By Christy Lyon
Illustration by Malcolm Garris/PhotoDisc
July 20, 1998

The nation is expected to spend about $71.6 billion on outpatient prescription drugs this year, according to a pharmaceutical industry group. Yet, some of the people who need their medications the most just don’t take them.

Experts on compliance issues estimate that only 50 to 75 percent of all patients take their medication as prescribed. Thirty to 40 percent are "partial compliers," people who forget doses or stop taking their medication after they feel better, and 10 to 20 percent are "noncompliers," those who ignore their regimens completely, according to Nancy Houston Miller, RN, associate director of Stanford University’s Cardiac Rehabilitation Program in Palo Alto, California.

Some of the most serious consequences of noncompliance made news this month at the 12th World AIDS Conference in Geneva, where researchers attributed new, drug-resistant strains of HIV to patients who don’t properly follow their complex medication regimens. And the long-term misuse of antibiotics has given rise to forms of previously treatable diseases that are impervious to the most advanced medications.

We pay a high price for noncompliance, too. The National Pharmaceutical Council estimates that noncompliance costs more than $100 billion a year in increased hospital and nursing home admissions, lost productivity, and premature deaths.

What’s the problem?

Noncompliance cuts across all categories of patients and illnesses. People with breast cancer, organ transplants, and hypertension, as well as people on a short course of antibiotics, can all forget to take their medications. Researchers have identified more than 200 variables that affect whether a patient will be compliant, according to Miller. Compliance rates are also likely to decline over time, especially for patients with asymptomatic diseases, she said.

"You can know a lot about your disease and the importance of taking your medication, but that doesn’t mean you’ll do it," said Joyce Cramer, a researcher at the Yale University department of psychiatry.

"Most patients intend to be compliant, but they frequently don’t understand instructions, or they can’t afford the medication," said Anne Schneider, LMSW, a manager in the division of patient social services with Kelsey-Seybold Clinic in Houston. It’s up to nurses and other healthcare professionals to examine the reasons patients may not be compliant, Schneider said.

Simple forgetfulness can be a big factor in noncompliance. Or people may not take their medication because they don’t understand how important it is, are embarrassed to discuss side effects like constipation or impotence, or feel uncomfortable taking medications in front of others. Still other reasons: cost, inconvenience, or denial of the disease process.

Never assume

Judith Kelly, RN, a certified rehabilitation nurse at Roper Hospital in Charleston, South Carolina, and chair of the Association of Rehabilitation Nurses’ staff nurses special interest group, always asks her patients to bring in all their medications and tell her what each is for and when it should be taken. That way, she can sense if the patient has been taking his or her medication. Then, with the patient and the physician, she goes over the list to make sure all the medications are still needed.

If you find that a patient is noncompliant, ask why he or she hasn’t been taking the medication—and then work with the patient to solve the problem. Showing patients how many doses they’ve missed is often enough to get them back on track, Cramer said. "Many times patients have no idea that they’ve missed so many."

Tips for success

One of the most important parts of a patient’s willingness to discuss compliance issues with providers is trust, said Cathy Martin, RN, a clinical nurse specialist with Kelsey-Seybold. "It’s important to build a rapport with patients and their families," she said. "It’s very difficult for a patient to say, ‘I can’t afford this’ or ‘I can’t remember when to take it.’ "

Nurses should try to anticipate barriers to compliance and help patients think about ways they can be more compliant, Miller said. Every visit offers an opportunity to find out whether patients are taking their medication regularly.

Compliance is often better when patients are given written information to take home about their treatment plan and instructions on taking their medications, Miller said. Other traditional approaches also work, such as keeping patients updated on the status of their condition, praising patients for improvements, having patients repeat instructions, and ensuring that patients understand and agree with their health status assessment.

Have a plan

Nurses also should ask patients how they plan to remember to take their medication, Cramer said. While it’s easy to just tell patients their medication schedule, they will have better compliance rates if the practitioner helps them develop a mental link between the medication and another activity. For example, Cramer suggests that patients link their medication times to brushing their teeth, blow-drying their hair, putting in their contact lenses, or walking the dog.

It’s a good idea to have compassion, too, said Connie Highsmith, RN, a nurse case manager at Isaac Coggs Community Health Center in Milwaukee. "I struggle to remember to take a multivitamin every day," she said. "How can we ask patients to take a complicated regimen without any problems?"