Oſten, compliance is also used and the two can be used interchangeably in research and clinical practice . It describes “the extent to which the patients’ behavior (including medication-taking) coincides with medical or healthcare advice”, yet its meaning has become more negative regarding patient’s behaviors, since it implies patient’s passivity.
Nevertheless,measurement of medication adherence can be quite challenging since and parameters of acceptable adherence need to be carefully delineated and appropriated for individual situations. There are numerous tools available for these measurements, but these need to prove to be valid, reliable, and sensitive to change. The selection of a method to monitor adherence should be based on individual attributes and goals/resources of the study or the clinical setting. Currently none of the available methods can be considered as a gold standard and the combination of methods is recommended.
Objective measures include pill counts, electronic monitoring, secondary database analysis and biochemical measures and are thought to represent an improvement over subjective measures. As such, objective measures should be used to validate and correlate the subjective ones. However, a meta-analysis on adherence outcomes states that a multi-subjective-measure approach may have higher sensitivity, but not accuracy, over employing a single objective measure. In summary, subjective and objective measures have both advantages and disadvantages and should be used in combination.
The Medication Events Monitoring System (MEMS) is the most commonly used EMP device in medication adherence studies.
Studies show that approxi- mately 25% of all prescribed doses are omitted by patients.
This was in 1999 more recent studies say 50% are non adherent. like the study below:
Who. Defining adherence. Who. 2003;:1–28. www.who.int/chp/knowledge/publications/adherence_report/en/?
No single intervention is totally effective for all patients and it is not yet possible to predict which individual or subgroup actually needs a given intervention.
Patients also are reluctant to admit non-adherence unless clinicians make specific efforts to monitor the degree of adherence on a regular basis.
Studies have demonstrated that MEMS is more accurate than other available methods and is therefore considered the ‘‘gold standard’’ of adherence measurement. Despite these advantages, this tool has not yet been applied widely due to its cost and other practical issues that limit its use in large studies and routine clinical practice.[Top]
Although poor adherence is directly linked to patient behavior, there is no definitive data that has defined a ‘non-adherent’ personality or revealed a relationship between adherence and the ability to follow self-care or lifestyle recommendations.14 Likewise, medication adherence has not been shown to be correlated to demographic variables such as age, gender, or race, although there is a weak relationship with lower education and income levels. There are many variables that can be factored into adherence behavior outside of demographic variables that have greater utility as a predictor of medication adherence behavior. Table 1 categorizes the predictive strength of consumer-related variables (and their interaction within the health care system) as they are presented in the literature.
Moreover, the decision to be adherent is unique for each medication, and driven by three factors: (1) the perceived need for the medication (related to their understanding of the disease and therapy): (2) the perceived concerns about the medication (related to side-effects and safety); and (3) the perceived medication affordability.
National Consumers League’s Approach
The National Consumers League has launched a medication adherence awareness campaign entitled “Script Your Future”. The multiyear effort focuses primarily on patients affected by diabetes, respiratory disease, and cardiovascular disease. It is a powerful campaign that educates the consumer that poor medication adherence can lead to consequences that affect their ability to take care of themselves and their loved ones, places undue emotional and financial burden on family members, and jeopardizes the ability to experience future family events and milestones. The campaign also encourages patients and health care professionals to better communicate about ways to improve medication adherence.
Physicians, particularly primary care physicians (PCPs) and other specialists that write prescriptions for chronic diseases, can play a key role in addressing medication adherence given that they represent the initiation of the prescription process and have the opportunity to develop a trusting relationship with the patient.
Ten health conditions were found in the included studies. Seven of these ten health conditions had at least one study reporting benefit from the use of a PHR: asthma, diabetes, fertility, glaucoma, HIV, hyperlipidemia, and hypertension. Diabetes was the most studied condition with eleven of twelve studies showing benefit. Three conditions had studies that meth the criteria but did not show benefit of the PHR: cancer, idiopathic thrombocytopenic purpura (ITP), and multiple sclerosis.
70% of studies (16/23) reported benefits associated with PHR use.
However, there is no evidence that any study of the above provided evidence of better medication adherence or at least persistence.
Self-Manage Care – Using the PHR to make day-to- day decisions about care management, such as medication dosing, food choice.
This is the only grounds that medication intake was improved.
