Medication nonadherence: What may cause it and how to prevent it

It’s a tale as old as time. You write a prescription for a patient with a chronic condition such as asthma and later on the patient reluctantly tells you that he or she has only being taking it a quarter of the time. Nonadherence for medication is an issue that many clinicians will have a number of frustrating anecdotes to share. In her presentation at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Heather De Keyser, MD, MS, assistant professor of pediatric pulmonology at the Breathing Institute, University of Colorado School of Medicine and Children’s Hospital in Aurora, discussed the impact and scope of non adherence, what may impact adherence, and ways to improve adherence.

Nonadherence to medication is a frustrating problem, with the worldwide average adherence for chronic diseases being around 50%. This nonadherence is costly with 1 study of 43,156 children who used Medicaid and asthma found that if high adherence to inhaled steroids rose from the 33.35% seen in the participants to just 40%, it would result in $8 million per year in cost savings and increasing adherence to 80% would result in $57 million per year in savings. Even with serious medical issues, adherence can be low with 58% nonadherence seen in the 6 months followed newly diagnosed epilepsy and rates of poor adherence for solid organ transplant ranging from 30% to 76%, with the poorest adherence in adolescent patients.

A variety of factors can influence adherence to medication including poor access to care, poor provider knowledge of formulary, patient/provider relationship, social determinants of health, stigma, medical beliefs that lead to intentional nonadherence, forgetfulness, poor technique, and medication administration responsibility. De Keyser noted that when you take into account primary nonadherence, meaning getting the prescription filled, which is 14% to 20% with the first fill and 24% to 40% for subsequent fills; secondary nonadherence, meaning the prescription have been filled but the medication hasn’t been use, accounting for 30% to 70%; and poor device technique, which accounts for 43% to 100%, true adherence with asthma medication is likely very little.

Ask any provider why a patient isn’t taking a medication and the answer is likely going to be “if only they knew how important it was.” However, De Keyser emphasized that the reasons behind nonadherence are complex. It can range from a prescription not being filled because it requires frequent refills to parents being unsure of the proper dose to the child or parent simply forgetting the dose. She also shared a study that looked at HIV medication adherence. Barriers related to habit were far more commonly reported by children and parents than barriers tied to education. Habit is indeed a strong driver of an action, thanks to the loop of cue, routine, and reward. The habit loop was used to improve oral care when a toothpaste company, wanting to sell more product, encouraged people via an ad to run their tongue along their teeth and if they felt a film to brush their teeth, which resulted the reward of no more film.

To improve adherence, she recommended asking all patients on chronic medications about adherence and verify with objective data, particularly when the condition is not well-controlled. When talking with patients and parents, it’s best to speak clearly, use data, and be non-judgmental. Using a personal anecdote about how you don’t always adhere to something related to good health, De Keyser mentioned lack of flossing for instance, can help put patients at ease and help them know that they aren’t alone. Then she recommended 4 techniques to improve adherence:

Place based cue - The patient puts the medication in a place where he or she will regularly see it throughout the day, such as the kitchen table or the sink in the bathroom.

Time based cue - The patient uses the medication at certain times of day like right before going to school or at morning and evening meal times.

Habit stacking - The patient connects using the medication to another established habit, such as right after waking up or right before brushing his or her teeth.

Technology - The patient uses timers on his or her smartphone, other smartphone apps, or electronic health monitors. De Keyser recommends using smartphone times and reminders for medications that require only a short course because notifications can become easy to ignore.

Reference

1. De Keyser H. It won’t work if you don’t take it: ways to improve medication adherence. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 10, 2021.