommendationoftheprescribedtherapies.Thebottom-linecontemporaryrealityis:despiteincreasedprofessional-patientdiscussionson

benefit-riskbalance,improvedtherapeuticadherenceresultsarenotforthcoming.Itappearsthatstakeholdersareadherenttonon-adherence;or,atleastamazinglytolerantofitsnegativeimpactonpatientoutcomes.Thus,despiteadvancesindiagnosticandtherapeuticcapabilitiesthatreducekeygapsbetweenbestandusualcare,theoverallimpactonimprovedpatientoutcomesremainslessthanoptimalbecauseofpoorcompliancewithprescribedevidence-basedtherapies.Thingscanbebetter.Oneoutstandingopportunitytoshrinktheadherencegapisadoptionofregularmeasurementandfeedbackofreal-worldclinicaladherencepracticesbyallstakeholders,aninnovationthatwouldlikelyproduceadherenceratescomparabletotheirveryhighlevelsinrandomizedclinicaltrials.Itseemsanoutstandingopportunity.Thetimeisrighttotestitshypothesis.

IntroductionTheterm‘caregap’connotesthedifferencebetweenwhatbest,evidence-basedmedicalcareandaccompanyingoutcomescouldbeforpatientsatdiseaserisk,versusactualcare(1).Therearefourmajorcontributorstothecaregap:sub-optimalpatientaccess;inadequatediagnosis;non-prescriptionofproventherapies;and,pooradherencetotherapies(1).Patientsinone,ormore,ofthesesituationscanbeconsideredasbeingonaninvisiblewaitinglist-waitingforbestcareandbestoutcomes(1–3).

Non-adherence to Prescribed Therapy : A Persistent Contributor to the Care Gap HCIC 2017

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Thispaperhighlightsthecontinuinghighdegreeofcontemporarynon-adherenceasamajorlostopportunitytoachieveoptimalhealthcareandoutcomesinCanada;and,reviewscontributingcausesandpossiblepathstomakethingsbetter.DataSources/MethodsTheprincipaldatasourcesforthisreviewweretherecordedviewsofrepresentativesamplesoftheadultCanadianpublicandabroadspectrumofhealthprofessionalgroups,polledonlineinthesummerof2016aspartofthemostrecentHealthCareinCanada(HCIC)survey(4).The2016HCICpublicstudypopulationsample(n=1500)wasnationallyrepresentativeofallCanadianadults.Healthprofessionals’samplesizes,althoughsmaller,werealsorepresentativeofeachtargetgroup:doctors(n=102),nurses(n=102),pharmacists(n=100),administrators(n=100).The2016surveyalsoincludedasampleofalliedprofessionals:nutritionists,dieticians,occupationaltherapists,physicaltherapists,psychologistsandsocialworkers(n=100).POLLARAStrategicInsightssupportedtheformattingandcollationofquestionsandresponsesonbehalfofallHCICpartners:CanadianCancerSociety;CanadianFoundationforHealthcareImprovement;CanadianHomeCareAssociation;CanadianHospicePalliativeCareAssociation;CanadianMedicalAssociation;CanadianNursesAssociation;CanadianPharmacistsAssociation;ConstanceLethbridgeRehabilitationCenter,CentreforInterdisciplinaryResearchinRehabilitation;McGillUniversity;HealthCharitiesCoalitionofCanada;HealthCareCAN;InstituteofHealthEconomics;StuderGroupCanada;MerckCanada;

StriveHealthManagement;and,CareNetHealthManagementConsulting.ComponentsofAdherenceAdherenceisanumbrellatermconnotingperseverancewithmutually-agreedtherapeuticcomponentsinthepatient-providercovenant,followingprofessionaldiagnosisandrecommendation/provisionofevidence-basedpharmaceuticalprescriptionsorotherevidence-basedtherapy(5).Theoverarchinggoalisattainmentofthebestpossiblepatientoutcomesinthelongterm.Incontemporarypatient-centredcare(6),concordantunderstandingofdiagnosesandconsentaroundtherisksandbenefitsofpossibletherapiesarehighlydesiredoutcomesofthebi-lateraldiscussionbetweenprofessionalsandpatientsastheyseekamutuallydeterminedtreatmentstrategy(6).Intheshortterm,theyreflectpatients’understandingandacceptanceofdiagnosisandprescribedtherapy.Inthelongerterm,thehoped-forexpectationsarethatpatientswillobtainaninitialprescriptionandfaithfullypersistinobtainingsubsequentrefills(5,7).Thecompliancecomponentsofadherencerefertopatients’understandingandcommitmenttospecificprescriptionrequirements,suchasdosageandtiming(5).ChallengesThescopeofthechallengestoachieveoptimaltherapeuticadherencearenotinsignificant.


