Poor medication compliance (i.e., noncompliance) can have devastating effects on a patient, including an increased risk of morbidity and death. It also costs the healthcare system billions of dollars. In fact, some have called medication noncompliance "the most ignored national epidemic."

In this blog, we are going to explore the question of "What is medication compliance?" by discussing five things to know about this concept, including why it is a subject that some healthcare professionals argue is no longer deserving of attention.

What is Medication Compliance?

Let's begin by reviewing some definitions of this concept.

The National Stroke Association (NSA) states, "Medication compliance is the act of taking medication on schedule or taking medication as prescribed.

Medication Compliance Statistics:

Medication compliance is a challenge for many patients, as is evident when reviewing some of the statistics concerning noncompliance:

• An article in The Journal of the American Osteopathic Association notes the World Health Organization reports that approximately 125,000 people with treatable ailments die each year in the United States because they do not take their medication properly, 10% to 25% of hospital and nursing home admissions result from patient noncompliance, and as many as 40% of patients do not adhere to their treatment regimens.
• A Mayo Clinic Proceedings article notes that approximately 50% of patients with chronic illness do not take medications as prescribed.
• The NSA states that "… the average length of stay due to medication noncompliance is 4.2 days. In the United States, 12% of people don't take their medication at all after they fill/buy the prescription."

Causes of Medical Non-Compliance

Several factors can discourage patients from maintaining medication compliance. In a previous blog, we identified seven causes of medication noncompliance and provided guidance to help address them. Let's examine a few of these causes further and review evidence supporting their significance.

Side effects: Disagreeable side effects may be the most significant contributor to noncompliance. In fact, as a Clinical Advisor article notes, data derived from an online survey of nearly 900 U.S. patients found that such side effects were the only statistically significant factor that influenced medication noncompliance among patients with chronic diseases.

Costs: A growing challenge affecting not just medication compliance but patient treatment as a whole is increasing costs. In a study published in Circulation, researchers determined that one in eight patients with atherosclerotic cardiovascular disease were noncompliant with their medications because of the high cost. 

In a news release on the study, Dr. Khurram Nasir, senior author, states, "The out-of-pocket cost of medications is a huge issue for millions of high-risk patients with cardiovascular diseases, such as heart attacks, stroke, angina, and other conditions. When faced with the expenses of taking lifesaving medications as prescribed or not taking them because they are too costly, many choose not to take them."

Forgetfulness: Reasons why patients may forget to take their medication, according to Breastcancer.org, include busy lives, feeling healthy, lack of reminders, and management of multiple medications (e.g., polypharmacy). Forgetting to take medications is a challenge affecting more than three out of every five patients, according to an article in BMC Health Services Research. As an article published in Circulation: Health Failure, notes, poorer cognitive function, especially concerning memory, predicted reduced medication compliance among patients with heart failure. 

This problem can be magnified if patients do not realize they have forgotten to take a medication. They may then alter their prescribed regimen to treat the missed medication not as forgotten, but as part of their routine. This will lead to ongoing missed medications.

Communication: While not specifically referenced as a cause of medication noncompliance in our previous blog, inadequate communication contributes to many obstacles to medication compliance. As an article in Patient Preference and Adherence notes, poor physician communication has been associated with up to a 19% higher risk of medication noncompliance.

The researchers who conducted the study published in Clinical Advisor, as referenced above, noted that almost half of participants in the survey reported that they never received information regarding the side effects of their medication from their prescriber. Furthermore, nearly 20% reported that they did not receive information from a practitioner, nurse, or pharmacist. The researchers conclude, "By improving communication between the healthcare community and patients, compliance can be improved by managing medication-induced side effects."

Difference Between Medication Compliance and Medication Adherence:

While the terms medication compliance and "medication adherence" are often used synonymously, some literature has strived to distinguish the concepts. A Pharmacy Times article states, "The available literature often confounds them, even though they both describe a gap between prescribed behavior and actual behavior."

As we noted in a blog on medication adherence vs. medication compliance, "Such a distinction is important when organizations set out to improve patient adherence and/or compliance with a medication regimen."