These conditions include: diabetes, hypertension, asthma, HIV, fertility management, glaucoma, and hyperlipidemia. Benefits were seen in care quality, access, and/or productivity. These conditions share several common characteristics: Each of these conditions is chronic. They have a significant benefit from self-management through behavioral changes. Many have an aspect of monitoring, either from the clinician or the patient (self-monitoring). Self-management is present in all. The seven conditions were conditions where the self-management behaviors could be suitably tracked in a PHR and were tightly linked to the feedback of monitoring/self-monitoring of indicators (Figure 3). For ex- ample, self-monitoring blood pressure in hypertension or glucose levels in diabetes allowed for more specific and direct feedback to patients using a PHR.
Health information systems (HIS) have potential to increase efficiency and save considerable amounts of health expenditure.
Current rates of adoption of health information technology are low and health information systems are under-utilized.
Kaplan notes that “there has been a long history of difficulties in achieving clinical use of some kinds of clinical informatics applications. ” Within this context, it is imperative that HIS implementation is evaluated and features of successful implementation identified.
Eysenbach summarizes the goals of technology in healthcare, suggesting that eHealth should be: (1) Efficient, thereby decreasing costs, (2) Enhance quality of care, (3) Evidence based, proven by rigorous scientific evaluation, (4) Empowering for consumers and patients, (5) Encouraging a partnership relationship between patient and health professional, (6) Educate physicians and consumers, (7) Enabling information exchange and communication in a standardized way between health care establishments, (8) Extending the scope of health care beyond its geographical and conceptual boundaries, (9) Ethical – e-health involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues, and (10) Equitable. Haux identified seven general tasks of HIS over time. These are : (1) to move paper-based processing and storage to computer-based; (2) to move from local to national and global HIS; (3) to include patients as HIS users; (4) to use HIS data for healthcare planning, clinical and epidemiological research (aside from patient care and administration); (5) to change the focus from technical aspects of HIS to management change and strategic information management; (6) to place more emphasis on image and molecular data; and, (7) to acknowledge the steady increase of new types of technologies, perhaps as yet un-imagined.
The reasons cited in favor of the implementation of HIS are primarily around efficiency, cost, quality and safety.
No matter how success or failure is defined (if it is) the evidence of effectiveness is generally weak and inconsistent. Information systems of all types notoriously fall short of their expectations and fail to deliver benefits (see for example, Gauld and Goldfinch. Shpilberg et al. reported that only 15% of business executives surveyed believed that their company’s IT capability was highly effective, ran reliably, and delivered projects with promised functionality, timing, and cost. Systematic reviews of healthcare settings consistently find that there is little evidence that care provided by technological innovations is any better than traditional methods. Whitten’s systematic review of HIS cost-effectiveness found that there is no conclusive evidence that telemedicine is a cost effective way of delivering healthcare. Mistry reviewed the cost-effectiveness literature ten years later and concluded that the results of their review were consistent with previous findings: there is no further conclusive evidence that technological interventions are cost effective compared to conventional healthcare. However, it is also the case that these reviews noted methodological shortcomings in studies evaluating cost effectiveness. These were particularly around the amount of methodological detail provided and the methods used to measure cost effectiveness.
Effective evaluation allows us to understand how and under what conditions HIS work, and determine the safety and effectiveness of the system. Evaluation can provide guidance to the implementation process and mitigate unplanned negative outcomes. Ammenwerth defines evaluation as “the act of measuring or exploring attributes of a health information system (in planning, development, implementation, or operation), the result of which informs a decision to be made concerning that system in a specific context.” This should include the inevitable organisational change which accompanies the implementation of HIS. Early approaches to evaluation focused on the “measurement of changes in processes and of the consequences of these changes” while more recently attention has been paid to the complex, iterative and multidimensional implementation process. Effective evaluation accompanies the whole life cycle of HIS, evaluating technology against a comprehensive set of measures throughout all stages. Measuring the success of HIS is not straightforward and the challenges in the organisation and setting of HIS make both implementation and evaluation of the HIS difficult. Evaluation processes are also often flawed.[Top]
This is a very important paper!
Although the term compliance has been in use for the longest period of time, nowadays it is considered that it is not entirely adequate and that changes in the relation between patients and healthcare professionals must be taken into consideration. Patients’ status is no longer submissive and passive and their role in accomplishing therapeutic objectives does not only imply compliance with medical instructions but active cooperation and agreement with a doctor and a pharmacist. Due to these reasons the term adherence has become more desirable in practice since the 90’s of the 20th century.
Differences between compliance and adherence are thus not only in the semantic sense but of essential nature. While in compliance the focus is on the healthcare provider who has a dominant status in relation to the patient, the concept of adherence is oriented to the patient and cooperation. In relation to this, the flow of information is one-way and the objective is to achieve obedience of the patient, while adherence implies a two-way information transfer and engagement of both subjects.[Top]