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OBJECTIVES

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Objectives

  • Define medication adherence.

  • Describe the scope and consequences of poor medication adherence.

  • Summarize the patient, clinician, and system factors that contribute to poor medication adherence.

  • Describe clinician–patient communication strategies to assess and promote medication adherence.

  • Identify interventions to promote medication adherence.

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INTRODUCTION

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Mr. Cruise is a 55-year-old janitor who left his job 1 year ago because of worsening heart failure, hypertension, and diabetes. He manages to keep his regular appointments with his cardiologist and primary care physician, but over the past year, he has been hospitalized four times for management of his heart failure. During each hospitalization, his medical team suspects poor adherence with his medication regimen.

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Patients living with chronic disease (e.g., hypertension, diabetes, or HIV) often have complex treatment regimens and use multiple medications. Patients may find that being adherent with medications is a challenge, and poor medication adherence makes it difficult to achieve the desired goals of chronic disease management.

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The World Health Organization (WHO) defines adherence as “the extent to which a person’s behavior—taking medications, following a diet, and/or executing lifestyle changes—corresponds to agreed recommendations from a health care provider.”1 Many factors influence an individual’s ability to adhere to medication instructions and agreed upon life-style behavioral changes required to manage chronic disease. Medication adherence is an essential element to achieving positive therapy ­outcomes. Therefore, strategies focused on improving ­adherence should also strengthen the collaboration between patients, family members, caregivers, and clinicians and mitigate patient, clinician, and system barriers to adherence.

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This chapter describes the problem of poor medication adherence, and explores patient, clinician, and system factors that contribute to poor adherence. It provides communication strategies designed to identify factors that result in poor adherence, clarify the causes of poor adherence, and promote higher levels of adherence.

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SCOPE OF THE PROBLEM

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Mr. Cruise’s clinical picture is complex and his responses to his medication regimen are unexpectedly poor. He has had frequent hospitalizations for his chronic illnesses, and few of his medications seem to be working as predicted.

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Poor medication adherence is a worldwide problem and the problem is growing as the burden of chronic disease is growing.1 Studies suggest that as many as half of medical patients do not completely follow the treatment recommendations of their clinicians in developed countries such as the United States; the rates are often much lower in developing countries in Africa and Asia.1,2 Poor adherence is of particular concern among those with multiple chronic medical problems, such as HIV, hypertension, and diabetes,3,4 as well as among lower-income patients who face many barriers to adherence, including access to medications and rising medication costs.5 In resource-poor countries such as Africa, patients on antiretroviral therapy experience barriers to adherence that include food insecurity and transportation costs.6

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