Adherence Versus Compliance

Abstract

Description

Adherence and compliance are 2 words that are used interchangeably by medical professionals. When we come across a patient who is not taking their medication as advised, we say the patient is non-compliant when the truth is that the patient is non-adherent. Although the terms are used as if they mean the same thing, the 2 words are different in so many ways. In order to understand the difference, it is important to understand the true meaning of these words. According to the literature, “adherence is an active choice of patients to follow through with the prescribed treatment while taking responsibility for their own well-being while compliance is a passive behavior in which a patient is following a list of instructions from the doctor.” Adherence is a more positive, proactive behavior, which results in a lifestyle change by the patient, and they must then follow a daily regimen such as taking his or her medications every day or doing exercise daily. Compliance is a behavior exhibited by a patient who is simply “doing as (he or she is) told” or following instructions given by the treating doctor.

Introduction

Adherence and compliance are two terms that are used interchangeably by medical professionals. When we come across a patient who is not taking medication as advised we say that the patient is “non-compliant” when the correct term is “non-adherent.” Although the terms are used as if they mean the same thing, the two terms are different in many ways. In order to understand the difference, it is important to understand the true meaning of these terms. In medical terms, adherence has been defined as “the extent to which a person’s behavior, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.”¹ Compliance, on the other hand, is defined as “the extent to which the patient’s behavior matches the prescriber’s recommendations.”¹ Compliance does not allow a patient to question the authority figure, such as a physician or a provider. While “adherence is an active choice of patients to follow through with the prescribed treatment while taking responsibility for their own well-being, compliance is a passive behavior in which a patient is following a list of instructions from the doctor.”^1–3 Adherence is a positive, proactive behavior, which results in a lifestyle change by the patient, who must follow a daily regimen, such as taking medications every day or doing exercise daily, while compliance is a behavior exhibited by a patient who is simply “doing as told” or following instructions given by the treating doctor.^2,3

Discussion

Now that we have some background on these terms, it is easy to understand that most of our patients are actually non-adherent as opposed to non-compliant. I was recently on an in-patient service and rounding with residents. When I asked the residents why the patient’s serum glucose levels were elevated one of the residents told me that the patient was non-compliant and refused to take medication. I asked the residents, "Do you think patient is non-adherent or non-compliant?" It was interesting to see that the residents thought that both terms had the same meaning. After talking to the residents, I turned to the patient and asked what happened. The patient, who has a very complex medical history and a long history of insulin-dependent diabetes told me, “I have been checking blood sugars by poking my fingertips for many decades, and every time I do it, it hurts.” The patient said that she requested that she check her own glucose levels rather than having a nurse do it. The patient reported that the nurse who had come to do this test got upset and said, “If you do not want us to do the necessary tests why do you come to the hospital then.” On hearing this, the patient got upset and responded “You know what, I don’t want to get better.” Upon review of the nursing notes, it was documented that the patient was refusing to get her glucose levels checked and was non-compliant with the necessary testing needed to manage her diabetes.

So, going back to the issue of adherence versus compliance, and the question of whether the medical community uses the terminology adherence and compliance inappropriately, the answer is resounding “yes”, because when we use the word non-compliant we do not give our patients any autonomy or choice. Patient autonomy is one of the most important aspects of patient care. Medical professionals have inadvertently and inappropriately substituted non-compliance for non-adherence. Adherence, when defined appropriately, means that the patient has a choice to receive or not to receive needed treatment, while compliance is considered more of a legal term. Frequently patients are trying to do the right thing when they don’t take their medications and this might be due to a genuine concern regarding potential side effects, adverse drug reactions, cost of the medication, or even the color of the medication about which the patient was not counseled. I remember a patient who was taking blood pressure medications for 10 years and when the patient’s blood pressure medication was refilled, the patient thought that it was not the correct medication because it was not the same color that it used to be. The patient did not take the medication dispensed by the pharmacy, out of concern that it was not the correct medication. Most physicians will document this as non-compliance; if they are aware of the accurate meanings of the terms compliance and adherence, they would say that the patient is non-adherent. It is time to train medical students and resident physicians on the accurate meanings of these terms and how to appropriately apply them.

Conclusion

To summarize, the terms adherence and compliance mean different things. While adherence ensures autonomy and seeks behavior change, compliance mandates treatment without seeking behavior change. Adherence is an active process in which a patient takes responsibility for their overall well-being, while compliance is a passive behavior in which a patient is following a list of recommendations from the doctor. Adherence puts the patient’s interests above physicians’ interests while making sure that the patient follows recommendations without coercion or pressure.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity.