Treatment success: from adherence to observance

Adherence, treatment adherence, compliance and observance are all familiar jargon to people suffering from chronic conditions such as high blood pressure, asthma, type-2 diabetes, osteoporosis, cardiac insufficiency or high cholesterol. Even though these key notions are important for optimising treatment success, they remain difficult to apply on a day-to-day basis.

Adherence is defined as acceptance of the treatment by the patient. This implies that they have accepted their illness and understand the benefits of the treatments prescribed. Adherence can be separated into three components: acceptance, persistence and observance. When someone goes to the pharmacy with a prescription for the first time, they have accepted their treatment. If they continue with their treatment throughout the period they are supposed to take it, they have persisted with it. Finally, if they take it exactly in accordance with the dosage instructions, they have been observant. Observance means that the patient’s behaviour matches their doctor’s recommendations about a treatment programme. A patient is classed as observant if they take at least 80% of their treatment. Non-observance is frequent after three treatments.

In terms of treatment adherence, there are no “good” or “bad” patients, but favourable or less favourable situations. Non-adherence may be intentional (based on patients’ beliefs or perceptions about their illness and its treatment) or unintentional, largely because of limitations associated with the patient’s physical resources (such as problems with dexterity, mobility or memory). Non-observance can be explained by several factors: the age of the patient (observance can be difficult for adolescents but also elderly people, who are often taking multiple medications), poor understanding of the treatment, a lack of conviction about the real benefits of the treatment, forgetting, the treatment routine, taking multiple daily doses, a poor relationship with the doctor, and so on. There are solutions to address these problems: simplifying the treatment (patients need to understand their treatment fully), education (observance increases with therapeutic education: patients who are better informed about their illness and treatment follow their prescription more closely), motivation (patients whose treatment places restrictions on them can easily feel discouraged and become less diligent) and physical aids, such as text message reminders to take a dose, or smart pill dispensers, can all be effective. Around 50% of oral medicines prescribed to treat high cholesterol, high blood pressure or diabetes in France are not taken.

Morisky's questionnaire

Adherence is classed as good for people who score 8 or more, average for those who score 6 or 7 and low for those who score less than 6.

The therapeutic relationship between doctor, patient and pharmacist, all working to the same end, lies at the heart of observance

Non-observance occurs where there is a disconnect between medical recommendations and patient behaviours. Poor observance results in negative effects for the patient, including a reduction in treatment efficacy and the appearance of risks of complications or more serious relapses. In addition to the medical consequences of non-observance, it also leads to an increase in health costs. According to a 2014 study by IMS Health-France-Crip, the annual cost associated with treatment non-observance in France is more than €9 billion a year*. The direct costs come from more expensive treatments, which could have been avoided if the initial treatment had been followed. For diabetes, for example, non-observance of oral medications often leads to the rapid introduction of insulin-based treatment, and possibly some severe and costly complications including amputations, blindness, etc. Diligence is essential but observance is far from being a given, particularly for people taking multiple types of medication. Solutions such as pill boxes help patients to take their treatments correctly and avoid missed doses: Pilbox offers a wide range of daily and weekly dispensers.

Observance failures are not just the patient’s responsibility, however: doctors and pharmacists have a part to play too. Patients play an active role in treatment observance if they cooperate with the treatment proposed by their doctor based on their own lifestyle. The expected benefits can include better health results, an improvement in the quality of life and savings for individuals, the health care system and society.

Informing the patient about their illness is the first step towards implementing proper observance. It needs to be done using simple, comprehensible terms. The challenge of providing information is not only down to doctors, but needs to be shared by all health professionals. Patients need information not only about their condition and its changing risks, but also treatment objectives: the expected benefits as well as the risks and side effects of treatment. If possible, the patient’s family and friends also need to be informed, to encourage their involvement in the treatment programme. This might seem obvious, but all too often, patients and their families still seem to lack reliable information, particularly on the negative or side effects of treatment, which play a big part in adherence.

The pharmacist is one of the health professionals who is best positioned and equipped to monitor adherence to medical treatments. Although there is no perfect way of measuring adherence, there are two particularly useful methods pharmacists can use: talking to the patient and looking at their pharmacological records.

No professional, however, can simply provide medical information, a prescription and recommendations. They also need to explore the patient’s perceptions about what they have been told and assess how much of the information they have retained. In fact, patients retain on average just 50% of the information they are given by their doctor, particularly if this is confused with other information that patients themselves or their families have obtained elsewhere, primarily on the internet. Acceptance of living in society with the illness has a significant influence on following a treatment correctly. It is therefore important for both the doctor, the pharmacist and even carers to take the time needed to explain things in detail and answer all the patient’s questions.

The 6 levers for improving observance

6 levier pour l'observance


* « Améliorer l’observance, traiter mieux et moins cher », IMS Health-France and the Cercle de réflexion de l’industrie pharmaceutique (Crip), November 2014