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Theybeginwiththelargefractionofthegeneraladultpopulationusingprescribedmedications.In2016,theprevalenceofprescribedmedicationtherapiesforchronicdiseasesaveraged40percent(Figure1).And,theaveragenumberof

prescribedmedicationswasmorethanthreeperpatient(Figure1).Thesefiguresareinkeepingwithcomparativefiguresfromthe2013-2014HCICsurvey:45percentoverallprevalence;and,4.0prescriptionsperpatient,respectively(8).

Figure1. Canadianadultpublic’sresponsesin2016whenasked:“Doyoucurrentlytakeanyprescriptionmedicationsonaregular(dailyorweekly)basis”(n=1500);and,“Howmanydifferenttypesofprescriptionmedicationsareyoucurrentlytakingintotal”(n=641)?

Beyondthehighprevalenceofadultscurrentlyprescribedmedications,isthespectrumofmultiplenon-compliantpatternsinallmajordiseasestates(Figures2,3).AmongthemillionsofCanadianscurrentlytakingprescriptionmedications,morethanhalf(52percent)arenon-adherentinsomeway–mostcommonlybecausetheytaketheirmedicationslessfrequentlythanprescribed(Figure2).Youngerpeopleweremorelikelytobenon-adherent,withonly35percentofthoseunder45yearsalwayscompliantwithinstructions,comparedto49percentofpatientsaged45to64years;and,55percentofthose65andolder.However,non-

adherencedoesnotappeartoberelatedtothenumberofmedicationsprescribed,northeirdosingpatterns(Figure2).Intermsofpatients’therapeuticadherenceinspecificdiseases,thehighestreportedlevelsin2016were:62percent,forpatientswithosteoporosis;and,55percentforcardiacpatients(Figure3).Inallothermajordiseasepopulations,includingpatientswithdiseasesthatcarrysomeofthemostdisablingsymptomsandguardedoutcomes,non-adherencedramaticallyoutweighedadherencerates(Figure3).

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Figure2. Overallprevalenceofnon-adherence,andspecificpatternsofnon-compliance,toprescribedmedicaltherapyinCanadianpatientsin2016(n=641).

Figure3. Comparisonofcontemporaryadherence,versusnon-adherence,ratestomedicaltherapyprescribedforimportantdiseasestatesamongCanadianadultsin2016.*Resultsshouldbeinterpretedwithcautionduetosmallbasesize.

Adherencepatternsofpatients(Figure3)mayappearsomewhatcounter-intuitivetohealthcareprofessionals;and,eventootherpatientsandnon-patientsamongthegeneralpublic.

However,asoutlinedinFigure4,thespectrumofreasoningaroundpatients’decisionsfornon-complianceprovidessomeinsight.Forexample,costsofprescriptions,worriesaboutefficacy,or


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negativesideeffects,areminimalconcernsforpatients(Figure4).Rather,patients’top-ratedreasonsfornon-complianceareforgetfulness;

and,asenseofhowtheyfeelinthemoment(Figure4).

Figure4. Patients’responseswhenasked:“Whydoyou,atleastoccasionally,dothefollowingwhenitcomestotakingyourprescribedmedication?” Whilethesedatadonotallowdefinitiveexplanationofwhyitissocommonforpatientswithsignificantchronicdiseasestonottaketheirmedicationsbecauseofforgetfulness;or,todecideonmeritsofhowtheyfeelinthemoment,somereasonablespeculationsarepossible.Forexample,thedatamayreflectanintegraloptimismamongpatientsthatistemporallyreflectiveofadecreasinglevelofseverity,ortransientabsence,ofdisablingsymptoms-fosteringwillfulbeliefthatabestcasescenarioisunfoldingforthemastheyhadhoped;and,consequently,theneedformedicationhasdecreased.Or,perhapsitjustreflectspatients’fatiguewiththepersistentprocessesofchronic

careanddiseasemanagement?Oneareaofpotentialcontributiontotheadherencecaregapisinadequateknowledgeexchangebetweenpatientsandtheirprofessionalhealthcareproviders.However,asindicatedinFigure5,thegreatmajorityofpatientsreporttheydonotlackknowledgeorunderstandingregardingtherationale,keycompliancehow-tofactorsandpotentialsideeffectsoftheirprescribedmedications.And,themajorityofhealthprofessionals’supportpatients’perceptionsofknowledgedeliverytoaveryhighdegree(Figure6).

