When patients fail to follow treatment recommendations made by their physicians, problems in clinical care can result. Nonadherence (also called noncompliance) typically involves, among other things, patients taking medications incorrectly or not at all, forgetting or refusing to make essential behavioral changes for their care, and persisting in behaviors such as smoking and high-risk sexual activity that jeopardize their health. As a result of their failure to adhere to recommended treatments, patients might become more seriously ill, and treatment-resistant pathogens may develop. Failing to recognize patients' nonadherence may prompt physicians to adjust medication dosages, and to be misled in their diagnoses. Practitioners and patients become frustrated by nonadherence, and the time and money spent on medical visits is wasted.
A great deal of research on nonadherence shows that although its prevalence varies with the type of regimen prescribed, at least a quarter of patients on average fail to adhere. Rates of nonadherence are quite high for long-term medication use in chronic disease (40–50%) and for lifestyle changes such as exercising or ceasing tobacco use (more than 75%). Adherence to treatment is most problematic when patients are quite ill with serious medical conditions (such as cardiovascular disease and end-stage renal disease) and their lives depend upon following complex treatment recommendations. Many of the regimens for these conditions are multifaceted and can include numerous medications with intolerable side effects, difficult dosing schedules, and restrictions on diet and activities. When patients are severely ill, frustration, pessimism, depression, cognitive deficits, and limited availability of social support may combine to threaten patients' continued adherence to treatments designed to manage their diseases.
It is important that both primary and specialty care providers recognize the potential for nonadherence among all patients, and avoid being judgmental toward them. Following medical treatments correctly can interfere with patients' quality of life and serve as constant and disturbing reminders of the illness. Patients need emotional and practical support, information, and guidance in order to be adherent; patients typically do only what they understand, believe in, and are able to do. The most important ingredients in achieving patient adherence are effective communication and patients' informed collaboration with their physicians.
Nonadherence is often difficult to recognize (Table 17–1), but should always be considered whenever a patient is not responsive to treatment or when the clinical picture is confusing and does not appear to make sense. Rarely do patients readily admit to having difficulties following their treatment regimens, and few patients tell their providers that they have no intention of following recommendations. Patients may weigh their physician's recommendations against their own beliefs and what they have learned from other sources, and may reject recommendations if the benefits of adhering do not appear to outweigh the interference in their quality of life.
Table 17–1. Typical clues to nonadherence.