Dr Benjamin Disney, Consultant Gastroenterologist, University Hospitals Coventry and Warwickshire NHS Trust, explains the essential role of patient adherence to treatment in achieving consistent results and reducing overall pressure on the health system.  

With better life conditions comes higher life expectancy, which means an older population on average. This demographic change, combined with the rise in chronic diseases sufferers – that currently make up for the 88 per cent of the total disease burden in the UK – and the strain Covid-19 has put on the National Health Service, is one of the many factors causing difficulties in accessing primary and secondary care for more and more people.  

Nursing staff especially are struggling to support both checked-in patients in health care facilities and those receiving domiciliary care. Over the last decade there has been a significant increase in the number of people receiving healthcare at home with patients receiving home care in the UK now accounting for more than 950,000. The drive to improve the delivery of treatment within the home has been further boosted during the recent pandemic, to help prevent infection, but also because of the increase in occupied hospital beds that reached 92.9 per cent this October in England. 

Given these circumstances, strengthening patients’ adherence to their prescribed therapy is critical to avoid a worsening in their condition, to maintain their quality of life but also so that no unnecessary additional pressure is placed on the health system. 

Strive for adherence, not compliance

One of the core principles of medical treatment is that patients, after consultation and prescription, will follow a given therapy. But there is an important difference between compliance and adherence. The first merely entails a passive following of instructions, while the latter implies a conscious choice and a two-way dialogue between patients and Health Care Providers (HCPs).  

If a patient understands the therapy and is aware of expected results and possible side effects, they might feel a sense of ownership over their treatment, resulting in a higher probability they will stick to it. Improving understanding of therapy can also help to reverse the worrying trend concerning medicines prescribed for chronic or long-term conditions, with between a third and a half of these not taken as recommended. 

How can Health Care Professionals encourage treatment adherence? 

As previously stated, knowledge and understanding are at the heart of treatment ownership and adherence. HCPs should therefore provide patients with clear and complete information about available therapies, their benefits and adverse effects, as well as the rationale on which the selection of a specific treatment or medical device is based. This information should include expected, common and rare side effects and predicted timeline, as well as any adjustment to said timeline or treatment.  

Another key part of every adherence journey are regular follow-up consultations. Knowing that their progress is being closely followed can motivate patients to stay on track. These appointments, have the dual function of allowing HCPs to review and potentially adjust the treatment and of providing patients with the opportunity to clarify doubts and ask for advice. 

To make professional-patient communication as easy as possible, patients should be advised to keep a treatment diary, to track their symptoms, therapy effects and consistency. It is also important, especially when it comes to taboo subjects that arise in gastroenterology, that patients feel fully supported and that HCPs stay well-clear of any form of blame, to avoid patients withholding crucial information in the future.  

Additional resources should be made available to patients during treatment too. These include access to emergency contacts and information about patient community groups that can serve as a safety net when they are struggling to keep up with treatment.  Technological reminder tools and other applications, that can help improve medication and therapy integration into patients’ daily life, can be useful, especially if treatment requires particularly high levels of commitment.  

Undoubtedly, this process will require time and resources on the part of the HCPs, but it will also motivate patients to see their treatment through, resulting in an improvement in treatment outcomes and reduced disease recurrence, but also lower monitoring costs in the long run. 

The main adherence obstacles 

On paper, the path to ensuring adherence is a pretty straightforward one. In reality, there are a multitude of different factors to consider, starting with the fact that not many HCPs are confident with checking patients’ adherence, as it might be perceived as questioning the professional-patient relationship, traditionally based on trust. Furthermore, this task may fall on nursing staff, that often do not feel they have the necessary training and tools to effectively keep track of the patients’ treatment journey. 

It is also important to remember that non-adherence can be intentional, meaning that the patient decides not to follow treatment recommendations, but also unintentional when patients are prevented from carrying out their treatment by obstacles and events beyond their control. Adherence obstacles are mainly linked to the specific therapy area and to each individual patient. HCPs therefore need to carefully assess how a disease interferes with a patient quality of life, but also how the related therapy or medications will fit into their daily routine as well as whether and how significantly, the side effects are going to impact patients’ day-to-day lives.  

In gastroenterology, patients tend to initially dismiss symptoms, especially when it comes to intermittent bowel symptoms, blaming them on diet or lifestyle, and choosing to self-treat instead of seeking professional help. This, together with the stigma traditionally surrounding this field causes people to avoid talking about their symptoms, perceived as embarrassing, until they become serious, lengthening overall treatment times.  

Relieving pressure  

Patient adherence is not only essential to improving treatment outcomes, but it can also reduce disease recurrence, together with the risk of comorbidities, and the consequent risk of hospitalization or invasive–and usually expensive–treatment options. With one study estimating that non-adherence costs the NHS more than £500 million every year, supporting and encouraging patients during their treatment adherence journey can contribute to lower monitoring costs in the long run and can help relieve pressure on hospitals and other health care facilities, which is especially relevant during the ongoing pandemic.  

Failing to understand adherence obstacles and how they can affect patients may prove counterproductive for both HCPs and patients in the long run. Ultimately then, the initial investment in both time and resources required on the part of the NHS and the HCPs will be more than compensated by higher rates of treatment adherence, with all the benefits these bring. 

Further useful information can be found in the Bowel Interest Group’s report on the ‘Importance of Adherence’: https://bowelinterestgroup.co.uk/resources/importance-of-adherence/