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Figure5. Patients’responseswhenasked:“Howmuchwouldyousayyouunderstandabouteachofthefollowing?”

Figure6. Professionals’responseswhenasked:“Howoftendoyoutellpatientswhythemedication(s)wasprescribed?” NextStepsNon-adherenceisaconsistentrealityinmedicalcare;and,notlikelyaplayofchancephenomenon.Previousstudies(9–12),aswellasthefindingsofthe2016HCICsurvey(Figure4),

suggestitmaybeshapedbypatients’intrinsichealthandmedication-relatedvaluesandbeliefs;and/orthesymptomaticrealitiesofmanagingoneormorechronicdiseases,allofwhichmay


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fluxovertime.So,wereturntotheenduringquestion:arethereanypracticalapproachestoimprovetherapeuticadherence?Intheacademicsphere,thetraditionalanswertothisquestionistorecommendfurtherstudies.Forexample,basedonthefindingsfromthe2016HCICsurvey,moredefinitiveclarityaroundpatients’precisedefinitionsofwhatismeantby“forgetfulness”and“decidinginthemoment”(Figure4)arelikelytoleadtobetterunderstandingofthesedecision-determiningfeelings.Intheinterim,adoptionofsomeotherpracticaladaptationsmayalsoimproveadherence.Forexample,existingdataconsistentlydemonstratethatpatients’decisionstonotadheretoprescribedtherapyoccurrelativelyearlypost-prescription(5,10,11).Thus,reinforcementoftheinitialpatient–providerdiscussionofbenefitversusriskinbalancingtheprescribedtherapyshouldbedonesoonerratherthanlater.Anotherintriguinginsightthatbearsfurtherexplorationtoadvanceadherencetomedicaltherapiesinrealworldpracticecomesfromtheworldofrandomizedclinicaltrials,whereadherencerateshavebeenreportedtobemaintainedatveryhighlevelsforprolongedperiods(5).Forexample,inareal-worldclinicalpracticesettingformanagementofriskreductionamong26,000Canadiancardiacpatientswithfullinsurancefordrugcoverage,useoftwoproventherapies(angiotensinconvertingenzymeinhibitorsandlipid-loweringagents)felltobelow80percentatthreemonthsfollowingtherapyinitiation;andthereafter,fellcontinuouslytoabout40percentadherenceat24monthspost-initiationoftherapy(5).In

comparison,theadherenceratesamongasimilarcohortofadultCanadiancardiacpatientstakingthesametwomedicationsintheSimvastatin/EnalaprilCoronaryAtherosclerosisTrial,continuouslyaveragedalmost95percentoverthefiveyearcourseofthetrial(5).Aleadingdifferenceintrials’practiceversusreal-worldclinicalpracticeistrials’demandforregularmeasurementandfeedbacktopatientsandprovidersofadherencetomedications.Trialsdemandboth;currentcommunitypracticedemandsneither.Unfortunately,despitestrongsupportamongpublicandprofessionalstakeholdersformanycomponentsofpatientcentredcare,priorityforimplementingregularmeasurementandfeedbackofpractices,suchasadherencerates,doesnotcomeclosetothetopofanystakeholders’prioritylistforimplementationinthenearfuture(4).

ConclusionsAdherencetoprescribedmedicaltherapyisanenduringprobleminachievingoptimal,evidence-basedcareandoutcomesinCanada.Italsoremainsarelativeorphanforinnovativesystemicinterventionstomakethingsbetter.Itscausationremainsunclear.Money,orthelackofit;doesnotseemanissue,nordospecificityofdisease,numberofmedications,theirnegativesideeffectsorcomplications.Itisnotdrivenbyalackofknowledgetranslationamongpatientsandhealthprofessionals.And,itpersistsdespiteincreasingawarenessandadoptionofpatient-centredcarephilosophyandprinciplesinCanada.


