Compliance (medicine)
Compliance is the congruence of medical planning and patient action. Compliance is a generic term for the cooperative behavior of patients in the context of therapy. The Germanized name is compliance and means " therapy loyalty ". The term adherence is also used synonymously in English .
Good compliance means consistently following medical advice. According to the World Health Organization (WHO), on average, only 50% of patients have good compliance. In the chronically ill, compliance is particularly important with regard to taking medication, following a diet, or changing lifestyle . In many therapy areas with chronic diseases, after one year only about 50% of the patients are in the initial therapy. More broadly, compliance is understood to mean the willingness of the patient and his or her relevant environment to defend themselves against the disease.
Influencing factors
The WHO defines five interrelated levels that affect compliance:
- socio-economic factors (poverty, educational level, unemployment)
- patient-dependent factors (self-organization, forgetfulness, knowledge)
- disease-related factors (symptoms, perceived benefit, concurrent depression)
- therapy-related factors (side effects, complexity of administration)
- Health system and therapist dependent factors (assumption of costs, treatment options, communication)
Measurement possibilities
Measuring compliance is difficult. Technology and partnership can help. There is no standard for it. The measure of compliance is an estimate of the patient's current behavior. Measurement methods:
- Diagnostics in vitro (blood sampling)
- MEMS (electronic monitoring of the removal of capsules / tablets from a container)
- Pill counting, calculation of drug availability over time
- Control of drug purchases
- Self-declaration (clarification by means of questions / questionnaires)
- Assessment of the doctor / pharmacist (overestimation, answers according to social desirability)
- Relatives / Outside Nursing Report
- Monitoring the intake (drug withdrawal programs, treatment of tuberculosis)
Measurements always reflect current behavior at a certain point in time and are not continuous with the exception of MEMS or the directly observed intake. This means that adherence to therapy can change over time and under various influencing factors. Compliance is often expressed as a percentage. In many therapeutic areas, compliance is said to be good if 80% or more of the planned dose has been taken over the observed period of time. It should be noted that compliance can range from zero to over 100% - 'over 100%' means that the patient has taken more medication than planned.
Non-compliance
Failure to comply with medical advice and non-fulfillment of therapeutically necessary duties is referred to as non-compliance . A distinction is often made between unintentional and intentional non-compliance. Unintentional non-compliance is most common. The reasons for this are diverse. The main reason, according to patients, is their forgetfulness. In addition, inconvenient intake, side effects, stress or costs can be the causes of non-compliance. Other important reasons are insufficient information or insufficient understanding of the disease and the possibilities and effects of the drugs. In addition, there are often attitudes and beliefs that can hinder the consistent implementation of the recommendations. In the case of many chronic diseases, a lack of symptoms can also lead to not following the therapy consistently. A lack of implementation of agreements with the doctor does not only occur in relation to the medication. Reducing risk factors such as obesity, smoking or lack of exercise is an important contribution to improving health and extending life expectancy. The implementation of the doctor's recommendations in these areas is difficult for many people, requires insight, the removal of barriers and often also the use of Professionals.
Insufficient implementation of the therapy plan can, depending on the underlying disease, be associated with an increased risk of death, more symptoms and a lower quality of life. A direct connection between mortality and the reliability of taking medication for statins and beta blockers in patients after a heart attack could be demonstrated. In addition to the reduction in life expectancy and increased disease symptoms, there are also unnecessary treatments and the associated costs. A certain number of hospital stays are caused by inadequate implementation of therapy plans.
The number of non-compliant patients is particularly high in neurology and psychiatry . In patients with schizophrenia , depression , epilepsy or multiple sclerosis , the non-compliancer rate is 50 percent. According to the Psychiatric Clinic of the Technical University of Munich , every second admission to psychiatry could be prevented if patients did not stop taking their psychotropic drugs on their own initiative. But also in the other disciplines about a third of the patients do not follow the therapy plans or do so incorrectly. According to the World Health Organization, poor compliance is a major global problem affecting all therapeutic areas.
A major factor in insufficient adherence to therapy has been identified in various studies today as inadequate communication in the doctor-patient relationship due to an unsuitable, detached medical language and a correspondingly low level of persuasiveness on the part of doctors. According to RM Epstein, a considerable number of doctors (43%) still practice an outdated asymmetrical, so-called “ paternalistic ” doctor-patient relationship. However, the resulting prescription, which is primarily based on authority, no longer works for many patients today. The more recent medical training is therefore in the process of taking into account the old demands for an improvement in the communication skills of prospective doctors through appropriate curricula and textbooks and to work on the corresponding deficits in medical training.
Funding attempts
Measures to promote compliance should be tailored to the reasons for the lack of compliance. It makes sense for the doctor, pharmacist and patient not only to talk about the diagnosis, the therapy plan and medical support, but also about the implementation of the therapy plan and the patient's ability to organize himself. It should also be clarified which risks exist in the event of non-compliance. B. Forgetfulness could be the most common reason and what measures help to avoid non-compliance and recurrences . For example, when taking medication that is difficult to anchor in the daily routine, measures should be sought to ensure that the medication is taken at the right time in the correct dosage. This should be taken into account, especially with drugs for which the time of ingestion is important for the effect (Parkinson's treatment, antibiotics, HIV drugs, immunosuppressants).
