Source: One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic, Andreas Storm, Stig Ejdrup Andersen, Eva Benfeldt, Jørgen Serup Journal of the American Academy of Dermatology. 59:1, 27-33

The Study

Using the Danish National Electronic Pharmacy Register, which contains all prescriptions issued within the past two years, Storm and associates studied 322 people, who were prescribed a total of 390 medications.

At four weeks after the medications were prescribed, 30.7 percent of the subjects had not filled the prescriptions while most people who did obtain the medication did so within the first week after receiving the prescription.

Older patients and those who were treated by specialists were among those more likely to have filled their prescriptions while those with chronic disorders were less likely (when compared to patients treated for acute diseases).

Commentary

There are no surprises; these findings are in line with those of earlier, similar studies.

These confirmatory results do, however, have practical implications for treatment. For example, given how common it is for large numbers of patients to never begin a prescribed medication, clinicians must always give nonadherence a high priority on the differential diagnosis of any treatment failure.

That importance of that reactive step is clear. In addition, I would also suggest a less obvious, proactive step.

One of the few things worse than one-third of all patients not filling their prescriptions is the clinician not knowing that one-third of his or her patients did not get their prescriptions filled. I believe a solid case can be made for working with patients in such a way a to encourage them to disclose that, in this case, they did not obtain the medications prescribed rather than hide it from their healthcare professional. My take on this matter is part of the post in which I originally suggested this tactic:

• CME: Treatment Nonadherence Among Individuals With Schizophrenia: Risk Factors and Strategies for Improvement
• Post-Transplant Medication Errors
• Improving Patient Adherence in Chronic Heart Failure - Online Continuing Education
• Connection Between Knowledge and Compliance Unclear
• Self-efficacy and Social Support Linked To Adherence With HIV Treatment

Calvin: Let’s say that life is this square of the sidewalk. We are born at this crack and we die at that crack. Now we find ourselves somewhere inside the square and in the process of walking outside of it. Suddenly, we realize our time in here is fleeting. Is our quick experience here pointless? Does anything we say or do in here really matter? Have we done anything important? Have we been happy? Have we made the most of these precious few footsteps?

From Calvin To Compliance

Calvin’s use of the sidewalk as a metaphor to explore the meaning of life triggers Donald B Ardell, in Calvin, Deep Questions And Promoting Exercise, to apply the same questions to the value of health education:

Happily, there is some reason for cautious optimism. The post continues,

Commentary

I chose to post on this issue because (1) I’ve long been a big fan of Calvin & Hobbes so I jumped on the first semi-legit rationale to feature them on this blog, and (2) Donald Ardell makes an important point that isn’t often emphasized on this site.

Although I am a dedicated proponent of a tailored approach to improving compliance (i.e., selecting the most efficacious compliance-enhancing interventions for a given patient or patient group) and, indeed, promote that stance in a commercial venture,¹ there is substantial evidence, including the study Mr. Ardell references, that brief, non-specific counseling from a healthcare or wellness provider to exercise, to follow a healthy diet, to quit smoking, … can be effective for at least a portion of the population.² Given the small amount of time and the relative ease of offering such advice, there is little excuse not to do so and, as Calvin and Mr. Ardell would point out, profound gratification in providing this service to our clients.

For the record, Calvin and Hobbes do offer another approach to motivating others.

Footnotes

1. See EnrichMap and Emap Profile Now Online and the EnrichMap web site. [back]
2. See, for example, How Physicians Can Help Their Patients Quit Smoking by Prochazka and Boyko, West J Med. 1988 August; 149(2): 188–194 [back]

• Diabetics Weigh Cost Of Compliance Vs Longer Life
• Life Insurance For HIV Patients Contingent On Treatment Compliance
• Compliance Or Defiance When The Stakes Are Life Or Death
• LIFE Program Enhances Adherence
• Noncompliance Despite Life Or Death Stakes

Source: Effects of Depression and Selective Serotonin Reuptake Inhibitor use on Adherence to Highly Active Antiretroviral Therapy and on Clinical Outcomes in HIV-infected Patients Michael Alan Horberg, MD, MAS, FACP; Michael Jonah Silverberg, PhD, MPH; et al. J Acquir Immune Defic Syndr. 2008;47(3):384-390.

The Study

This large (3359 patients) retrospective cohort study was designed to “determine the impact of depression on highly active antiretroviral therapy (HAART) adherence and clinical measures and investigate if selective serotonin reuptake inhibitors (SSRIs) improve these measures.”

