The Link Between Medication Adherence and Patient Outcomes

The Link Between Medication Adherence and Patient Outcomes

In 2022/23, overall there were some 1.08 billion prescription items dispensed from pharmacies in England. Whilst a vast number of those drugs and treatments will be put to good use in tackling the nation’s burden of ill health, a significant proportion of what is dispensed will not be. 

Medication non-adherence – that is, when patients don’t take their medications as prescribed – is unfortunately fairly common. The World Health Organization (WHO) estimates that up to 50% of people do not take their medicines as prescribed. WHO defines medication and treatment adherence as the “extent to which a person’s behaviour, taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations from a healthcare provider”. According to guidance from the National Institute for Health and Care Excellence (NICE), between a third and a half of all medicines prescribed for long-term conditions are not taken as recommended.

Medication non-adherence can be unintentional, where a person either forgets to take a medication, accidentally takes the wrong dosage, or takes the medication at the wrong time of day. Or it can be intentional, where a person may consciously decide not to follow the treatment prescribed to them.

What are the main factors which influence medication adherence?

A wide range of factors influence medication adherence. These include but are not limited to:

• The type or severity of the condition or disease – if a person has minimal or no apparent symptoms, or the symptoms resolve themselves during treatment, the person may stop their treatment or alter their dosage.
• Denial – a person may not accept that they have a health issue that requires the prescribed treatment.
• Trust – this may or may not be trust in healthcare professionals, but can also be trust in the medication itself. A person may undertake, for example, online research including social media which may inform their decisions to adhere to medications prescribed. A person may also mistrust because of past experiences or take into account other people’s past experiences of the medication.
• Sociodemographic/socioeconomic variables – factors such as cultural, ethnic or religious values and beliefs can contribute to medication adherence, as can factors such as literacy and comprehension levels.
• Personality/behaviour traits – this can include not being prepared to make dietary or lifestyle changes required during medication such as abstaining from alcohol, or taking medication at a particular time of day or before or after food etc. Other behavioural factors might include skipping doses, taking medications at incorrect times or in incorrect doses, or even taking more medication than prescribed.
• Provision of clear information – this may include a lack of communication from or poor relationship with the doctor causing the person to not have sufficient information about their medication and treatment. Also, a lack of understanding of instructions given, whether verbally or in writing.
• Concerns about or experience of side effects and other unwelcome effects of medications – medication information leaflets give details of all known side effects which if not fully explained may cause a person to decide not to adhere to the medication whether or not they actually experience the side effects themselves. Also, a person may stop taking their medication because they do experience a side effect rather than contacting their healthcare provider for further advice and information. Some people have concerns about becoming dependent on a medication, which can also lead to non-adherence.
• Mental capacity – when a person lacks cognitive ability, they may require additional support to help with medication adherence. If this support is not provided or is intermittent, the person may not have the ability to adhere to the medication regime.
• Motivation – a number of factors may influence a person’s motivation to adhere to a medication regime including depression and/or feelings of negative self-worth. Some patients are also too impatient and do not wait long enough before discontinuing medication to see the results, whilst others may have low motivation to adhere to the medication regime due to a perceived lack of efficacy of the medication. This can be a particular issue for patients whose medication is life prolonging rather than a cure for their condition.
• Medication fatigue – a person who is prescribed either a long-term and/or complex medication regime often for chronic conditions may begin to feel “tired” of having to adhere to medication regimes and may either deviate from or halt treatment.
• Resource limitations – although under the NHS many people are eligible for free prescriptions, many other people on limited disposable incomes are not. The costs of medication, at present £9.65 per prescribed item, can be prohibitive for some people or prohibitive on a longer-term basis. The quarterly and annual pre-payment certificates whilst offering a reduction on single prescription charges, at £31.25 per quarter and £111.60 per year, can still be prohibitive for some people.
• Drug or alcohol abuse – this can cause a person to take their medication in a way other than their doctor has prescribed.

Some factors were generated during the Covid-19 shielding measures and have become embedded behaviours, exacerbating medication adherence issues, factors such as:

• Less contact with healthcare professionals – an increase in the levels of telephone and video appointments which can impact information disclosure and impede non-verbal communication.
• Fewer face-to-face general practitioner (GP) consultations – the availability of GP appointments does not appear to have returned to pre-Covid-19 levels.
• Increasing use of electronic prescribing, repeat dispensing and home delivery services – this relies heavily on patient self-management and motivation.
• Digital interventions supporting electronic triage and self-management – this relies heavily on patient disclosure and recognition of signs and symptoms.

