Interventions for enhancing adherence to prescribed medications

Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X

Published Online:

October 8, 2008

Many people do not take their medication as prescribed. Our review considered trials of ways to help people follow prescriptions. For short-term drug treatments, counseling, written information and personal phone calls helped. For long-term treatments, no simple intervention, and only some complex ones, led to improvements in health outcomes. They included combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement, family therapy, psychological therapy, mailed communications, crisis intervention, manual telephone follow-up, and other forms of additional supervision or attention. Even with the most effective methods for long-term treatments, improvements in drug use or health were not large. Several studies showed that telling people about adverse effects of their medications did not affect their use of the medications.

Abstract (click to read)

Background:

Objectives:

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search strategy:

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria:

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis:

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results:

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions:

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

This record should be cited as:

Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub3

Assessed as up to date:

January 31, 2007

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are interventions for enhancing medicine adherence?

Bottom line:

For short term treatments, several interventions improved adherence, including counselling, written information and personal telephone calls, but the effects were inconsistent from study to study, with only 4 of 10 interventions reporting benefits for both adherence and clinical outcomes. For long term treatments, no simple intervention, and only some complex ones, led to improvements in health outcomes.These included combinations of more convenient care (eg, provision at home), more thorough patient instructions, counselling, information, reminders, close follow-up, supervised self-monitoring, rewards for success, family therapy, couple-focused therapy, mailed communications, crisis intervention, manual telephone follow-up and other forms of additional supervision or attention.

Caveat:

Short term treatments were limited to acute infections. Long term treatments included those for hypertension, hyperlipidaemia, asthma and/or chronic obstructive pulmonary disease, epilepsy, ischaemic heart disease, heart failure, rheumatoid arthritis, diabetes,TB, HIV infection, schizophrenia and depression. Even with the most effective methods for long term treatments, improvements in drug use or health were not large, considering the amount of effort and resources they can consume. Several studies showed that telling people about adverse effects of their medications did not affect their use of the medications.

Context:

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but might also increase their adverse effects.There are many reasons for non-adherence, including (but not restricted to) problems with the regimen (such as adverse effects), poor instructions, a poor provider-patient relationship, poor memory, and the patient's disagreement with the need for treatment or inability to pay for it.

Cochrane Systematic Review:

Haynes RB et al. Interventions for enhancing medication adherence. Cochrane Reviews 2008, Issue 2. Article No. CD000011. DOI: 10.1002/14651858.CD000011.pub3. This review contains 9 trials of short term treatments and 69 trials of long term treatments, involving a total of 12,633 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Consumer & communication strategies > Enabling consumers to know about their health & treatment

Consumer & communication strategies > Improving care co-ordination or integration or the total care package

Consumer & communication strategies > Preventing or managing adverse events of treatment & disease complications

Consumer & communication strategies > Promoting acquisition of skills and competencies

Consumer & communication strategies > Providing personal or peer support to manage health & treatment

Consumer & communication strategies > Supporting health, treatment, or management behaviours

Cochrane Summaries

Independent high-quality evidence for health care decision making

Interventions for enhancing adherence to prescribed medications

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