Medication compliance has been a matter of great interest and attention for many years. But more recently, the term medication compliance has come under increased scrutiny, with some even questioning its usage. So, what's the controversy?
What is Medication Compliance?
Before we dive into what makes medication compliance controversial, it will be helpful to review the definitions of medication compliance and a few related terms that ultimately factor into the debate.
In a blog focusing on "what is medication compliance," we shared definitions provided by multiple sources, including this one from the National Stroke Association, "Medication compliance is the act of taking medication on schedule or taking medication as prescribed."
The Epilepsy Foundation elaborates, stating, "People who follow their doctor's recommendations regarding medications and lifestyle are said to be 'compliant' and those who don't are 'noncompliant.' Using the words 'compliant' and 'noncompliant' are shortcut ways of saying whether patients are really following the treatment plans or doing what the doctor asked."
Medication Compliance: The "Other" Definition
As these definitions indicate, medication compliance is a term often used when discussing patients following their medication regimen. However, it's also a term that can be used to discuss an entirely different matter.
In a blog titled, "5 Medication Compliance Tips for Practitioners and Pharmacies," we explained that medication compliance can also "… concern the rules practitioners who prescribe medications, their organizations, and pharmacies must follow to comply with medication-related laws and guidelines." This piece reviews such issues as Drug Enforcement Administration prescription rules, controlled substance security, record keeping, and e-prescribing.
While it is important to understand this usage of the term medication compliance and how it differs from the patient-focused definition, it is not part of the controversy.
What is Medication Adherence and What is Medication Persistence?
There are two other terms we need to understand to help us effectively understand the medication compliance controversy. First is "medication adherence."
We have a blog that speaks to the definition of medication adherence. It includes this from the U.S. Pharmacist: Medication adherence is the act of taking medication as prescribed by a physician. This includes consistently taking the proper dose, at the correct time, and for the recommended length of time."
Second is "medication persistence." Prescriptions for a Healthy America states that medication persistence is "The duration of time a patient takes medication, from initiation to discontinuation of therapy."
Medication Persistence Controversy
While the controversy we are focusing on in this blog concerns medication compliance vs. medication adherence, it is important to acknowledge that medication persistence has had its own controversy. This concerns the usage of medication persistence synonymously with medication compliance or medication adherence.
As a Value in Health column notes, "Medication compliance and medication persistence are two different constructs. Medication compliance (synonym: adherence) 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. It may be defined as 'the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen.' Medication persistence refers to the act of continuing the treatment for the prescribed duration. It may be defined as 'the duration of time from initiation to discontinuation of therapy.'"
An article in Expert Review of Pharmacoeconomics & Outcomes Research states that although medication adherence and medication persistence often used interchangeably in the literature, "… it is important to recognize that they are unique and are at times two mutually exclusive constructs. Saying patients are adherent to their medication regimens does not necessarily imply that they are persistent, and the opposite is also true. To clarify, patients who purposefully skip some of their prescribed daily doses of medication would not be considered to be adherent; however, they may be persistent provided that they continue treatment for the agreed period of time specified by their healthcare providers. In this way, it is often simpler to view adherence as whether or not patients take their medication as prescribed for the duration of time that they are persistent with treatment."
The American Pharmacists Association (APhA) notes, "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."
Medication Compliance vs. Medication Adherence Controversies
Now let's shift our attention back to medication compliance vs. medication adherence. There are two controversies associated with these terms. The first controversy, like that of medication persistence, is the synonymous usage of medication compliance and medication adherence. A frequently cited quote from this New England Journal of Medicine article is as follows: "Adherence to (or compliance with) a medication regimen is generally defined as the extent to which patients take medications as prescribed by their healthcare providers." And yet, as we've discussed, medication compliance and medication adherence are not only different concepts, but their difference is significant — and very important for understanding the second controversy.
The APhA does an effective job of simplifying these differences when it provides the following definitions:
- "Medication adherence: the extent to which a patient's behavior (e.g., taking medications with respect to timing, dosage, and frequency) with agreed-upon recommendations from a healthcare provider."
- "Medication compliance: the extent to which a patient passively follows the advice of their provider."
A Pharmacy Times article compares medication noncompliance and medication nonadherence when the author states, "I would propose that noncompliance is best defined as gaps that occur for unintentional reasons (or factors beyond the patient's control), while nonadherence is best defined as gaps that occur because of unilateral and intentional decisions to alter therapy."
Not only should medication compliance and medication adherence not be used synonymously, but some healthcare organizations and professionals have argued over the past several years that healthcare professionals should stop using the term medication compliance when speaking about patient regimens.
Here are the reasons in support of moving away from medication compliance from a few such organizations and professionals:
Epilepsy Foundation: " … the word compliance puts the focus on what the doctor says, and not what the person does. People feel that they are being 'blamed' with the word compliance. This term also doesn't consider all the different reasons why a person may not be able to take the medicines as prescribed. The term 'medication adherence' is a better term to describe if a person can adhere or keep to a certain schedule. It doesn't have the blame or stigma attached to it."
APhA: "The terms 'medication adherence' and 'medication compliance' are often used interchangeably in healthcare. 'Medication adherence' is typically preferred because the term 'medication compliance' suggests a passive following of provider directions and implies that the patient was not involved in developing the treatment plan."
Drs. Denise Bentley and Jacob Potts of FreseniusRx: Clinical practice has shifted away from the term 'compliance,' with clinicians now favoring 'adherence' as an alternative. Adherence is the extent to which patient behavior aligns with clinical decisions that were mutually decided upon by the patient and provider. 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."
Medication Compliance: Where Do We Go From Here?
The points raised by these organizations and professionals are valid and important to acknowledge. To improve the delivery of care, we migrate away from a culture that blames patients and toward a culture that focuses on patient engagement.
As noted, Cureatr has blogged about medication compliance and will continue to do so. It remains a widely used term representing a significant challenge for healthcare providers.
With that said, we will work to do so in a manner that avoids criticizing patient actions. Rather, we will focus on actions providers can take to reduce noncompliance and nonadherence through mechanisms such as enhanced care coordination via strengthening patient engagement and participation in the delivery of care. Hopefully we can play a role in supporting the shift toward patient empowerment as noted by Drs. Bentley and Potts.