For older adults, adherence to medication can be particularly challenging due to various factors, including:

• Cognitive decline – this can impact a person’s memory to either take medication or to take the correct dosage.
• The use of multiple medications and/or a complex dosing regime – this can be confusing for the patient and may lead to halting medication or taking the wrong dosage.
• Physical limitations such as mobility, visibility and/or dexterity – this can impact obtaining prescriptions from the healthcare provider and/or fulfilling the prescription at the pharmacy. Medication packaging can be difficult to open for some people and reading instruction leaflets or labels may be difficult for anyone visually impaired to any degree.
• Socioeconomic factors – although prescriptions are free to those over 60 years, some people may have little or no access to the internet, or limited disposable income for travel to medical appointments or pharmacies.
• Dependence upon someone else for support to adhere to medication – availability and/or quality of support may be an issue.

There are, however, a high number of people who simply forget to take their medication. Whilst occasional lapses are unlikely to do much harm, if these lapses become more frequent, or if the patient “double doses” when they remember, the consequences can be much worse.

How does medication adherence impact patient outcomes?

Poor adherence to prescribed therapy whether that is medication or a medical device, is linked with poor clinical outcomes, particularly in older patients. Poor adherence also leads to increased demand for further healthcare due to a lack of improvement or deterioration of the original condition. 

Non-adherence to prescribed therapy prevents patients from gaining access to the best treatment, and this may be particularly problematic in chronic medical conditions such as cancer, dementia or heart disease, for example. According to the World Health Organization (WHO), medication adherence can have a more direct impact on patient outcomes than the specific treatment itself. Medication adherence can affect quality and length of life, health outcomes, and overall healthcare costs.

A 2019 study linked good adherence with a 21% reduction in long-term mortality, and non-adherence with a 17% higher risk of hospitalisation in adults aged 50 and older.

Failing to properly manage older people’s medications is having a significant impact on their care and is making poor use of NHS resources. Older people are being admitted to hospital as an emergency from avoidable health problems including an increased risk of falls and confusion. These can follow adverse reactions to medications or be caused by unchecked prescribing and implementation of multiple medications that each cause dizziness or nausea or that affect cognition, having a serious cumulative effect. Older people can also miss out on treatment because of the burden of taking multiple medications, which can lead to them taking none at all.

Non-adherence to prescribed therapy has been found to predict poorer outcomes for mental health patients, including hospital admission, violence, suicide and premature mortality. Non-adherence to prescribed therapy can also be a risk factor for violence in psychosis. In suicide research, adherence to prescribed therapy has been identified as the ‘strongest modifiable protective factor’ against suicide in patients with bipolar disorder. 

What are the elements of medication adherence?

Adherence to medication has three elements:

• Initiation – this occurs when the patient takes the first dose of a prescribed medication.
• Implementation – this is the extent to which a patient’s actual dosing corresponds to the prescribed dosing regime, from initiation until the last dose.
• Discontinuation – this occurs when the patient stops taking the prescribed medication, for whatever reason(s).

Non-adherence to medications can occur at any or various stages of these elements, for example:

• Late or non-initiation of the prescribed treatment
• Issues within the implementation of the dosing regime
• Early discontinuation of the treatment

The doctor-patient relationship is key to the management of these elements to improve adherence to medication regimes. 

Identifying patients’ barriers to medication adherence

For some people, the barriers to medication adherence are practical difficulties such as being unable to swallow medication, unable to open the packaging due to dexterity issues, or being unable to fulfil the prescription due to difficulties getting to a pharmacy or not having internet access to order the medication online for home delivery. 

Identifying these or any other barriers to medication can be done by reviewing a patient’s ability to cope with their medication regime. Medication reviews should be performed by either the GP or practice pharmacist to optimise, clarify or simplify the patient’s medication regime. The reviewer may wish to ascertain what the patient can manage, such as:

Understanding – they are able to understand:

• Each medicine dosage instruction
• The importance of each medicine
• How to take medication
• How to take variable doses

Memory – they are able to remember to:

• Take their medication regularly and at the appropriate time
• Order their repeat medication

Dexterity – they have the ability to:

• Open medicine boxes
• Open blister strips
• Open and close child-resistant lids
• Open and close winged lids
• Grip medicine bottles
• Halve tablets themselves (if needed)

Sensory visual and auditory – they are able to:

• Read standard print labels
• Read large print labels (16- to 18-point Arial)
• Read braille labels (if the patient is blind)
• Hear verbal instructions

Swallowing – they are able to:

• Swallow all their tablets and capsules

Under the Equality Act 2010, healthcare professionals, pharmacists and dispensing practices have a duty to make “reasonable adjustments” to enable people to access and use their medications. These “reasonable adjustments” can mean any of a range of support mechanisms tailored to the specific needs of the individual. According to NHS guidelines, “any solution should be patient centred and provided in a way that supports patient capability and independence and should not perpetuate dependence and incapacity.”

Patient and healthcare system relationships

Health professionals are among the most trusted and respected groups in society, especially in UK society. The doctor-patient relationship is critical to good person-centred healthcare. When the NHS was set up in 1948, it was primarily focused on treating single conditions or illnesses, but over the following 75 years the health and care needs of the population have changed. People are living longer with multiple, complex, long-term conditions and increasingly require long-term support from many different services and professionals.