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Anoutstandingquestioniswhetheradoptionofregularmeasurementandfeedbackofpracticepatternsintomodernpatient-centredcare(13),bypatientsandprofessionalcareproviders,canclosetheadherencegap,similartoitsimpactinclinicaltrials?Itmayalsobeanoutstandingopportunity.Thetimeisrighttofindout.Thingscanbebetter.References1.MontagueT.2004.PatientsFirst.ClosingTheHealthCareGapInCanada.JohnWiley&SonsLtd.,Mississauga,ON.Canada.2.CoxJ,JohnstoneD,Nemis-WhiteJ,MontagueT,fortheICONSInvestigators.2008.Optimizinghealthcareatthepopulationlevel:ResultsoftheImprovingCardiovascularOutcomesinNovaScotia(ICONS)Partnership.HealthcareQuarterly11(2):28-41.3.ParadisPE,Nemis-WhiteJ,MeilleurM-C,GinnM,CoxJ,MontagueT,fortheImprovingCardiovascularOutcomesinNovaScotia(ICONS)Investigators.2010.ManagingCareandCosts:TheSustainedCostImpactofReducedHospitalizationsinaPartnership-MeasurementModelofDiseaseManagement.HealthcareQuarterly13(4):30-9.4.KnowledgeTranslationTeam.2016.HealthCareinCanada(HCIC)Survey:SummaryofKeyResults.RetrievedJanuary30,2017.<http://www.mcgill.ca/hcic-sssc/hcic-surveys/2016>.5.WahlC,GregoireJ-P,TeoKK,BeaulieuM,LabelleS,LeducB,CochraneB,LapointeL,MontagueT.2005.Concordance,ComplianceandAdherenceinHealthCare:StrategiesforClosingGapsandImprovingOutcomes.HealthcareQuarterly8:65-70.6.MontagueT,GogovorA,Aylen,J,Ashey,L,AhmedS,Martin,L,Cochrane,B,Adams,O,Nemis-White,T.2017.PatientCentredCareinCanada:PublicandProfessionalPerceptionsofKeyComponents.HealthcareQuarterly;(InPress).

7.KardasP,LewelP,MatyjaszczykM.2013.Determinantsofpatientadherence:areviewofsystematicreviews.FrontiersinPharmacology4(91):1-16.8.AhmedS,MarshallL,GogovorA,MortonW,NormanJ,Nemis-WhiteJ,MontagueT,forthe2013-2014HealthCareinCanadaSurveyMembers.2015.ChallengesandOpportunities:Resultsofthe2013-2014HealthCareinCanadaSurvey.https://www.mcgill.ca/hcic-sssc/files/hcic-sssc/hcic_challenges_opportunities_2015.pdf.9.TamblynR.2016.DataimpactchallengeII–unfilledprescriptions.Whatproportionofprescriptionsareunfilledornotpickedupbypatients?RetreivedFebruary3,2017.http://imaginenationchallenge.ca/data-impact-ii-challenge-questions/10.FischerM,StedmanMR,VogelC,ShrankWH,Brookhart,MA,WeissmanJS.2010.Primarymedicationnon-adherence:analysisof195,930electronicprescriptions.JGenInternMed25(4):284–90.11.GadkariA,McHorneyCA.2010.Medicationnon-fulfilmentratesandreasons:narrativesystematicreview.CurrMedResOpin2010;26:683–705.12.McHorneyC.2009.Theadherenceestimator:abrief,proximalscreenerforpatientpropensitytoadheretoprescriptionmedicationsforchronicdisease.CurrMedResOpin25:215-38.13.HebertPC,FleigelK,MacDonaldN,StanbrookM,RamsayJ.2010.Measuringperformanceisessentialtopatient-centredcare.CMAJ;182:225.HowtociteMontagueT,MannesL.J,CochraneB,GogovorA,AylenJ,MartinL,Nemis-WhiteJ.(2017).Non-adherencetoPrescribedTherapy:APersistentContributortotheCareGap;http://www.hcic-sssc.comaccessedon<<Date>>.


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AbouttheAuthors

TerrenceMontague,CM,CD,MD,isPrincipal,CareNetHealthManagementConsultingLtd.,andAdjunctProfessorofMedicine,UniversityofAlberta,Edmonton,AB.Lori-JeanManness,BScPharm,isanIndependentConsultantservingpatientsandthehealthcarecommunitytoenablehealthbehaviorchange,Winnipeg,MB.BonnieCochrane,RN,MSc,isVice-PresidentandDirector,PartnerDevelopmentandLeadershipCoach,StuderGroupCanada,MountPearl,NL.AmédéGogovor,DVM,MSc,isaPhDcandidateandResearchAssistant,FacultyofMedicine,McGillUniversity,Montréal,QC.JohnAylen,MA,isPresident,JohnAylenCommunications;and,LecturerinMarketingCommunications,JohnMolsonSchoolofBusiness,ConcordiaUniversity,Montréal,QC.LesliMartin,BA,isVice-PresidentPublicAffairs,PollaraStrategicInsights,Toronto,ON.JoannaNemis-White,BSc,PMP,isPrincipal,StriveHealthManagementConsultingInc.,Halifax,NS.