Working together to improve adherence

On reading the NICE guidance on medicines adherence, one of the depressing facts that jumps out is that between a third and half of all medicines that are prescribed for long-term conditions are not used as recommended (National Collaborating Centre for Primary Care [NCCPC], 2009). It may be an even bleaker picture for people with diabetes, where one report mentions that about two thirds of people do not take their oral anti-diabetes medications properly (Donnan et al, 2002).

There are thought to be two types of non-adherence: unintentional and intentional (Gray and Celino, 2008). Unintentional non-adherence (“cannot take”) is more about the practical problems of taking medicines, such as memory loss or difficulty opening packages, which may prevent someone taking medicines as planned. Intentional non-adherence (“will not take”), on the other hand, is based on a person’s beliefs about the medicine, for example whether or not it will work. Obviously for some people it may be mixture of both intentional and unintentional non-adherence issues.

Common factors that can affect medication adherence include:

• Complex regimens involving multiple doses and several medicines.
• Concerns about side-effects.
• Concerns about the value or appropriateness of taking medicines.
• Denial of illness.
• Confusion or physical difficulties with medicine taking.

Identifying a non-adherent person
It may be obvious that a person is not requesting their chronic medicines regularly from the GP repeat medication re-ordering system or the pharmacy medication records. However, it should be noted that a dose of drug ordered is not necessarily a dose taken, so this is not a foolproof method of identification. 

NICE (NCCPC, 2009) recommends that healthcare professionals should consider asking individuals if they have missed any doses recently, such as in the past week, ensuring that the question is asked in a way that does not suggest any blame, explaining why it is being asked and enquiring about medicine-taking habits.

What can healthcare professionals do to increase adherence?
NICE recommends a number of ways to help support adherence and these are summarised below (NCCPC, 2009):

• Adapt your consultation style to the needs of the individual so that they have the opportunity to be involved in decisions about their medicines at the level they wish.
• Establish the most effective way of communicating with each person (for example, using large print, different languages, an interpreter or a patient advocate).
• A person may decide not to take, or to stop taking, a medicine. If, in the healthcare professional’s view, this could have an adverse effect, then information provided on risks and benefits, and the person’s decision, should be recorded.
• Accept that an individual has the right to decide not to take a medicine as long as they have the capacity to make an informed decision and have been provided with the information needed to make such a decision.
• Offer people information that is relevant to their condition, possible treatments and personal circumstances, and that is easy to understand and free from jargon.

Another way to help people with diabetes and adherence issues is to refer them to their local community pharmacist for a medicines use review, which may help identify and solve some of the more practical difficulties they may be experiencing with their medications.

It should be recognised that increasing adherence is not a one-off exercise and that one intervention method will not suit all. It is something we all need to be involved in, including the GP, practice nurse and community pharmacist.