The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow


January 16, 2014

In This Article

How Much Compliance Is Enough?

The Centers for Medicare & Medicaid Services has introduced uniform standards for compliance outcomes with its 5-star rating system for Medicare Advantage plans. The top rating is awarded to plans that achieve 70%-80% compliance in hyperlipidemia, hypertension, and cholesterol management in their members.[41]

But this raises another niggling issue: From a population-based perspective, how much compliance is enough? Setting optimal compliance rates across the board at 80% is arbitrary and potentially counterproductive, John Steiner believes.

"There's almost no evidence that can allow us to set those sorts of thresholds in a scientific way," he asserts. "For example, for first-generation antiretroviral drugs, studies showed that you needed adherence of 95% or greater to knock out the virus. An 80% adherence threshold would not have been stringent enough for those old drugs.

"The converse is also true. Years ago, when rheumatic fever was common, doctors prescribed penicillin to knock out strep throat, because that triggered rheumatic fever. However, studies showed that you only probably needed to take a third of the doses to knock out all the strep. So for that kind of situation, 30%-40% adherence was probably just fine. If it were 80%, you would increase the risk for side effects, as well as the cost, without increasing the clinical benefit."

"If lower levels of adherence are sufficient to achieve clinical goals, pursuit of higher adherence is wasteful," Steiner wrote in the Annals of Internal Medicine in 2012,[36] "and if higher levels are required, even these adherence targets will not suffice."

Moderate Progress on Compliance Issues

Despite a tsunami of unanswered questions, this is not to suggest that the enormous amount of research that has gone into compliance has largely been a waste of time. On the contrary, it has produced some valuable insights. The second article in this series looks at the healthcare industry's initiatives to improve compliance on the basis of this research.

With more than 40,000 peer-reviewed studies on the subject conducted over several decades,[13] you'd think we'd at least be at Compliance 2.0 by now in the state of our knowledge. In reality, it's more like Compliance 1.5. We are not on the verge of solving this immensely complex problem. The outlines of what is, at best, a partial solution are only just starting to emerge.

Despite moderate progress, "the heterogeneity in how adherence is assessed, measured, and defined is a major limitation to the data on barriers of adherence," investigators at RAND concluded in 2009.[15]

In 2014, that continues to be the case.


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