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What’s New about Medication Adherence?

Medication adherence is the foundation of effective drug therapy. It is defined as the extent to which a person takes his or her medications according to the agreed upon instructions. Adherence is a health-related behavior that is prerequisite to achieving desired outcomes: drugs cannot be effective if they are not taken.

Yet we know that approximately 50% of older adults are nonadherent or have poor adherence to their drug therapy. We also know that nonadherence is associated with 125,000 deaths per year in the US and $300 billion dollars per year in healthcare expenditures (direct and indirect costs).

What drives medication adherence? Why do you adhere to certain health behaviors and not others? Some patients have stellar adherence and routinely take their medications on time and every day. More commonly, though, patients stumble with adherence for various reasons. Over the past several months, I have pondered not only what makes the patients I work with take their medications, but what drives my medication- or supplement-taking behavior.

Adherence may not be a stimulating topic, but it is an essential one. Health outcomes depend on it. In this article, I want to re-look at medication adherence with a 20-year look back on progress we have made in health care regarding adherence and where we have fallen short. It is a good time for you to think about your own or your clients’ adherence to medications and other health-related choices—daily exercise, getting more fiber, or limiting alcohol intake, anyone?—and consider what drives you.

Improving Medication Adherence: It is a Journey

Historical perspective

In 2003, the World Health Organization (WHO) published its landmark report: Adherence to Long-Term Therapies: Evidence for Action. This report was instrumental in drawing much-needed attention to the global problem of poor medication adherence and non-adherence. This landmark report homed in on the adherence problem and its deleterious impact on chronic health conditions. It laid out in clear terms that healthcare systems and clinicians need to address barriers to adherence as a “central component of efforts to improve population health worldwide” (p. 22 of the report). It served as a global wake-up call to clinicians and researchers and emphasized the need to focus more resources on improving adherence.

Another major benefit of the report is that it provided a universal approach to identifying the broad scope of barriers to adherence. Specifically, it described adherence as a multidimensional phenomenon that is “determined by the interplay of five sets of factors,” referred to as the Five Dimensions of Adherence. These five dimensions defined by the WHO remain the backbone that frames our understanding of the complex and interdependent nature of barriers that impede a person’s adherence behavior. Bottom line: adherence is complex and cannot be ignored. For more detail about these five dimensions of adherence, see the WHO 2003 report or my discussion of them in Maybe It’s Your Medications: How to Avoid Unnecessary Medications and Adverse Drug Reactions.

Progress Made & Automatic Refill Programs

Twenty years on from this landmark publication, an international group of experts published an article reflecting on the state of adherence and progress made since that original WHO report. Kardas and colleagues created their “top 10” lists of achievements and future goals, including the following accomplishments since 2003:

  • Better access to medications through generic drug availability and insurance coverage
  • Development of medications that are easier to administer or need less-frequent dosing
  • Greater interest in understanding the patient-related reasons for poor adherence
  • Greater interest in the impact of multiple chronic conditions on adherence
  • Greater appreciation of the importance of person-centered care and the need to include the patient in decision making

Other achievements are more questionable. A shift to value-based reimbursement for healthcare services led to creating incentives to improve adherence by health systems including pharmacies. Quality metrics have been implemented to improve medication adherence, which has led to pharmacies encouraging patient enrollment in automatic refill programs. These programs might improve the refill rate (a measure of adherence) for a pharmacy and thus impact reimbursement, but an unintended consequence has been stockpiles of medications in some patients’ homes. It is not uncommon for me to see a disconnect between what the pharmacy is dispensing and what the patient is actually taking at home. Adherence efforts can only go so far. Patients ultimately must actually take the medications. Thus despite encouraging progress, efforts to improve adherence still are needed. The problem continues to befuddle our healthcare system.

What makes us adherent, the role of Health Beliefs

Sometimes a simple adherence aid like a pill organizer can flip the adherence switch for patients and help them take their medications every day. In other situations, we can recommend all the adherence aids in the world, and it still won’t “fix” the problem. There is not now nor never has been a one-size-fits-all solution. Overcoming adherence barriers requires a high-touch approach.

One thing that has become increasingly clear over the past 20 years is that a person’s health beliefs play a major role in determining medication adherence. Patients need to believe in the benefits they will gain by taking the medication and that taking the medication is worth the effort and costs, both financial and side effects. They need to believe that long-term benefit is worthwhile so they will continue to take the medication over time.

While some patients will “do whatever my doctor tells me,” another sector of patients is not such an easy sell. This is why discussing adherence on a routine basis between patients and clinicians—especially when we know a person is nonadherent—is key.

Symptoms versus Prevention, the role of Shared-decision Making

What motivates a person to take a medication? Treating symptoms often is a motivator. Drug therapy for health conditions that have no symptoms, such as high cholesterol or osteoporosis, can be an adherence barrier. Contrast this with health conditions that are symptomatic, as with arthritis, asthma, or allergies. My adherence to an antihistamine during allergy season is excellent.

What about drug therapy that is prescribed to prevent a health event in the future, for example, taking blood pressure or cholesterol medication to prevent heart disease 10 years down the road? As we strive for healthy aging, this is a common situation—preventing long-term adverse health events in someone who has no or few symptoms. Health beliefs about the risk of a future health problem or the effectiveness of a medication must be discussed as part of shared-decision making when deciding on drug therapy. I am writing this both to clinicians and to patients and caregivers. If the doctor or pharmacist doesn’t bring it up, the patient should, and vice versa.

Summary

The past 20 years have reinforced that adherence ultimately is a high-touch situation. It is a matter of talking about it at every heath care encounter—at the pharmacy counter and at doctor visits. We need to celebrate successes and explore barriers. Adherence needs to become a normative conversation. It requires healthcare providers to ask every patient without judgment: what are you taking and what are you not taking; and why. One of the most useful questions I ask my patients is, do you think this medicine is helping? If patients don’t think a medicine is effective, it opens the door to explore adherence and other medication safety issues.

Medication adherence is directly related to health outcomes. It will continue to befuddle healthcare systems and individuals because we are human. Adherence is a behavior, just like any other behavior humans choose to do or not to do. So I ask, what drives your adherence behavior?

 

Written by Hedva Barenholtz Levy, PharmD, BCPS, BCGP

10-09-2025

This material is intended to encourage discussion with your health care provider. It is informational only and does not replace the guidance of your health care team.

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