Medication Nonadherence: Finding Solutions to a Costly Medical Problem1
Harold Gottlieb, PhD, Drug Benefit Trends 12(6):57-62, 2000
Medication Noncompliance: Generic Problems and Solutions
The paper opens with a review of the now familiar statistics limning the extent and cost of medication noncompliance. The special issue of the aging patient and noncompliance is addressed, as are the possible causes of noncompliance, patient-clinician relationships and communication, and the difficulties of assessing adherence. Finally, a number of compliance enhancements are suggested.
Medication Adherence Contract
The author devotes a significant portion of the article to the promotion of a “Medication Adherence Contract” that not only includes information about the medication, its dosage and schedule, and the means by which the medication will be readjusted but also a “behavioral contract:”
Most significant, however, is the notion of treating this as a full-fledged legal agreement:
The contract can be signed and treated as if it were a legally binding document. For those who have difficulty reading, the contract can be taped, and the patient can be encouraged to listen periodically to the recorded message. A designated caregiver can be assigned to those patients who exhibit special needs, with the caregiver reading the contract to the patient and helping him to adhere to its terms.
Commentary
The portions of this paper that discuss the cost, prevalence and frequency of noncompliance, its causes, and the possible solutions to poor adherence are based on standard statistical data and are appropriately referenced. The organization of this information is erratic and the headings are sometimes confusing, but these are relatively minor criticisms.
I find the enthusiastic promotion of a formal treatment contract, especially one the author suggests should be explicitly considered a legally binding agreement, more worrisome.
Providing written instructions as to the use of the medication, its side-effects, how to handled likely problems, etc. appears worthwhile but can be equally helpful whether or not it is part of a so-called “contract.”
The legalistic approach, however, could antagonize many patients. Further, this type of contract seems equivalent to an ultimatum. Not addressed is the appropriate response on the part of the clinician if the patient refuses the contract altogether to is found in default at some date. Is the patient terminated from the practice? Given a 2nd or 3rd chance? Are penalties exacted?
Contracts can prove treacherous in business settings and can be proportionately more dangerous in a healthcare environment. That risk, given the lack of evidence supporting the contention that contracts enhance medical compliance, should limit their clinical use to extraordinary situations.
Footnotes
- Note: While references to CME credits may appear on the referenced web pages, CME eligibility for this article, published in 2000, has expired↩