Design & Results: (Excerpted)

Commentary

Conclusions:
Depression significantly worsens HAART adherence and HIV viral control. Compliant SSRI use is associated with improved HIV adherence and laboratory parameters.

The conclusions¹ drawn by the authors are straightforward, immediately useful to clinicians, and heartening, an all too unusual set of qualities for a clinical study dealing with patient compliance.

Moreover, while the researchers are appropriately careful to limit these conclusions to those being treated for HIV, a disorder frequently accompanied by depression (a prevalence of greater than 30% in some studies in HIV-infected patients), it is certainly possible that depression and SSRI treatment have analogous effects on adherence to the treatments of other disorders. There is little evidence that depression associated with HIV is a different pathology than free-standing depression or depression associated with other diseases or that patterns of compliance and noncompliance with HAART are fundamentally different from adherence and nonadherence to other disorders.

Because adherence is a life or death matter for HIV patients and because the HAART regimen has been an especially rigorous and difficult protocol for patients to follow, clinicians and researchers working with this disorder have been long been concerned about compliance issues and their efforts have resulted in advances in clinical practice. My subjective impression is that the results of these labors have sometimes remained isolated to those working in this field. If so, perhaps it’s time for an organized effort to assure that patient compliance research is distributed across diagnostic and professional boundaries.

Footnotes

1. In more expanded form, the conclusions read … depression negatively affects adherence and clinical parameters among HIV-infected patients taking HAART, including the odds of achieving at least 90% adherence over 12 months and achieving an HIV RNA level <500 copies/mL by 12 months. We found that improved SSRI adherence is associated with improved HAART adherence, leading to improved HIV RNA levels and CD4 T-cell counts approaching or even exceeding results seen with nondepressed HIV-infected patients. SSRI use is likely beneficial in depressed HIV-infected patients if they can be compliant with their SSRI medication. [back]

• Asking About Adherence
• Caregivers And Patient Compliance
• Benefits Of Compliance Enhancement Diminish When Program Ends
• Adherence Research Needed In Poorer Countries
• LIFE Program Enhances Adherence

The Safety Issue and The Personal Medication Record

While my recent posts on the Personal Medication Record focused on its utility as a tool to decrease unintentional noncompliance,¹ the medication list also serves as an important safety function, as explained in What Medications Does Your Patient Take? Enhancing Medication Safety in the Outpatient Setting, an article published on the Institute for Healthcare Improvement web site.

I’ve included some excerpts to give a flavor of the essay:

Additional Sources

The Massachusetts Coalition has developed materials closely related to What Medications Does Your Patient Take? Enhancing Medication Safety in the Outpatient Setting. These include letters to patients, providers, and pharmacists to give patients and families useful tips for using medications wisely, and to inform providers and pharmacists about specific actions required to ensure patient health and medication safety:

Med List Letter to Patients
Med List Letter to Providers
Med List Letter to Pharmacists

Footnotes

1. The Alignmap posts dealing with Personal Medication Record include
   • Everyone Needs A Personal Medication Record
   • Choosing The Right Personal Medication Record
   • Compiling The Personal Medication Record
   • How To Create and Use A Personal Medication Record
   • Test-Driving The Personal Medication Record

   [back]

• How To Create and Use A Personal Medication Record
• Once More, Everyone - Not Just The Elderly - Needs A Personal Medication Record
• Test-Driving The Personal Medication Record
• Post-Transplant Medication Errors
• CME: Treatment Nonadherence Among Individuals With Schizophrenia: Risk Factors and Strategies for Improvement

Primary Source: A Randomized Controlled Trial of the Impact of Targeted and Tailored Interventions on Colorectal Cancer Screening, Ronald E. Myers, Randa Sifri, et al, CANCER; Published Online: September 24, 2007; Print Issue Date: November 1, 2007.

Secondary Source & CME:
Targeted Interventions May Improve Rates of Colorectal Cancer Screening¹

The Study

Despite widespread recommendations from organizations such as the US Preventive Services Task Force (USPSTF) and the American Cancer Society, colorectal cancer screening remains underutilized. rates remain lower than desired. For example, the USPSTF recommends that persons aged 50 years or older have an annual screening stool blood test and/or other alternative CRC screening test every 5 years, a double-contrast barium enema every 5 years, or a colonoscopy every 10 years. However, data from the 2003 National Health Interview Survey showed that only 16% of Americans reported having a stool blood test within the past year, 36% underwent some type of endoscopic screening within the past 5 years, and 42% had either stool blood test screening within the past year or endoscopy screening within the past 5 years.

