This Is News?

On first reviewing Report: Skipping Doses Could Be Deadly, an AP story by Lauran Neergaard published July 30, 2007, I placed it in my Might Be Worth An AlignMap Post Sometime If Nothing Better Comes Along stack.

After all, the largest portion of the article is little more than a competently done riff on your standard Patient Compliance Story Template, i.e., medication noncompliance is rampant, noncompliance is responsible for huge proportions of unnecessary healthcare costs as well as increases in mortality and morbidity, healthcare literacy, cost of medication, and forgetfulness ares part but not all the problem, X% of all patients with Disorder Y are noncompliant, consider these statistics about and examples of medical noncompliance,¹ … .²

The only additional items in the story are (1) the report of the specific study referenced, which turns out to be a review of recently completed research showing that medication noncompliance is rampant, noncompliance is responsible for huge proportions of unnecessary healthcare costs as well as … and (2) the information that The Agency for Healthcare Research and Quality plans to launch “an ‘in your face’ campaign to improve medication adherence.”

The promotion of “Report: Skipping Doses Could Be Deadly” from back-up fodder to today’s topic is consequent to the story being picked up, as far as I can determine, by every existent newspaper and healthcare blog, many of which seem to be presenting it as news.

To which I can only respond, What the heck?

OK, perhaps a key motivation for dragging myself from the cheap and tawdry novels that have been transformed into legitimate reading material by my official status of convalescent to my keyboard to produce this post is that I’m a tad miffed that while some of us have been plugging away about patient compliance for years, perhaps even, say, creating a web site and blog about treatment adherence, it’s The Agency for Healthcare Research and Quality that somehow earns notoriety throughout the media for stumbling over the phenomenon in mid-2007.

Well, better late than never, I guess.

And even I would find it difficult not to like any physician or bureaucrat, who declares, as did Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality,

We go into this [campaign against noncompliance] with some humility. … It’s really pretty appalling how badly we [deal with noncompliance].

Is This Rediscovery Of Noncompliance Different From Earlier Discoveries Of Noncompliance?

Clinicians have battled noncompliance since at least the fifth century BC (and no doubt long before that) when Hippocrates advised physicians1 to “keep watch also on the faults of the patients which often make them lie about the taking of things prescribed.”³

Interest in patient compliance has waxed and waned. A medical journal devoted to compliance was, in fact, published briefly. Individuals or research groups or pharmaceutical companies or someone is always coming up with the news that noncompliance exists.

Public interest is likewise sporadic. The first words from the body of the AP article published yesterday, “Consider it the other drug problem,” calls to mind the June 2, 1998 New York Times feature on healthcare noncompliance by Zuger, called “The ‘Other’ Drug Problem: Forgetting to Take Them.” And it was C. Everett Koop, a U.S. Surgeon General of these United Sates, who semi-famously observed that “Drugs don’t work in patients who don’t take them.”

And what’s come of all this? I quote from my favorite source, The AlignMap site. In this case, the relevant text is excerpted from The Verdict From Patient Compliance Research:

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, and, 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.

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 as well as that of my colleagues over many years of medical practice in various settings, locations, and specialties is that patient compliance is only rarely a discrete topic in clinical settings or an issue that comes quickly to the minds of most clinicians, even in situations, such as treatment failure, in which noncompliance is a likely, and perhaps, the likely cause. 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.

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.

The Agency for Healthcare Research and Quality Campaign

Quoting from the article,

Got it - the key is educating the patient with ads, better drug labels, and web-based videos.

And now to quote from - ahem - the AlignMap site, The Top Ten Patient Compliance Points: #7

#7. “Better patient education” is the answer — but only if the question is “What is the only response made to correct noncompliance in 90+% of cases?”⁴

This is a specific case of Mencken’s observation, For every complex problem, there is a solution that is simple, neat, — and wrong

There is no indication that patient education is uniformly the appropriate corrective reaction to noncompliance; there is evidence that patient education, regardless of how well structured the teaching process and how motivated the client, is unsuccessful in achieving compliance in a significant portion of cases.

More information does not necessarily result in more compliance. It is a difficult intuitive leap, for example, to concur with the bureaucratic a priori rationale that providing a patient a three-page listing of a medication’s adverse effects (instead of a one-page list of a subset of those adverse effects) will result in that patient taking the medication more faithfully.

Educating the patient without first determining if education will solve the problem for that patient in that situation is no more rational than automatically prescribing antibiotics to every patient complaining of coughing and a sore throat.

Footnotes

1. I believe, but lack the motivation to double check, that nearly every factoid mentioned in the article, along with, of course, many more, is currently on display on the AlignMap web site [back]
2. The author does earn extra points for eschewing the use of the nearly ubiquitous quotation from Hippocrates warning physicians to “keep watch also on the faults of the patients which often make them lie about the taking of things prescribed” or its occasional substitute, C. Everett Koop’s observation that “Drugs don’t work in patients who don’t take them,” both of which I reference later in this post. [back]
3. Wright EC, Non-compliance-or how many aunts has Matilda? Lancet 1993; 9; 342(8876): 909-913. [back]
4. This material was published on this site on 09-19-2006 and was written years earlier for a presentation. I’m one prescient son-of-a-gun, eh? [back]

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