Compliance

erratic, nil, or there may be overcompliance. To make a diagnosis and to prescribe evidence-based effective treatment is a satisfying experience for doctors, but too many assume that patients will gratefully or accurately do what they are told, i.e. obtain the medicine and consume it as instructed. This assumption is wrong.

The rate of nonpresentation (or redemption) of prescriptions42 (UK) is around 5% but up to 20% or even more in the elderly (who pay no prescription charge). Where lack of money to pay for the medicine is not the cause, this is due to lack of motivation.

Having obtained the medicine, some 25-50% (sometimes even more) of patients either fail to follow the instruction to a significant extent (taking 50-90% of the prescribed dose), or they do not take it at all.

Patient noncompliance is identified as a major factor in therapeutic failure in both routine practice and in scientific therapeutic trials; but, sad to say, doctors, are too often noncompliant about remedying this. All patients are potential noncompliers;43 good compliance cannot be reliably predicted on clinical criteria, but noncompliance often can be.

In addition to therapeutic failure, undetected noncompliance may lead to the best drug being deemed ineffective when it is not, leading to substitution by second-rank drugs. Noncompliance may occur because:

• the patient has not understood the instructions, so cannot comply,44 or

• understands the instructions, but fails to carry them out.

42 Many factors are associated with prescription nonredemption. Perhaps the cameo of a person least likely to redeem a prescription is a middle-aged woman, not exempt from prescription charges (in UK National Health Service) who has a symptomatic condition requiring an 'acute' prescription that is issued by a trainee general practitioner on a Sunday (Beardon P H G et al 1994 British Medical Journal 307: 846).

43 Even where the grave consequences of noncompliance are understood (glaucoma: blindness) (renal transplant: organ rejection), significant noncompliance has been reported in as many as 20% of patients; psychologists will be able to suggest explanations for this.

Prime factors for poor patient compliance are:

• Frequency and complexity of drug regimen. Many studies attest to compliance being inhibited by polypharmacy, i.e. more than three drugs to be taken concurrently or more than three drug-taking occasions in the day (the ideal of one occasion only is often unattainable).

• Unintentional noncompliance, or forgetfulness,45 may be addressed by associating drug-taking with cues in daily life (breakfast, bedtime), by special packaging (e.g. calendar packs) and by enlisting the aid of others (e.g. carers, teachers).

• 'Intelligent' or wilful noncompliance.46 Patients

44 Cautionary tales:

— A 62-year-old man requiring a metered-dose inhaler (for the first time) was told to 'spray the medicine to the throat'. He was found to have been conscientiously aiming and firing the aerosol to his anterior neck around the thyroid cartilage, four times a day for two weeks (Chiang A A, Lee J C 1994 New England Journal of Medicine 330:1690).

— A patient thought that 'sublingual' meant able to speak two languages; another that tablets cleared obstructed blood vessels by exploding inside them (E A Kay) — reference, no doubt, to colloquial use of the term 'clot-busting drugs' (for thrombolytics).

— These are extreme examples, most are more subtle and less detectable. Doctors may smile at the ignorant naivety of patients, but the smile should be replaced by a blush of shame at their own deficiencies as communicators.

45 Where noncompliance, whether intentional or unintentional, is medically serious it becomes necessary to bypass self-administration (unsupervised) and to resort to directly observed (i.e. supervised) oral administration or to injection (e.g. in schizophrenia).

46 Of the many causes of failure of patient compliance the following case must be unique:

On a transatlantic flight the father of an asthmatic boy was seated in the row behind two doctors. He overheard one of the doctors expressing doubt about the long-term safety in children of inhaled corticosteroids. He interrupted the conversation, explaining that his son took this treatment; he had a lengthy conversation with one of the doctors, who gave his name. As a consequence, on arrival, he faxed his wife at home to stop the treatment of their son immediately. She did so, and two days later the well-controlled patient had a brisk relapse that responded to urgent treatment by the family doctor (who had been conscientiously following guidelines recently published in an authoritative journal). The family doctor later ascertained that the doctor in the plane was a member of the editorial team of the journal that had so recently published the guidelines that were favourable to inhaled corticosteroid (Cox S1994 Is eavesdropping bad for your health? British Medical Journal 309: 718).

decide they do not need the drug or they do not like the drug, or take 2-3-day drug holidays.

• Lack of information. Oral instructions alone are not enough; one-third of patients have been found unable to recount instructions immediately on leaving the consulting room. Lucid and legible labelling of containers is essential, as well as patient-friendly information leaflets, which are increasingly available via doctors and pharmacists and as package inserts. (In hospitals, pharmacists have been known to throw away patient package inserts because they present problems for their administrative routine.)

• Poor patient-doctor relationship and lack of motivation to take medicines as instructed offer a major challenge to the prescriber whose diagnosis and prescription may be perfect, but yet loses efficacy by patient noncompliance. Unpleasant disease symptoms, particularly where these are recurrent and known by previous experience to be quickly relieved, provide the highest motivation, i.e. self-motivation, to comply. But particularly where the patient does not feel ill, adverse effects are immediate, and benefits are perceived to be remote, e.g. in hypertension, where they may be many years away in the future, then doctors must consciously address themselves to motivating compliance. The best way to motivate patients compliance is to cultivate the patient-doctor relationship. Doctors cannot be expected actually to like all their patients, but it is a great help (where liking does not come naturally) if they make a positive effort to understand how individual patients must be feeling about their illnesses and their treatments, i.e. to empathise with their patients. This is not always easy, but its achievement is the action of the true professional, and indeed is part of their professional duty of care.

Suggestions to doctors to enhance patient compliance are:

• Form a nonjudgemental alliance or partnership with the patient, giving the patient an opportunity to ask questions

• Plan a regimen with the minimum number of drugs and drug-taking occasions, adjusted to fit the patient's lifestyle. Use fixed-dose combinations or sustained-release (or injectable depot), as appropriate; arrange direct observation of each dose in exceptional cases

• Provide oral and written information adapted to the patient's understanding and medical and cultural needs

• Use patient-friendly packaging, e.g. calendar packs, where appropriate; or monitored-dose systems, e.g. boxes compartmented and labelled

• See the patient regularly and not so infrequently that the patient feels the doctor has lost interest

• Use computer-generated reminders for repeat prescriptions.

Directly observed therapy (DOT) (where a reliable person supervises each dose). In addition to the areas where it is obviously in the interest of patients that they be supervised, e.g. children, DOT is employed (even imposed) where free-living uncooperative patients may be a menace to the community, e.g. multiple-drug-resistant tuberculosis.

• An account of the disease and the reason for prescribing

• The nime of the medicine

• The objective

— to treat the disease and/or

— to relieve symptoms, i.e. how important the medicine is, whether the patient can judge its efficacy and when benefit can be expected to occu r

• How and when to take the medicine

• Whether it matters if a dose is missed and what, if anything, to do about it (see p. 23)

• How long the medicine is likely to be needed

• How to recognise adverse effects and any action that should be taken, including effects on car driving

• Any interaction with alcohol or other medicines.

A remarkable instance of noncompliance, with hoarding, was that of a 71-year-old man who attempted suicide and was found to have in his home 46 bottles containing 10 685 tablets. Analysis of his prescriptions showed that over a period of 17 months he had been expected to take 27 tablets of several different kinds daily.48

From time to time there are campaigns to collect all unwanted drugs from homes in an area. Usually

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