Medication Compliance and Avoiding Adverse Drug Reactions Lars Osterberg, MD, MPH; Terrence Blaschke, MD. Medscape August 30, 2006; CME/CE Valid for credit through August 30, 2007

This review is directed toward primary care clinicians. The requisite paragraph on the pervasiveness and cost of noncompliance is followed by a section entitled and dealing with “Recognizing Noncompliance and Compliance-Improvement Strategies.” Primary points include

• Clinicians should increase their index of suspicion re the possibility of noncompliance in all patients, especially those not responding to therapy.
• Clinicians should collaborate with rather than confront patients. (Specific examples of properly phrased interview questions are given.)
• Research indicates that complex combinations of compliance interventions are most effective, but even the most effective interventions have not led to substantial improvements in medication compliance.

Compliance improvement strategies suggested include

• Monitoring missed appointments, non-response to treatment, and failure to make medication refills to identify poor medication compliance.
• Sending reminders to patients about missed refills.
• Soliciting patients’ perspectives about their medications.
• Educating the patient re the value of the treatment regimen and the possible risks.
• Facilitating patients’ development of personal medication-taking methods.
• Encouraging family support of patient adherence.
• Prescribing treatments that are simple rather than complex.

The medication compliance portion of the article ends with a reminder that unrecognized noncompliance can lead to overtreatment, polypharmacy, or adverse reactions as more potent medications are prescribed in the belief that the original medications have been ineffective.

Commentary

The information provided is fairly standard. I have some quibbles with relatively minor points. For example, the paper’s implication that there is a correlation between attending doctors’ appointments and taking medications as prescribed may be misleading. Richardson and colleagues, for example, found that adherence to clinic attendance did not assure adherence with medication. Of patients keeping more than 60% of appointments, 40% were found to be noncompliant with medication, as determined by urine metabolite measurement.¹

My more significant concern is the utility of the recommendations. Prescribing treatments that are simple rather than complex, for example, is probably a valid notion, but it is difficult to imagine a responsible, practical clinician who would prescribe an unnecessarily complex treatment program in any case. Likewise, collaborating with patients rather than confronting them has been, it seems, the touchstone of patient-clinician relationship training at least since I was in medical school 25 years ago. Monitoring missed refills is a common recommendation that is only rarely possible to carry out. Other than consciously increasing ones awareness of the possibility of noncompliance, there seems little here for the primary care physician to use. This is, I should note, less the fault of the authors than the failure of medicine to develop useful tools to enhance compliance.

Footnote

1. Richardson JL, Skilton DR, Krailo M, Levine AM. The effect of compliance with treatment on survival among patients with haematologic malignancies. J Clin Oncol. 1990;8:356-364. [back]

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