Dr. Myers, interviewed by Medscape, explained the barriers to higher compliance with screenings:
The reality is that most primary providers have essentially decided that there are 2 options. Colonoscopy is the preferred option followed by SBT [stool blood test]. One of these two screening options is commonly used. This needs to be addressed in the real world of patients and clinicians, who have made their choices. Another barrier to screening is that the procedures are fairly complex and require preparation. Although it has been simplified, the traditional guaiac smear test for fecal blood requires a special diet for 48 to 72 hours before the test, with the avoidance of certain foods. A colonoscopy is even more involved, requiring a person to take a day off from work and bowel preparation beginning several days ahead of the test. The process is becoming easier, but the lack of convenience and ease of screening is still an obstacle.

It is, however, the third reason, that primary care clinicians often do not promote CRC screening as a major issue in their practice and have not been as strident as they should be, that is the focus of this study.

This study looked at the impact on compliance with colorectal cancer screening of targeted interventions.

Methodology (excerpted from abstract):

Results(excerpted from abstract):
Screening rates in study groups were 33% in the control group, 46% in the SI group, 44% in the TI group, and 48% in the TIP

Commentary

The literature is replete with recommendations to tailor compliance enhancements. Rarely, however, does one see a study based, as this one is, on protocols that appear appropriate for day-to-day clinical use.

While it is disappointing that this study found that the compliance increased by the same statistical increment in all intervention groups rather than being improved the most by the customized interventions, that the issue is being studied at all is heartening.

My own, also unproven bias is that the interventions should be tailored not to the disorder or treatment but to the specific patient or, more practically, specific groups of patients.

Footnotes

1. News Author: Roxanne Nelson, CME Author: Désirée Lie, MD, MSEd, release Date: October 1, 2007; Valid for credit through October 1, 2008. Credits Available: Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians; Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians; Nurses - 0.25 nursing contact hours -None of these credits is in the area of pharmacology [back]

• CME: Treatment Nonadherence Among Individuals With Schizophrenia: Risk Factors and Strategies for Improvement
• Results Of Differing Methods Of Communicating Treatment Benefits To Patients
• Noncompliance & Treatment-Resistant Schizophrenia
• Increasing Sensitivity To Noncompliance
• Depression & Decreased Adherence To Asthma Therapy

Large Study Reports On Multiple Variables Affecting Compliance

While I prefer and typically insist on reviewing the published article describing a clinical study before posting on it, this meeting report/press release from the American Heart Association regarding the presentation at that organization’s 61st Annual Fall Conference of the Council for High Blood Pressure Research of a large survey of patients being treated for hypertension contains enough information with potential impact on clinical practice that I have excerpted significant portions relevant to compliance for this post, appending only the caveat that, again, I have not seen the full writeup and cannot warrant the completeness or accuracy of this data beyond the referenced report.

The Study

To obtain a clearer picture of high blood pressure treatment in their state, David J. Reynen, M.P.P.A., M.P.H., lead author of the study, and his colleagues at the California Department of Public Health’s Heart Disease and Stroke Prevention Program in Sacramento proposed a series of questions to be included in the California Health Interview Survey, which is conducted by telephone every two years, and then analyzed the results.

Of 42,044 California adults, 11,467 said a doctor had told them they had high blood pressure. When adjusted for age, this yielded a prevalence rate of 24.5 percent.

Of those diagnosed with hypertension, 49.4 percent were not taking drugs to lower it.

People who had seen a physician during the prior year were more than five times more likely to be on medication than were those who had not. [My emphasis] “That was informative,” said David J. Reynen, M.P.P.A., M.P.H., lead author of the study. “It really underscores the importance of having routine care.” “Unfortunately, the data are collected in such a way that we don’t know to what degree the individual respondents have hypertension,” Reynen said. “One in four adults in California, including one in three African Americans, is hypertensive,” he said. “We talk about people needing to know their numbers. That means not just whether your blood pressure is high or low, but your actual numbers. This study reinforces that.”