Possible measures include:
- Attention to the problem of poor adherence to therapy
- Information about the illness, medication and the importance of taking medication regularly
- Simplifications of drug therapy
- Frequency of intake
- Combinations
- Organizational aids to make it easier to take:
- Pill boxes
- calendar
- Anchoring in the daily routine (pack in toothbrush cup, magnet / adhesive on the refrigerator, alarm clock)
- Reminder aids in electronic calendars
- Compliance reminder systems: SMS reminders on mobile phones
- Monitoring
- Self-measurement (high blood pressure, glucose values, weight)
- MEMS (electronic measurement of tablet removal from container) - can only be organized at home
- Measurement of blood values (HbA1c, cholesterol) at regular intervals by a doctor or pharmacy
- directly observed intake (e.g. methadone program, tuberculosis treatment)
Psychological factors
The patient contributes to increased compliance when he
- is convinced of his general susceptibility to disease,
- considers himself particularly susceptible to his illness,
- realizes the seriousness of his suffering,
- believes in the effectiveness of the therapy,
- is satisfied with the medical care,
- is supported by his relatives in his observance behavior,
- does not dare not to follow the advice of the therapist and
- is aware of his weaknesses in his self-organization and seeks support.
Furthermore, adherence to therapy can be improved through psychoeducation .
Factors in the environment
The doctor should tailor therapeutic instructions and strategies to the patient's capabilities and wishes. For example, it is advantageous to prescribe combination preparations in long-term drug therapy that only have to be taken once a day instead of giving half or even quartered tablets several times a day.
Easy-to-open packaging and preparation for daily intake by sorting it into a pill box or dispensing medication in prepared individual packs ( blisters ) can also be helpful here . Electronic systems for monitoring tablet removal and for acoustic or visual reminders to take medication are also used.
In 2003, representatives of the pharmaceutical and packaging industry as well as patient organizations founded the non-profit organization Healthcare Compliance Packaging Council of Europe to support patients in taking medication through intelligent packaging design.
See also
literature
- Viviane Scherenberg: Patient Orientation - Compliance and Disease Management Programs. Publishing house for science and culture (2003).
- Adherence to Long-Term Therapies: Evidence for Action . WHO Report 2003
- Lars Osterberg, Terrence Blaschke: Adherence to Medication . In: NEJM , 2005, 353, p. 5.
- E. Battegay, A. Zeller, L. Zimmerli: Drug Adherence in Cardiovascular Risk Patients . Bremen 2007.
- So that drugs work - what you can do yourself! - The interactive knowledge page with illustrations by Werner Tikiüstenmacher - www.damit-arzneimittel-haben.de
Web links
Individual evidence
- ↑ Wolfgang Miehle: Joint and spinal rheumatism. Eular Verlag, Basel 1987, ISBN 3-7177-0133-9 , p. 173.
- ↑ a b WHO Report 2003
- ↑ Freyberger (Ed.): Compendium Psychiatrie, Psychotherapy, Psychosomatic Medicine . 11th edition. Karger, Basel / Freiburg (Breisgau), Paris / London / New York / New Delhi / Singapore / Tokyo / Sydney 2002, ISBN 3-8055-7272-7 , pp. 412 ( books.google.de ).
- ↑ Poor compliance is fatal. MMW update Med. No. 5/2007 (149th year), p. 22; quoted from JN Rasmussen et al., JAMA, 297 (2007) 177-186.
- ↑ Stephanie Müller, Werner Kissling, Michaela Stiegler: Financial incentives to promote compliance. In: Psychiatric Practice. 36, 2009, p. 258, doi: 10.1055 / s-0029-1220399 , quoted from SZ of January 26, 2010, p. 16.
- ↑ Julia A. Glombiewski, Yvonne Nestoriuc, Winfried Rief, Heide Glaesmer, Elmar Braehler, Richard Fielding: Medication Adherence in the General Population. In: PLoS ONE. 7, 2012, p. E50537, doi: 10.1371 / journal.pone.0050537 .
- ↑ M. Härter, A. Loh, C. Spies (Eds. :) Decide together - treat successfully. Deutscher Ärzte-Verlag, Cologne 2005.
- ^ RM Epstein: Physician self-disclosure in primary care visits. Arch Intern Med 167, 2007.
- ↑ Linus Geisler: Doctor-patient relationship in transition. Strengthening the dialogical principle. In: Final report of the Enquête Commission "Law and Ethics of Modern Medicine". May 14, 2002 pp. 216-220.
- ↑ Sascha Bechmann: Medical communication: Basics of medical conversation. University paperbacks UTB, Tübingen 2014.
- ^ JC Heneghan: Reminder packaging for improving adherence to self-administered long-term medications . The Cochrane Collaboration, Cochrane Reviews.
- ^ Website of the Healthcare Compliance Packaging Council of Europe