The International Union of Basic and Clinical Pharmacology (IUPHAR) states, "Medication compliance is the act of taking medication on schedule or taking medication as prescribed, to achieve the desired health benefit (i.e., following a healthcare professional's advice). Adherence includes an indication of the tenacity that patients need to achieve in sticking to a therapeutic regimen, and also takes into consideration social and environmental influences."

A Geriatric Nursing article cuts to chase with its title, "Medication adherence is a partnership, medication compliance is not."

Further complicating efforts to differentiate these similar concepts is the term "medication persistence." As a Value in Health article notes, "Medication compliance refers to the degree or extent of conformity to the recommendations about day-to-day treatment by the provider with respect to the timing, dosage, and frequency. … Medication persistence refers to the act of continuing the treatment for the prescribed duration."

American Pharmacists Association (APhA) defines medication persistence as "the duration of time from initiation to discontinuation of therapy." APhA goes on to state, "Adherence is measured over a period of time and reported as a percentage, whereas persistence is reported as a continuous variable in terms of number of days for which the therapy was available. It is important to take into consideration both factors as clinical outcomes are affected not only by how well patients take their medications but also by how long they take them."

Movement Away from Medical Compliance:

We will conclude this blog by briefly examining an ongoing debate concerning medication compliance. Over the past several years, there has been a push by many healthcare professionals to stop using the term.

As Drs. Bentley and Potts of FreseniusRx write, "Clinical practice has shifted away from the term 'compliance,' with clinicians now favoring 'adherence' as an alternative. … In contrast to compliance, adherence encompasses patient freedom of choice and does not blame the patient for non-adherence. The movement to using adherence in place of compliance represents an important shift toward empowering the patient in health-related decisions in today's practice of patient-centered care."

An article for Patient Preference and Adherence states, "Medication compliance is the act of taking medication on schedule or taking medication as prescribed; however, recently, this term has fallen into disfavor. Medication adherence is the act of filling new prescriptions or refilling prescriptions on time, and this term better represents the more complex interplay among patient, provider, and medication and reflects the fact that following a medication regimen is not necessarily a simple choice."

Finally, Dr. Guido R. Zanni, Ph.D., in a Pharmacy Times column, states, "Medication adherence — the extent to which patients take medications as prescribed by their providers and agreed upon in the treatment plan — is essential for optimizing health outcomes. The term previously used, 'medication compliance,' has fallen out of favor, because it suggests the patient is passively following orders, as opposed to being actively involved in treatment planning."

Improving Compliance and Adherence via Comprehensive Medication Management:

Organizations striving to improve medication compliance and/or adherence should look to comprehensive medication management (CMM). CMM is a powerful tool that organizations are increasingly leveraging in their efforts to better manage and optimize medication therapy. CMM, which is typically led by clinical pharmacists, takes what can be described as a "whole-person approach" to therapy. It considers not only medications, but a patient's condition, clinical history, interventions (those tried, succeeded, and failed), lab and test results, medical problem list, and clinical notes.

What makes such an approach so effective? For starters, CMM has many benefits, eight of which we highlighted in a previous blog. These include more personalized therapy, stronger collaborative care, better patient engagement, all of which contribute to measurable improvements in outcomes, costs, and satisfaction.

You don't just need to take our word from it. Research recently presented at the American Society of Health-System Pharmacists' 54th Midyear Clinical Meeting and Exhibition demonstrated that when pharmacists take on a greater role in care transitions, there are tangible improvements in patient outcomes and safety.

In addition, a research report on CMM, funded by The American College of Clinical Pharmacy, the American College of Clinical Pharmacy Research Institute, and the UNC Eshelman Institute for Innovation, states, "The integration of clinical services focused on optimizing medication use into patient care may help primary care providers, specialists, and other members of the health care team meet the quadruple aims of improving population health, increasing patient satisfaction, reducing per-capita health care costs, and addressing provider satisfaction. CMM holds promise as a key strategy for meeting these goals."

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