Among those surveyed with high blood pressure, the analysis showed that the age-adjusted odds of a person taking drugs to lower blood pressure are:

• 5.23 times higher for people who saw a physician within the past year compared to those who did not;
• 2.47 times higher for those with diabetes than those without the disease;
• 2.05 times higher for those who had health insurance than those who did not;
• 1.71 times higher for African Americans than for whites (the racial/ethnic groups, respectively, with the highest and lowest high blood pressure rate);
• 1.46 times higher for people who described their health as poor or fair compared to those in good health;
• 1.40 times higher for patients diagnosed with heart disease than those without it;
• 1.38 times higher for smokers than nonsmokers;
• 1.27 times higher for U.S.-born individuals than foreign-born;
• 1.21 times higher for people with some form of formal education after graduating high school than those with less formal education.

The age-adjusted prevalence of high blood pressure and drug treatment sometimes varied considerably among the various groups surveyed:

• African Americans had the highest prevalence of high blood pressure (35 percent), followed by American Indians (29.8 percent), Pacific Islanders (27.2 percent), those of other race/ethnicity (25.9 percent), Latinos (25.0 percent), Asians (24.5 percent) and whites (23.1 percent).
• African Americans had the highest rate of drug use to control their high blood pressure (56.6 percent), followed by American Indians (53.1 percent), Asians (52.1 percent), Pacific Islanders (52 percent), whites (49 percent), Latinos (45.8 percent) and those of other race/ethnicity (44.4 percent).

• Designing Treatment Planning For Treatment Adherence
• Adherence To Treatment: Tips To Patients
• Psychoeducaton For Psychotic Disorders Found To Have No Effect On Medication Adherence
• Pillbox Organizers May Improve Adherence To HIV Treatment
• AMA Passes New Policy On Adherence To Treatment Plans

Is Ethnicity An Independent Determinant Of Compliance?

Mechanisms for Racial and Ethnic Disparities in Glycemic Control in Middle-aged and Older Americans in the Health and Retirement Study
Michele Heisler, MD, MPA; Jessica D. Faul, MPH; Rodney A. Hayward, MD; Kenneth M. Langa, MD, PhD; Caroline Blaum, MD, MPH; David Weir, PhD. Arch Intern Med. 2007;167:1853-1860.

The Study

The researchers sent surveys to 1901 respondents 55 years or older with diabetes mellitus, 1233 of whom completed valid at-home hemoglobin A1c (HbA1c) kits. Multivariate regression models were used to examine racial/ethnic differences in HbA1c control and to explore the association of HbA1c level with sociodemographic and clinical factors, access to and quality of diabetes health care, and self-management behaviors and attitudes.

Results and Conclusions, excerpted from the abstract, follow:

Commentary

The pertinence of this study vis-a-vis patient compliance is its support for race as an independent determinant of adherence. Unfortunately, it is difficult and perhaps impossible to assess the significance of its conclusions because of the many other studies that show that race has no impact on compliance and the somewhat lesser number of other studies that indicate that race is a mild, moderate, or major influence on compliance.

And the complexity increases exponentially when race as an interactive factor is considered. For example, studies have looked at - and come to different conclusions regarding - the effect on compliance of racial differences or similarities of patient and doctor. The possibilities seem endless: it’s possible, for example, that variations exist between, say, Whites and Asians but not between Asians and Blacks; perhaps race is a more significant compliance factor in societies rife with racial conflict than in communities characterized by interracial harmony; race could be important in determining adherence for certain specific treatments or disorders but not others; … .

The improbability of controlling for so many confounding factors, alone or in combination, as well as the many conflicting studies about the importance of demographics like ethnicity should make one leery of basing clinical practices on this study’s finding that racial differences in compliance are significant. It is, in fact, difficult to imagine a practical, affordable scheme for investigating potential racial differences in compliance that would provide results that could be confidently used in clinical practice.

• Cultural Differences & Presumed Noncompliance
• Meta-Review: Improving Medication Adherence In Chronic Cardiovascular Disorders
• Medication Adherence Reminders and Doctor-Patient Communication In The Wall Street Journal
• Many Losers In Patient Medication Quiz
• Patient Compliance With Medication Prescribed In Emergency Department Visits

The Diabetics’ Quality Of Life Study

Patient Perceptions of Quality of Life With Diabetes-Related Complications and Treatments
Elbert S. Huang, MD, MPH1, Sydney E.S. Brown, AB1, Bernard G. Ewigman, MD, MSPH2, Edward C. Foley, MD, MPH2 and David O. Meltzer, MD, PHD1 Diabetes Care 30:2478-2483, 2007

This study quantified how 701 adult patients with diabetes weigh the quality of life associated with complications of their disease and treatments for that disorderby “elicit[ing] utilities (ratings on a 0–1 scale, where 0 represents death and 1 represents perfect health) for hypothetical health states by using time-tradeoff questions. [The researchers] evaluated 9 complication states (e.g., diabetic retinopathy and blindness) and 10 treatment states (e.g., intensive glucose control vs. conventional glucose control and comprehensive diabetes care [i.e., intensive control of multiple risk factors]).”

