Research Shows Improved Adherence Rare, Expensive With Current Methods1
The labors of compliance researchers have resulted in an impressive number of papers published (a Medline search for “patient compliance” turns up more than 27,000 articles over the past 20 years; and the chart below by Dusing et al indicates the pace of such publications is accelerating), a similarly impressive internet presence established (Google shows about 408,000 hits for “patient compliance”), numerous post-graduate degrees earned, some positive PR generated, occasionally, an isolated, situation-specific improvement in compliance rates.
None of this, however, has led to reproducible methodologies that can reliably and enduringly enhance compliance. Nor has a foundation been laid for the progressive growth of knowledge about and ability to manage treatment adherence.
No practical, efficient methods have yet been demonstrated to reliably
and significantly improve compliance for a wide range of patients.
Compliance Enhancement: The State Of The Art
The most damning evidence of the practical ineffectiveness of contemporary compliance enhancement theories and programs is the absence of their influence on day to day clinical practice. My experience, which mirrors that of my colleagues and every clinician to whom I’ve spoken, over many years of medical practice in various settings, locations, and specialties is that patient compliance is only rarely a discrete topic in outpatient or hospital settings. Even in situations, such as treatment failure, in which noncompliance is a likely, and perhaps, the likely cause, it is not an issue that comes quickly to the minds of most clinicians. Even fewer clinicians (other than those treating a few special populations, such as HIV infected patients and organ transplant candidates) implement specific interventions with the goal of managing noncompliance.
Still, it is undeniably tricky to prove the absence of an effect on a system as ambiguous, variegated, and unwieldy as American healthcare.
A reasonable proxy, however, is available; the following passages are drawn from medical literature dealing with compliance and not only summarize the findings of the article from which they were excerpted but are also representative of the overwhelming majority of scholarly and clinical reviews on the topic.
Excerpts:
Most methods of improving adherence have involved combinations of behavioral interventions and reinforcements in addition to increasing the convenience of care, providing educational information about the patient’s condition and the treatment, and other forms of supervision or attention. Successful methods are complex and labor intensive, and innovative strategies will need to be developed that are practical for routine clinical use.2
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Several complex strategies, including combinations of more thorough patient instructions and counseling, reminders, close follow-up, supervised self-monitoring, and rewards for success can improve adherence and treatment outcomes. However, these complex strategies for improving adherence with long-term medication prescriptions are not very effective despite the amount of effort and resources they consume.3
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The conundrum of compliance is extremely complex, and as yet whilst there are possible indicators as to some possible understandings and explanations, amongst some patients, in some contexts, with some areas of treatment/advice, these are still rather theoretical. Despite the wealth of research into determinants and management of compliance, few simple conclusions can be drawn.4
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It is unlikely that there will ever be a “cure” for noncompliance. No single, specific strategy that will enhance compliance in all patients—or even in the majority of patients—has been found. Compliance researchers agree that a range of strategies must be used, targeted to the underlying cause or causes of noncompliance and tailored to the needs and circumstances of each individual patient.5
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No single approach to improving adherence can be recommended on the basis of the evidence reviewed. Complex interventions may improve adherence and control in difficult patients. Worksite, nurse-led, protocol-guided care may have some advantages over usual care in younger men. Unfortunately, the wide variation in the types of intervention used and the outcomes measured make statistical meta-analysis methods inappropriate.6
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The Final Verdict On Patient Compliance
So there it is. After almost 2500 years of pondering, healthcare’s consensus is that compliance problems are complex, and the most promising solutions are also complex, as well as impractical and diverse, with no sure means of determining which interventions are most likely to work for a specific patient. And, few reviewers confidently endorse any specific tactic without extensive hedging.
Footnotes- Portions of the contents of this paper were originally published at AlignMap.com, a web site dedicated to treatment adherence and operated by Allan Showalter, MD. [↩]
- Osterberg L, Blaschke, T. Adherence to Medication. N Engl J Med 2005;353:487-97. [↩]
- Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. (Reprint of a Cochrane review 2003, Issue 4) Update Software Ltd, Summertown Pavilion, Middle Way, Oxford OX2 7LG, UK. 9 [↩]
- Playle J. Concepts of compliance: Understandings and approaches, Br J Fam Plann 2000: 26(4): 213-219. [↩]
- American Pharmacists Association and Pfizer U.S. Pharmaceuticals, Medication Compliance-Adherence-Persistence (CAP) Digest. 2003. pp 7-8. [↩]
- Ebrahim, S. Detection, adherence and control of hypertension for the prevention of stroke: a systematic review. Health Technol Assess 1998; Vol. 2: No. 11 p 25. [↩]
