Dr Benjamin Disney, Consultant Gastroenterologist, University Hospitals Coventry and Warwickshire NHS Trust, talks about patient adherence and how clinicians can tackle this issue with their patients.

That patients will adhere to their prescribed therapies is something that many healthcare professionals (HCPs) take for granted. Yet, the reality is that between a third and a half of all medicines prescribed for long‑term conditions are not taken as recommended in the UK. [1] Poor adherence to to prescribed therapy – whether medication or a device (e.g., transanal irrigation) – is linked with poor clinical outcomes. By compromising the effectiveness of the treatment, poor adherence also leads to increased demand for healthcare due to lack of improvement or deterioration of the condition. The World Health Organization (WHO) considers poor adherence to treatment of chronic disease ‘a worldwide problem of striking magnitude’[2] and improvements in this area could undeniably have a significant positive impact.

What causes poor adherence?

To address the issue, we must first understand the elements that influence adherence. These can be split into intentional and unintentional causes and include: the therapeutic alliance; perceived lack of control; risk of dependence on medications; stigma associated with medication use; and lack of knowledge, education and support. Successful adherence comes from providing support to the patient throughout the entire process, from assessment to establishing long-term use of the treatment.

This is particularly important for patients with bowel dysfunction who may be reluctant to discuss their symptoms and have a tendency to ‘self-help’ and delay seeking medical help. Symptoms are often intermittent for bowel conditions, and patients may be tempted to avoid the issue when symptoms temporarily abate. Furthermore, treatment for bowel conditions can include strong medications and invasive treatments, which can interfere with some aspects of daily life and therefore discourage patients from sticking to their regime. Yet, the longer patients wait to seek treatment, the more the condition can worsen, leading to extended treatment times. This is further exacerbated by current difficulties in accessing primary and secondary care,[3] and more recently by COVID-19’s impact on waiting times to see specialists.

Tackling non-adherence

   1. Communication, time and empathy 

Crucially, non-adherence should not be seen as the patient’s fault: adherence must be a partnership between patient and HCPs. Receiving adequate support from HCPs is vitally important, especially during those first few months of beginning a new treatment. HCPs should aim to help patients make informed decisions about their own treatment and should ensure that all information is accessible. It helps to provide clear and complete information about the benefits and adverse effects of available therapies or medical devices, including alternatives to the treatment or device that is chosen. Explaining the rationale behind the selection of a treatment – such as improved symptoms – is crucial, as well as setting expectations for side effects and speed of improvement. Finally, any adjustments that may be needed during treatment should be made clear to the patient from the onset, so that they are not taken by surprise.

    2.Treatment ownership

By providing this in-depth information, patients can have a sense of ownership of their treatment and feel more motivated to adhere. Having a motivation to adhere will make patient adherence more likely than if patients are merely passive recipients of advice. This investment of time is worthwhile since informed and empowered patients are more likely to stick to their medication regime or device treatment plan. Similarly, involving patients in prescribing decisions and adapting consultation style to the individual can help HCPs to establish how involved their patients would like to be in decision making. Patients may also require some support in implementing adherence strategies, for instance setting up reminder applications or alarms on their phones.

   3.Tailored interventions

Adopting an open, no-blame approach encourages patient engagement, enabling them to discuss their concerns about treatment. In turn, this helps HCPs to understand and anticipate any factors which could stop them taking their medicine. A strategy that works for one patient may not be so effective for another so assessing each case on an individual basis is a good approach. The more tailored interventions are to the patients and their specific difficulties, the better.

   4.Follow-ups 

After initial advice and prescription is delivered, regular follow-ups should be carried out. This can be carried out more easily through teleconsultation, particularly with patients accustomed to this format due to the COVID-19 pandemic. HCPs can recommend that patients keep a treatment diary where appropriate, in which they track their symptoms and any treatment side-effects. Catch-up sessions also provide patients with an opportunity to report back on their experience and HCPs to personalise the therapy if necessary.

With healthcare systems under increased pressure due to the pandemic, strengthening adherence to improve patient outcomes and prevent condition escalation should be given more attention. HCPs can play a greater role in optimising adherence for their patients. For the strategies outlined above to work, a joined-up approach is best – whereby patients receive coordinated support from healthcare professionals and organisations. The shift to integrated care systems in the NHS will help foster this consistency throughout the patient journey. Tackling non-adherence will require some investment of time and resources from HCPs and healthcare organisations, however, the widespread benefits that stem from improved adherence will make it worthwhile from both a patient quality of life and a health economics perspective.

For further information and resources for treating bowel dysfunction, please visit https://bowelinterestgroup.co.uk/resources/

References

[1] National Institute for Clinical Excellence (NICE), Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, 28 January 2009

[2] World Health Organization, ADHERENCE TO LONG-TERM THERAPIES: Evidence for action, 2003

[3] The Patients Association, Pandemic Patient Experience II: From lockdown to vaccine roll-out

April 2021; The Times, A record 5.45m await routine hospital treatments, 12 August 2021