‘Adherence’ relies more on an active partnership between the prescriber and the patient, while ‘compliance’ describes a passive ‘command and order’ relationship.

Compliance captures a main part of the dilemma: the prescription is hardly ever agreed upon between the prescriber and the patient. A typical dialogue is as follows:
Doctor: ‘To stabilise your chronic disease, I will prescribe ‘XYZ medication’. You should take two of these pills each day, one in the morning and one before bedtime. Any questions?’

As the patient hasn’t agreed to this treatment plan, a consequence can be non-adherence over time. As an example, published adherence for migraine treatments shows 92.6% of patients are adherent after one month, but that drops to 40.7% after two months, 30.9% after three months and is only 20.8% after six months. A community-based study of initiation rates in chronic disease medications in the US found that 20-30% of patients failed to collect their first prescription.

In clinical trials, the problem is less drastic, probably because patients seek access to experimental therapies. Compiled adherence data across 95 clinical trials found 4% non-initiation, followed by 20% of non-adherence by day 100. This data is very different from patients’ self-reported adherence. This is not a surprise because patients that received an ‘order’ want to look ‘compliant’, and report back whatever the doctor wants to hear. An analysis of self-reported versus objectively measured compliance (by urine levels of the drug) showed a complete lack of association.

‘Medication non-adherence by patients with chronic diseases contributes to 10% of hospitalisations, 125,000 deaths per year and up to $290bn in annual costs in the US’

Some characteristics determine the expected individual risks for non-adherence. All items listed below increase risks.

• Chronic therapies
• No observable benefit in prophylactic treatments or even observed side effects
• Illness factors (psychiatric diseases and dementias)
• Disruption of lifestyle, limited autonomy
• Low socio-economic status
• Living alone and having low social support
• Complex medication schema (multiple pills, multiple times a day) and number of medications to take
• Complex (or even invasive) routes of administration such as subcutaneous injections or the use of inhalers
• No perceived reward for adherence or incentives for being fully truthful (no blaming from the prescriber when not disclosing the non-adherence)
• Poor doctor-patient communications.

A first step is to match ‘adherence’ with lifestyle, expectations and goals, and come to an agreed treatment plan. A more constructive conversation than the previous example might look like this:

Doctor: ‘To stabilise your disease, I will prescribe XYZ medication. You should take two of these pills each day. Ideally, you should take one in the morning and one before bedtime. Can you manage that?’

Patient: ‘Well, I do shift work and often come home in the afternoon and then go to sleep around 5pm.’

Doctor: ‘I’m glad you mentioned that, as both pills must be taken about eight to 12 hours apart. Can you manage that?

Patient: ‘Ah, you mean I can take the pills on one day at 6am and 5pm, and on another day at 11am and 10 pm, and that is still ok? That is doable. I’ll just take them before I leave and when I get home.’

Doctor: ‘Yes, that is a good plan. How do you make sure you will not forget to take your medication when you’re in a rush?’

A true bi-directional conversation will reveal risks for non-adherence that can be addressed in prescriber-patient discussions.

Not only in clinical routine, but also in clinical research, an in-depth assessment of the patients’ reality and their ability and interest to be adherent should be done. A question that should never be missed but is hardly ever asked is: ‘How easy is it for you to regularly take medication? Would it be beneficial if we send you reminders or would that be annoying?’

That aspect can also be quantified through personality questionnaires that categorise patients based on behavioural patterns, such as those available from Cognivia and Observia.

This time investment is worthwhile. Patients who received good background information about diseases and the relevance of prophylaxis were actually 96% adherent at six months, compared to 58.5% for those patients who received no education.

How else can we help patients’ adherence? There are many supportive DHT-based digital interventions in multiple therapeutic areas. Full benefits of these digital interventions are realised when accepted by patients to ensure integration with their lives.

It starts with a simple medication plan as shown in the example below:
Once it is clear how many pills a patient has to take each day, they should be provided with an adequate pill system for all the pills they need to take.

Patients who express a concern they may forget to take the medication can benefit from digital pill systems (e-boxes) that detect when they are opened. There are also some e-boxes that send customised reminders to patients.

The next level is software packages that combine optical face recognition with digital pill or capsule recognition. The costs for such tools are prohibitive for wider use but may be of benefit in therapies at high risk for non-adherence (as listed above).

Most recently, a passive and touch-free monitoring approach of adherence (as long as the patients are at home) was proposed, using motion detectors and an analytical algorithm. However, these types of technologies are crossing the line from ‘support’ to ‘control’, which may not be accepted by some patients.