In other words, patients had to select their preferences from a series of either-or options such as “Would you prefer five years of perfect health or 8 years life with blindness?” and “Would you prefer four years of life without taking insulin or six years of life taking insulin?”¹

Results and Conclusions, excerpted from the abstract, follow:

Commentary

1. This may be the rare case when the clinician reading the published scientific report may benefit by also perusing a secondary article about the same research carried in the lay press.

The findings are appropriately, if dryly, reported in the Diabetes Care article but take on additional impact when a specific case is described. The Chicago Tribune article about the study, Some diabetics sick of treatment ,² for example, begins with the story of William Haynes:

2. I suspect that no clinician who treats patients with chronic disorders will be surprised by the findings (although seeing these outcomes expressed in such stark terms as “I’d give up 5 years of life to quit taking the pills” is likely to take one aback regardless). Given that, the fact that this is the first such study to quantify patient perceptions of quality of life on diabetes treatments and living with diabetes-related complications is amazing and not a little embarrassing for the profession.

3. Most poignant of all may be Dr Huang’s summary,

That 10 percent to 18 percent of the total (and perhaps more, given that the study included only patients currently opting for treatment) felt their treatments were sufficiently burdensome that they would be willing to die earlier (up to 10 years earlier) if that were the tradeoff for stopping their medications renders adherence reinforcement efforts exponentially more complex both ethically and clinically.

Viewed from another angle, however, that quandary also speaks to the insufficiency of current definitions of compliance and adherence and the need to reorganize those principles into a more useful form. I’ve made this argument many times in the past and today will settle for providing links to one such essay captured in this set of two pontification-posts: The New, Improved Patient Compliance and Running Patient Compliance Up The Flagpole

Footnotes

1. These specific questions were not taken from the study but are offered only as examples of the forced choice format [back]
2. Some diabetics sick of treatment By Deborah L. Shelton. Chicago Tribune. September 27, 2007 [back]

• Cost Of New Prescriptions Rarely Given Patients
• SSRIs Vs Older Antidepressants: Effect On Compliance
• Healthcare Cost-sharing And Medication Compliance
• More On Cost-sharing And Medication Compliance
• Self-Reported Vs Actual Compliance With Mammogram Screening By Older Women

Health Literacy Problems and Lack of Social Support Systems Contribute to Non-Adherence

Number of elderly cancer patients to double by 2030, a brief news item from the European Cancer Conference in Barcelona, focuses on the prediction by cancer researchers that “the number of elderly cancer patients would likely double from 2000 to 2030, creating ‘huge challenges’ to healthcare systems worldwide.” One of the specific problems noted is noncompliance.

According to Kathy Redmond, editor of “Cancer World” and a featured speaker at the European Cancer Conference,

This article is available online at
~ Number of elderly cancer patients to double by 2030 ~

• As Severity Of Illness Increases, Compliance Decreases
• Decision-Making Processes Of Prostate Cancer Patients
• Suicide As Sequela of Noncompliance
• Noncompliance With Breast Cancer Medication
• A Pragmatic Consideration Of Noncompliance In Patients With (Or Without) ADHD

The Impact of Parents’ Medication Beliefs on Asthma Management
Kelly M. Conn, MPHa, Jill S. Halterman, MD, MPHa, Kathleen Lynch, BAa and Michael D. Cabana, MD, MPHb. PEDIATRICS Vol. 120 No. 3 September 2007, pp. e521-e526. Published online August 31, 2007

The Study

This study looked at the effect parental beliefs about asthma medications have on their children’s medication adherence. To determine the parents’ beliefs, they were asked to complete a Beliefs About Medications Questionnaire (BMQ), which measured the necessity, or the extent to which they believed a child’s sickness necessitated taking medication and the concern, or the extent to which a parent worried about possible risks associated with the drugs, such as side effects and potential for dependency. A differential score was calculated by subtracting the concern score from the necessity score. This served as a weighed appraisal of each parent’s beliefs.

