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Feedback on Medication Dosing Enhances Patient Compliance

1993; Elsevier BV; Volume: 104; Issue: 2 Linguagem: Inglês

10.1378/chest.104.2.333

1931-3543

Joyce A. Cramer,

Medication Adherence and Compliance

The axiom “Patients tell us what they think we want to hear”1Cramer JA. Overview of methods to measure and enhance patient compliance.in: Cramer JA Spilker B Patient compliance in medical practice and clinical trials. Raven Press, New York1991: 3-10Google Scholar now has a corollary: “Patients try to appear compliant for a visit to the doctor.” In this issue, Nides et al (see page 501) report that 15 percent of patients who did not know how they were being monitored emptied their nebulizer just before the visit so that it would be light in weight when checked. Similar stories of pill dumping are well known in all fields of medicine. The issue of exactly how patients are taking their medications is crucial in a clinical trial in which determination of efficacy is made and reported to the medical community. Undetected partial compliance can void an otherwise important difference between treatments because the drugs are not used in a standardized manner as required by the protocol. The Lung Health Study Group demonstrated the value of showing reports to patients to help them understand their pattern of medication usage, thereby enhancing the success of the clinical trial. A variety of monitors are available for clinical research (pill, liquid, and aerosol dispensers).1Cramer JA. Overview of methods to measure and enhance patient compliance.in: Cramer JA Spilker B Patient compliance in medical practice and clinical trials. Raven Press, New York1991: 3-10Google Scholar Use of this technology has equally important implications for treatment effectiveness in managed-care settings. The low cost of monitoring patients whose medical course is unstable would easily be recouped by avoiding extra visits, medication changes, and laboratory tests.2Cramer JA Mattson RH Prevey ML Ouellette VL. How often is medication taken as prescribed? a novel assessment technique.JAMA. 1989; 261: 3273-3277Crossref PubMed Scopus (981) Google Scholar The new microelectronic monitoring technology allows clinicians and researchers to better understand whether a medication (or dose level) has failed because of inefficiency or failure of the patient to take the medication as directed. This concept has broad implications not only for improving patient outcome, but also for reducing the cost of medical care. Patients with chronic diseases who should maintain a careful regimen of prophylactic treatment often require extra medical attention because of exacerbations caused by partial or erratic compliance or a period of noncompliance.3Cramer JA Scheyer RD Mattson RH. Compliance declines between clinic visits.Arch Intern Med. 1990; 150: 1509-1510Crossref PubMed Google Scholar Unfortunately, a physician rarely knows what led to the medical problem and is faced with a decision to increase the dose, change the medication, or add another treatment. If the patient had used a microelectronic device, the printed report would clearly document the pattern of self-administration, simplifying the physician's decision-making process. As Nides et al comment, patients are often unaware of their lapses in doses. Forgetfulness, other priorities, misunderstanding of instructions—all are typical reasons for missed doses.2Cramer JA Mattson RH Prevey ML Ouellette VL. How often is medication taken as prescribed? a novel assessment technique.JAMA. 1989; 261: 3273-3277Crossref PubMed Scopus (981) Google Scholar In another recent report in this journal, Mann et al4Mann MC Eliasson O Patel K ZuWallack RL. An evaluation of severity-modulated compliance with QID dosing of inhaled beclomethasone.Chest. 1992; 102: 1342-1346Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar described microelectronic monitoring data for a qid regimen of beclomethasone. They found no significant correlation between medication compliance and asthma severity, suggesting other issues for exacerbations. In the absence of a device, I urge all health-care providers to be more specific with two aspects of the clinical interview:5Cramer JA. Identifying and improving compliance patterns: a composite plan for health care providers.in: Cramer JA Spilker B Patient compliance in medical practice and clinical trials. Raven Press, New York1991: 387-392Google Scholar (1) Provide specific instructions to patients, in the form of either a handwritten note (apart from the prescription) or a preprinted list of detailed instructions. (2) Ask the patient at every visit how he or she takes the medication. Ask for the name of the pill, number of pills, and times the doses are taken. Provide feedback on the optimum dose regimen guided by the pharmacokinetics of these specific drugs. Children and adolescents should also be able to tell you when they take their medication to encourage their sense of responsibility. Yes, microelectronic monitoring costs some money and some time. Nonetheless, the costs are far lower than the potential gain in clinical trial efficiency, improved clinical care of patients, and the rational use of health care in managed-care settings.