Editorial N° 133

Why medication adherence
is still an important
health issue today

by R. Messina and C. Taranto, Italy


Health Economist
Centre for Studies in Health
Economics, Milan, ITALY

Roberto MESSINA,
President of Senior Italia
FederAnziani, Rome, ITALY

Thanks to an improvement in quality of life and to new technologies, the number of older people is increasing year by year in Europe and, in general, all over the world. In Western countries in particular, older people consume the most resources in terms of care and medicines. Until recently, there has been little-to-no concern about the real burden of poor adherence to treatment regimens in European countries, even though it has long been recognized to be an issue affecting health outcomes and increasing health care costs. The literature shows that, each year, nonadherence causes almost 194 500 deaths and costs €125 billion in the European Union,1 and costs $300 billion in the USA.2

It is estimated that in developed countries only 50% of those who suffer from a chronic condition are compliant with therapies.3 This lack of compliance, according to the World Health Organization (WHO), is one of the most important reasons for the failure to attain good blood pressure control in patients with hypertension, hyperlipidemia, or diabetes.3 Moreover, it has been demonstrated that patients who are able to maintain high levels of medication adherence are less likely to suffer exacerbations of their medical conditions than those with low levels of adherence.4 This means that the greater the adherence and medication expenditure, the lower the need to resort to costly health care interventions.

There are several factors that play a role in poor compliance. The WHO has classified them into five distinct dimensions: patient-related, therapy-related, condition related, health system–related, and a social and economic dimension.3 We will focus on the first two dimensions in this article because they are the ones that most concern our federation, Senior Italia FederAnziani.

Patient-related dimensions may include forgetfulness (30%), a deliberate decision to omit doses (11%), a lack of information (9%), emotional factors (7%), and having other priorities (16%).1,5 Therapy- and condition-related dimensions can be easily found in aged and frail individuals, due to the co-occurrence of multiple diseases in the same subject, which makes optimal care a challenging task.6 With regard to this dimension, there are other relevant issues, like the severity of symptoms, presence of disability, length of treatment, previous adverse drug reactions and/or therapeutic failures, and the complexity of the therapeutic regimen.

In relation to this last issue, it is useful to highlight that polypharmacy (prescription of ≥5 drugs) is now very common in older subjects. An Italian study carried out in most (94.2%) of the Italian elderly population ≥65 years old indicated that almosthalf (49.0%) were receiving 5 to 9 drugs and that 11.3% were receiving 10 drugs or more simultaneously. The age group that was most exposed to polypharmacy (69.1%) was that of the 75 to 84 year-olds, with 55% receiving 5 to 9 drugs and 14.1% receiving 10 drugs or more.7 The very elderly (≥85 years) fared little better: two-thirds (66.4%) were on polypharmacy. Polypharmacy was less common (52.2%) in the young elderly (65-74 years). Unsurprisingly, in subjects aged 75-84 years, low levels of adherence to treatment were found.

To combat issues like these, the most important Italian federation for the elderly (with more than 3.8 million members), Senior Italia FederAnziani, has held several events within the last few years dealing with adherence to therapy in order to empower both medical and patient groups. Senior Italia Feder- Anziani, with its center for health economics studies, made the first estimation of the economic burden of lack of adherence, since there was no awareness of the costs of nonadherence in Italy. The methodology used was based on the application of an American benchmark to health expenditure in Italy. Potential savings for the main chronic illnesses amounted to €6.1 billion: cardiovascular diseases, €2 billion; respiratory diseases, €1.4 billion; urologic diseases, €1.1 billion; metabolic diseases, €1.1 billion; psychiatric diseases: €0.5 billion. When all illnesses were considered, the projected savings amounted to €11.4 billion.

Savings were related mainly to a reduction in hospitalizations (67%), but also to reductions in outpatient visits (22%), emergency admissions (6%), and inappropriate pharmaceutical spending (5%).8 Improvements in adherence to therapy could, however, increase pharmaceutical expenditure (as more medication might be taken) and, for this reason, it would be wise to keep an eye on the benefits and costs of better treatment adherence. This caveat aside, it is easy to understand—from both a health and financial perspective—the importance of good medication compliance by chronically ill patients: better health and quality-of-life outcomes and better use of limited health resources.

In order to make constructive plans to improve the levels of adherence, especially in older people, Senior Italia FederAnziani gathered different experts from different European countries to form a scientific advisory board with the duty to create a strategy to help institutions and politicians to enhance the availability of health resources for elderly people and their quality of life.

Seven relevant interventions were identified and classified according to their target: patient, therapy, or public health organization. The interventions were the following: (i) comprehensive geriatric assessment; (ii) optimization of treatment (reviewing medication and dosage schemes); (iii) use of adherence aids; (iv) patient (and caregiver, if needed) education to improve patient empowerment; (v) education of physicians and other health care professionals; (vi) adherence assessment; and (vii) facilitating access to medicine by better connection of health services.5

Tackling nonadherence effectively requires the common determination of all the stakeholders involved in addition to a well-organized health system, providing different but complementary and connected health services that assist the patient in moving toward the same health objective.5 Patient-level approaches should be improved, taking into account that patient behavior can be influenced by knowledge (information, education, and communication), skills (training, coaching, and tools), and personal motivation (empowerment, encouragement, and concerns). In addition to this, the scientific literature shows that improvement of adherence requires a good relationship between patient and physician, so the latter plays a key strategic role.

Simplifying drug regimens represents another important facet of better treatment adherence, as critical nonadherence issues include complicated drug administration and a heavy pill burden.9 Alleviation of these detrimental issues aids adherence. In this context of assisting patients with adherence, information and communication technologies—such as telemedicine, internet-linked clinical support models, standardized wireless sensor networks, and so on—may help both patients and caregivers with the self-management of chronic diseases. Last but not least, integrated care at a national level, eg, closer, bidirectional collaboration between general practitioners and pharmacists, could improve the quality of care and enhance the efficiency of health providers and the satisfaction of patients.■

1. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353: 487-497.
2. Senst BL, Achusim LE, Genest RP, et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health Syst Pharm. 2001;58:1126-1132.
3. Sabaté E, ed. Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organization; 2003:1-199. http://www.who.int/chp/knowledge/ publications/adherence_full_report.pdf?ua=1. Accessed April 28, 2017.
4. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43:521-530.
5. Marengoni A, Monaco A, Costa E, et al. Strategies to improve medication adherence in older persons: consensus statement from the Senior Italia Federanziani Advisory Board. Drugs Aging. 2016;33:629-637.
6. Marengoni A, Angleman S, Melis R, et al. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011;10(4):430-439.
7. Onder G, Bonassi S, Abbatecola AM, et al; Geriatrics Working Group of the Italian Medicines Agency. High prevalence of poor quality drug prescribing in older individuals: a nationwide report from the Italian Medicines Agency (AIFA). J Gerontol A Biol Sci Med Sci. 2014;69(4):430-437.
8. Messina R. General medicine and the new needs of society [in Italian]. In: 72nd Congress of the Italian Federation of General Practitioners (FIMMG); October 3-8, 2016; Chia Laguna, Domus de Maria, Sardinia. http://bit.ly/2ohEn2s. Accessed April 28, 2017.
9. Martial L, Mantel-Teeuwisse AK, Jansen PAF. Update on 2004 Background Paper 7.3: Priority Medicines for Elderly. Published May 21, 2013. Geneva, Switzerland: World Health Organization; 2013: 1-66. http://www.who.int/medicines/areas/ priority_medicines/BP7_3Elderly.pdf. Accessed April 28, 2017.