Results (excerpted from the study):

Commentary

It’s no surprise that children are dependent on their parents to make healthcare decisions and that ones attitude toward the usefulness and dangers of medication affect adherence to that medication dosage schedule. Still, that this assumption has been verified by research is heartening.

• Fixed-Dose Combinations Improve Medication Compliance: A Meta-Analysis
• As Severity Of Illness Increases, Compliance Decreases
• Increasing Sensitivity To Noncompliance
• The Effect Of The Spouse Of An Autonomous Patient On Adherence
• Self-efficacy and Social Support Linked To Adherence With HIV Treatment

Effectiveness of psychoeducation for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders: A meta-analysis
T.M. Lincoln, K. Wilhelma and Y. Nestoriuca. Schizophrenia Research (Article in Press, Corrected Proof) Available online 7 September 2007. doi:10.1016/j.schres.2007.07.022

Testing Assumptions

As the introduction to this article notes, psychoeducation is widely credited as an effective means of improving outcomes for patients with schizophrenia and other psychotic disorders, and, in fact, meta-analytic data has demonstrated efficacy for PE when interventions include family members. This study, however, focuses on the effectiveness of psychoeducation directed solely at patients. Specifically, “this meta-analysis evaluates short- and long-term efficacy of psychoeducation with and without inclusion of families with regard to relapse, symptom-reduction, knowledge, medication adherence, and functioning.”

A literature search found 18 studies, reporting on 19 comparisons, that met the inclusion criteria. Results of the meta-analysis follow:

Commentary

The value of this study originates in its motivation. Key to medical science is the unwillingness to accept “common sense,” random recall of ones own experience, or “clinical wisdom” in place of evidence. The weakness of the scientific method in the realm of treatment adherence, however, is the conceptualzation of patient compliance as a task. Consequently, the questions and issues are divided, subdivided, and further split into ever tinier data points. In this case, the data point is that current studies indicate that psychoeducation directed only at a psychotic patient does not improve medication compliance, which is an important finding that should be considered in planning treatment for such patients.

The problem lies in the arbitrary nature of the parameters. Implicit in the study’s terms is that these findings are valid for schizophrenic and psychotic patients. Why are those findings not pertinent to patients diagnosed with borderline personality disorger? Are they valid for schizophrenic patients with concomitant substance abuse? Is there any reason other than historical diagnostic divisions to think that psychoeducation for psychotic patients has a different effect than it would on nonpsychotic patients?

Perhaps it’s time to consider compliance a trait rather than a task.

• Adherence As An Independent Marker Of Decreased Mortality
• As Severity Of Illness Increases, Compliance Decreases
• Statin Compliance
• Bandolier On Patient Compliance
• Fixed-Dose Combinations Improve Medication Compliance: A Meta-Analysis

Patient Compliance CME

Faculty: William T. O’Byrne, MD

The Course

Targeted to Primary Care physicians, this course is introduced with case studies one might routinely encounter in a family practice clinic or an internist’s office.

The content, however, centers on pertinent research (with full citations provided), including at least one study that I had not previously seen with counter-intuitive findings holding significant implications for day to day practice.

I was also impressed that Dr. O’Byrne was careful to indicate that the interventions recommended were the best the literature had to offer rather than research based, well documented protocols with high success rates, a category of compliance enhancement methodologies that, as Dr. O’Bryne points out, has been and continues to be empty.

This is a well done, brief introduction to thinking about patient compliance that is a step up from the “10 Steps To Better Compliance” laundry list of one-size-fits-all clinical interventions which is, unfortunately, the sort of content that turns up all too often in CME and training classes.

This worthwhile course can be found at ~ Patient Compliance CME ~

CME Details: This course is certified for 1 AMA PRA Category 1 Credit and is Co-Sponsored by the University of Alabama School of Medicine Division of Continuing Medical Education and The Alabama Quality Assurance Foundation. Expiration Date: September 8, 2008

And a section of the CME Certificate looks something like this:

• Running Patient Compliance Up The Flagpole
• Noncompliance With Vaccines
• A Pragmatic Consideration Of Noncompliance In Patients With (Or Without) ADHD
• The Blog, The Resources, & The Rest
• The State of the Art