Generality
In medicine, the English term compliance (acquiescence) indicates the degree to which the patient follows the medical prescriptions, be they pharmacological or non-pharmacological (dietetic, life regimen, periodic monitoring examinations, etc.).
Good Compliance
Good compliance occurs when the patient puts into practice what is prescribed by the healthcare professional; for example:
- take a given drug respecting the prescribed dosage;
- adopt lifestyle changes suggested by the doctor (eg abandonment of smoking, abstention from alcohol and drugs, increased physical activity, etc.), avoiding risky behaviors for one's health;
- observe the prescribed diet of the doctor;
- respect appointments for follow-up visits.
In these cases it is said that the patient is compliant ; specifically, to be considered as such, the patient must complete the prescribed therapy for at least 80%.
Bad Compliance
Poor compliance is synonymous with poor adherence to the prescribed therapy; for example, the patient - on purpose or involuntarily - modifies the doses and times of intake of the prescribed drugs.
Causes of Bad Compliance
The causes of poor compliance can be numerous.
First of all the poor adherence to treatments can be:
- unintentional (for example the patient does not correctly understand the therapy or parts of it);
- intentional (the Patient consciously chooses not to follow medical therapy for the most disparate reasons, be they rational or irrational).
The main causes of poor compliance include:
- Age : compliance is lower in adolescence and old age; in the child, it obviously depends on the parents. The elderly, for example, can unintentionally change the intake of a drug, forgetting the medical prescriptions, forgetting the daily intake or confusing the packaging of medicines.
- Physical state linked to the disease : cognitive, visual and / or acoustic deficits decrease compliance;
- Psychic state linked to the disease : in depressed or highly stressed patients, compliance is less;
- Type of therapy : for example, the compliance for non-pharmacological prescriptions regarding lifestyle (eg correct diet, smoking cessation, etc.) is low;
- Pharmaceutical form : in general, drugs that require a lower frequency of administration translate into better compliance, and vice versa; the acquiescence, for example, tends to be superior if the dermal application of a cream product 3 times a day is replaced by the application of the same product by means of patches to be changed once a day;
- Complexity of therapeutic schemes : the need to take more drugs and / or take them at different times of the day significantly reduces adherence to prescriptions;
- Difficulty in reaching care facilities and follow-up visits;
- High cost and difficulty in supplying drugs : the greater the economic difficulties and the physical retrieval of the drugs, the lower the compliance
- Duration of treatment : compliance tends to be high for short treatments and much lower for chronic treatments;
- Failure to accept the disease : the patient could reject the idea of being sick, for example because the symptoms and disorders of the disease have not yet manifested or because this has not yet arisen (preventive therapy in individuals at risk).
- Chronic diseases : the patient's awareness that he cannot recover from an illness, but at the most control its symptoms, can trigger a desire to abandon the prescribed treatment or to seek an alternative solution, perhaps naively relying on "hearsay".
- Phases of remission and asymptomatic diseases : when a chronic disease remains asymptomatic for a long time, the patient could reject the idea of resorting to therapy in the phases in which the symptomatology is absent, or being convinced of being cured.
- Fear of drug side effects : especially in cases where the patient interprets the prescribed therapy as unnecessary (see previous cases); for example, in the management of a chronic disease the pharmacological intervention could create disorders that were not present before;
- Unfavorable social environment : family support and social support networks are useful to improve compliance;
- Poor doctor-patient relationship : compliance, in its classic definition, implies a passive acceptance by the patient of what is prescribed by the doctor. However, most patients want to take an active part in defining the therapeutic path, discussing the effects of therapy, alternatives, past experiences, etc. with the doctor; consequently, to improve compliance the physician should argue his choices with understandable language, responding to the Patient's doubts and requests, involving him in the management of the disease and creating realistic expectations about the therapeutic effects he will be able to achieve and the time needed to reach these results.
- Lack of trust towards the attending physician, which leads to the so-called "medical nomadism", that is, in search of a new doctor from time to time who can prescribe better therapy.
How to Improve Compliance
Better compliance is achieved by intervening on the causes that can lead to bad acquiescence.
As regards the patient-physician relationship, as anticipated, it is very important to move from a patient's liability relationship to a collaborative relationship in which he / she feels fully involved in the treatment program.
During preliminary visits, it is therefore important that:
- the doctor provides information on the illness and the prescribed therapy, involving the patient and verifying their correct understanding; for this purpose it is useful:
- Provide information that inspires confidence;
- Use simple language;
- Limit the instructions to 3-4 main points;
- Integrate verbal information with written material;
- Reinforce the concepts discussed, repeating them.
- the Patient is encouraged to express his questions and concerns, to be able to discuss them together;
- the purposes, priorities and methods of processing are clarified, also with the help of paper documents (eg brochures) and / or digital documents that help the patient remember them (according to some statistics, most patients forget what the doctor said as soon as he left the clinic, and about half of what the patients remember is wrongly remembered)
- the possible obstacles that can reduce the adherence to the therapy and the useful strategies to prevent such difficulties are identified and discussed
- if necessary, the family is also involved, making it aware of the illness and other aspects related to the prescribed therapy.
This relationship will then be cultivated over time, on the occasion of subsequent checks (follow-up therapy):
- the Patient should be encouraged to express his opinion on the therapy followed, underlining any reasons for dissatisfaction or concern and reporting the frequency and extent of any deviations from those prescribed;
- the importance of the treatment and the utility of the same is reiterated (for example remembering that the discomfort and difficulties of accession are less than the benefit that one derives from it);
- strategies to reduce these difficulties are established where possible.
Positive Evolution of the Term
Compliance : implies a concept of the patient's passivity, which must comply with the doctor's prescriptions (decision-making assimilation) → Adherence : a term now preferred to the previous one, in which it underlines the active role of the patient and his participation in the treatment → Concordance : still little used, emphasizes the therapeutic alliance that should be created between doctor and patient, the result of a negotiation process, with full respect for the needs of both.
