What do we mean when we talk about Medication Noncompliance, Adherence, and Persistence?
Language matters. For many patients the words compliance, adherence and persistence are all loaded terms. But for those of us working in the pharmaceutical patient support space, we need consistent accurate terminology.
Medication Adherence is “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.” No overarching term combines these two distinct constructs.’
– Kramer et al, 2008
Medication adherence refers to the extent to which one sticks with the timing, dosage and frequency of a prescribed medication
Persistence is the extent to which you continue the medication for the duration prescribed
Compliance is out. Adherence is in.
Compliance and adherence are synonyms that refer to the actions people take to fulfill their treatment plan on a daily basis, such as taking medication, completing lifestyle activities and self-care activities. But the word compliance seems to be on the way out because of the connotations that a “compliant” patient is submissively complying with orders.
Compliance, as a pejorative word has its roots in public health campaign from the 19th Century, where health officers were to be obeyed and rules were to be complied with.
Today, we see health through a new lens of collaborative care—where the patient is an active participant in decision making related to treatment and care. In the #HCHLITSS Tweet Chat on the topic, many patients said they disliked both adherence and compliance as terms. One respondent raised a good point—“Why not just say medication taking? It is naming the behavior without judgement.”
Adherence vs Persistence
If we think of medication adherence as taking our medications on a daily basis, as prescribed, persistence is about taking it day after day, until the prescription is done.
For people with chronic illnesses, the challenge to increase persistence is often the greatest one. It is a common story that once someone starts to feel better they cease to persist in taking their medication. They may give themselves permission to “take a break”, either to save money, or relieve themselves from the side-effects for a while, or they may just not be convinced that the medications are helping.
The opposite of persistence, attrition refers to the loss over time of adherent medication consumers. Attrition can be the result of many factors, and it is often a combination of a few:
· Patients feel better (or their illness is asymptomatic),
· They had unrealistic expectations and are disappointed in the immediate results,
· They may feel the side effects outweigh the benefits,
· Financial barriers,
· They forget to refill or it’s inconvenient to do so,
· Their self-concept doesn’t fit with “being on medication”.
Added to our terminology we have “switching”, which is particularly of interest to pharma marketers. Here a patient may be compliant, adherent and persistent, just not on the same medication they started with. They have switched their loyalty to a generic, another brand or another closely-related therapy.
Medication Noncompliance: Falling off the The Adherence Cliff
We see patterns in the patient journey, as people move from diagnosis to first prescription (Rx), to first fill, daily adherence, persistence and second fill or switching. At each sign post, we see patients “leaving” the ideal path.
Click on the image below to view The Adherence Cliff.