A new taxonomy for describing and defining adherence to medications

Abstract

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Figure 1

Flow diagram of the paper selection process

Figure 2

Frequency histogram presenting the evolution over time of the main terms used among the 146 papers to describe deviations from prescribed treatments. Adherence (); Compliance (); Persistence (); Concordance (); Pharmionics (); Therapeutic Alliance (); Persistency (); Patient irregularity (); Pharmacoadherence (); Other ()

Figure 3

Time-line of changes in terminology for deviations from prescribed dosing regimens

Figure 4

Illustration of the process of adherence to medication (light blue) and the process of management of adherence (dark blue)

Figure 5

Examples of electronically compiled drug dosing history data in three patients for whom a twice daily dosing regimen was prescribed. Blue dots indicate the dates and times of drug intake. Grey bars indicate missed doses. (A) Patient with late initiation but good implementation. (B) Patient with suboptimal implementation (missed single and consecutive doses, large variability in timing of drug intakes). (C) Patient with excellent implementation but short persistence (early discontinuation)