To deliver joined-up support that better meets the needs of the modern population, different parts of the NHS, including hospitals, primary care and community and mental health services, and health and social care are required to work in a joined-up way known as an integrated care system (ICS), These are partnerships that bring together NHS organisations, local authorities and others to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas.

Patient involvement is also key to these healthcare system relationships. Involving people in their care and treatment means supporting people to manage their own health and wellbeing on a daily basis. Building strong, trusting relationships between patients and healthcare professionals may then protect against non-adherence to medication and treatment. 

What are the effects of non-adherence? 

Non-adherence to prescribed medicines is one of the biggest obstacles to effective healthcare. One of the main effects of non-adherence is the waste of medication; in the UK, it is estimated that as much as £300 million is wasted every year on unused or partially used medication and is a serious and growing problem within the NHS. This figure does not take into account the countless visits to the doctor, further tests and sometimes hospital admissions and other medical costs incurred when a patient does not take their medication as prescribed.

It can also lead a doctor who assumes their patient is adhering to their prescribed medication to increase the dose or add in additional therapies when they do not see the desired effect, further adding to medical costs.

The effect of non-adherence to medication on the patient themselves can include:

• Worsening of their health condition – this is one of the biggest effects of medication non-adherence. Non-adherent patients, especially those with chronic conditions, tend to experience more symptoms, complications and comorbidities. Over time, medication non-adherence can also cause faster disease progression, often resulting in a need for prolonged, intensive care.
• Prolonged hospitalisation – hospital admissions associated with medication non-adherence are a common concern in healthcare, especially for patients with chronic conditions such as diabetes, heart failure or coronary artery disease. Poor medication adherence increases the risk of hospitalisation for many other conditions too.
• Increased doctor and/or Accident and Emergency (A and E) visits – as a non-adherent patient’s condition worsens, their likelihood of visiting urgent GP care or an accident and emergency department increases. This adds to costs for the NHS.
• Poor medication adherence has a negative effect on the patient’s family, friends and carers who witness at first hand a patient’s condition worsen.
• Adverse health effects and eventual mortality are the most severe patient effects of poor medication adherence. In most cases, non-adherence deaths are both avoidable and unnecessary.

Current strategies to improve patient medication adherence

Patient adherence has been a top priority in healthcare for quite some time. Strategies to improve medication adherence currently include, but are not limited to:

• Personalised interventions – these include face-to-face counselling and Cognitive Behavioural Therapy (CBT) to establish reasons for non-adherence.
• Adherence packs for prescription medicines – these were first introduced in the UK in the 1990s, and an estimated one million patients benefit from them as a means to delivering their personalised medication regimes. These packs organise multiple medications in an easy-to-follow format which allows patients, or their carers, to check what needs to be taken and when.
• Timed medication dispensers – these are particularly useful if forgetting to take medicine is a significant risk factor. They have a built-in timer that beeps to remind the person to take their medication. Using a timed dispenser can be useful if someone needs to take medication several times a day.
• Intelligent or SMART medication packs – these are able to record the doses being taken and if they identify that a dose has been missed, they can notify the patient, carers or healthcare provider. Smart medication adherence products (MAPs) include smart pills, pill bottles, medication organisers, and blister packaging that contain radio frequency identification (RFID) technology and track real-time medication intake. Embracing smart MAPs enables healthcare professionals to monitor patients remotely and respond to maintain or improve medication adherence.
• New technologies and innovations – the use of apps and digital technology for healthcare, and specifically for medication and therapy adherence, is a relatively recent development, but it is one that looks set to expand in the coming years. Reminder mobile apps help patients track their own medication intake, addressing memory issues and forgetfulness as barriers to adherence. Incorporating medication reminders onto smartphones has become a mainstay in healthcare, offering patients a convenient and affordable way to monitor their own medication adherence.
• Smart wearable devices (SWDs) – these feature built-in biosensors that allow real-time medication monitoring. SWDs go beyond simple medication reminders, incorporating self-reporting capabilities. Wearable devices ranging from smartwatches to patches have proven to be one of the more effective medication adherence strategies.
• Artificial intelligence (AI) – analytics and machine learning make data-driven predictions that enhance the effectiveness of patient support programmes. AI is used by pharmaceutical organisations worldwide to predict non-adherence, personalise engagement strategies, and maximise interventions for the best possible patient experience and outcomes. Healthcare organisations receive data-driven actionable recommendations for the optimal channel, messaging and timing for each patient. For example, some patients will benefit more from low-touch medication reminders via text message or mobile app, whereas others may require higher-touch methods, such as personal phone calls, to educate on the importance of medication adherence.

Final thoughts

Medication adherence can have a tremendous impact on patients’ quality and length of life, their health outcomes, and the overall healthcare costs to providers such as the NHS. With AI evolving, healthcare providers can become more successful in their efforts to improve medication adherence through the development and use of digital health technologies, as the strategies used can be personalised for individual patients and be as patient-centric as possible to achieve positive results.