• Adherence to treatment

SABA – Scientific Advisory Board on Adherence

Rome, October 24, 2014

SIHA believes that the issue of adherence to treatment is central to a positive development of health systems. For this reason it has taken steps to bring together the stakeholders of the health system (physicians, patients, experts, representatives of institutions) to work together on the issue and find shared solutions. On October 24, 2014 SABA – Scientific Advisory Board on Adherence was held, organized by SIHA and composed of experts from different countries in Europe in order to develop proposals to implement adherence to treatment.



European Day for Health Rights: Advisory Board on Adherence to treatments

November 22, 2014

On November 22, 2014, during the European Day for Health Rights organized in Rimini (Italy) by SIHA, adherence to treatment has been one of the central topics of the working sessions. On that occasion, which saw the participation of the highest European institutions, medical-scientific companies and patient organizations from all over Europe, the International Advisory Board on Adherence to treatment has met. The work of the Advisory Board held on November 22, 2014, starting from the indications emerging from SABA, had the aim of identifying an integrated strategy to improve adherence to treatment.


Aging population and adherence to treatment

An overview

The aging process is characterized by a high level of complexity which makes the care of older adults and in particular the use of medications a challenging task.

Typically, older adults show the co-occurrence of multiple chronic diseases (multimorbidity) and conditions (the so-called geriatric syndromes, such as urine incontinence, delirium or falls) that cannot be ascribed to a specific organ system pathology and frequently have multiple causes.

Pharmacological treatment of this complex patient represents a challenge for the prescribing physician, as confirmed by the high prevalence of iatrogenic illness observed in this population. Indeed, the application to complex older subjects of evidence-based, disease-specific treatment guidelines is not straightforward, as they rarely provide recommendations applicable to older adults with multimorbidity, geriatric conditions, cognitive and functional impairment. In addition, the efficacy of drugs used to treat chronic diseases is usually evaluated in clinical trials held in younger subjects, in general affected only by the index disease or, at most, by a limited burden of comorbidities, usually strictly related to the target disease. As a further problem, because of cognitive deficits or disability, older persons often are unable to assume drugs as prescribed. In these situations the risk of iatrogenic illnesses is high and may exceed the potential benefit expected from a given pharmacological treatment.

Older subjects are the major drugs consumers , with more than 90% of them receiving drug prescriptions. It has been reported that around 50% of older subjects receive 5 and 10% 10 drugs. Of note, polypharmacy increases the risk of adverse drug reactions and poor health outcomes including falls, hospitalization and death.

Nonetheless, suboptimal drugs prescription is very common in older subjects (12% to 40%, depending on the indicators used). Taken together, all these factors negatively affect adherence to medical prescription. Poor adherence to treatment regimens has long been recognized as a substantial roadblock to achieving better outcomes for patients. Data from the United States show that as many as half of all patients do not adhere to the medication regimen prescribed and it has been estimated that more than $100 billion are spent each year on avoidable hospitalizations.

Non-adherence to medication regimens also affects the quality and length of life. The growing population aging is the successful result of public health policies, but it also represents a burden for economic sustainability and functioning of health systems. The classification of poor adherence to pharmaceutical treatment, especially in chronic, life-threatening diseases, as a high priority issue for European health systems is justified by the extensive evidence demonstrating the high proportion of patients, especially the older ones, with limited adherence to treatment, and the negative effect of this behaviour on the benefits expected from the cure.

The reasons behind poor adherence are multi-factorial and complex, related to social and economic aspects, health systems and professionals, specific diseases (e.g. cognitive impairment, or depression) as well as individual patient’s characteristics, such as poor health literacy. Tackling non-adherence, with its complexity, requires a multi-stakeholder, patient-centred approach. Indeed, increased adherence to medication requires behavioural change at the level of the patient, who may be influenced by three factors: knowledge (information, education, and communication), skills (training, coaching, and tooling) and motivation (empowerment, encouragement, addressing concerns).

In addition to patient-centred approach, possible interventions to improve adherence may target the prescribing physician. Scientific literature showed that improvement of adherence requires optimization of drug prescribing and good patient-physicians relationship. Simplification of complex drug regimens and enhancing the communication between physician and patient are key strategies in boosting patient’s ability to follow a medication regimen.

Critical issues to improve adherence to medical prescriptions in older subjects include the need for easy administration in the context of polypharmacy, possible dose reduction, the effects of visual and motor impairment, inadequate caregivers or social support. In this context, non-drug information and communication technology (ICT) systems may become relevant for monitoring and improving adherence (use of information systems supported by Tele-Medicine approaches and Internet-linked clinical support models; standardised wireless sensor networks technologies, etc). ICT technologies may provide self-management utilities for patients and caregivers; education modules for patients, caregivers, or health professionals; information integration for patient management by physicians.

No single intervention strategy, or package of strategies has been shown to be effective to improve adherence across all patients, conditions and settings. Consequently, interventions that target adherence must be tailored to the particular illness-related demands experienced by the patient and combine different approaches targeting complex aspects of older adults into an holistic approach.

To accomplish this, health systems and providers need to develop means of accurately assessing not only adherence, but also those factors that influence it. Despite an extensive knowledge base, efforts to address the problem have been fragmented, and with few exceptions have failed to harness the potential contributions of the diverse health disciplines.

A stronger commitment to a multidisciplinary approach is needed in order to make progress in this area. This will require coordinated action from health professionals, researchers, health planners and policy-makers. Experiences combining different strategies and health professionals should be reviewed and, based on these data, new standardized and innovative interventions proposing holistic and integrative approaches should be tested.

There is a compelling need that the best practices assessed in several European countries and involving different stakeholders may become practice through an operational and organizational context that promote, facilitate and implement those activities by deploying all the enabling conditions.