Current Patient Compliance Programs

1. There are multitudes of programs & devices designed to enhance compliance

2. Most of these programs & devices are never scientifically tested

3. For the overwhelming majority of these devices & single-premise programs, there is little evidence of effective compliance enhancement for more than a small fraction of the patient population

4. The programs that show the most promise for effective compliance enhancement are typically multifaceted, well-staffed and resource-rich

Overview of Current Compliance Program Design

While a relatively limited number of theoretical models of compliance has been accepted by consensus, and expositions, reviews, and critiques of each are readily available, programs and interventions promoting adherence are ambiguously defined, often operate in obscurity or are initiated with fanfare and surreptitiously terminated, and typically do not meet the standards for scientific investigation, even when they are described and catalogued as research. Peterson’s meta-analysis of trials of interventions to improve medication adherence, in fact, found that only 61 of 484 pertinent studies met minimal inclusion criteria as randomized, controlled trials with at least 10 subjects per intervention group.

Interventions may require complex and extensive staffing and monitoring logistics, consist of no more than a printed sheet of information, or call for the equipment ranging from a give-away plastic pill box with compartments for each day of the week to wristwatch alarms to timed medication dispensers to internet connected devices that alert the patient that a dose is due, electronically documents that the medication was dispensed, provides informational prompts to the patient, and warns if a dose is missed or taken at the wrong time.¹ Other compliance enhancement interventions include but are assuredly not limited to

• One on one counseling provided by a pharmacist, nurse, educator, or physician
• Educational videos, brochures, and tapes presented to individuals or groups
• Court mandated and monitored treatment
• Promotions of self-reliance and self-efficacy
• Improved patient-clinician communications
• Directly observed therapy (e.g., treatment for Tuberculosis)
• Mechanical or electronic reminders with visual or auditory cues
• Adherence programs provided by a pharmaceutical manufacturer and often limited to a single medication
• Automated or personal phone calls or email
• Disease management programs
• Celebrity endorsements
• Public Service Announcements in broadcast media or publications
• Simplification or alteration of regimes
• Assistance to increase accessibility (e.g., increased clinic hours, transportation, home services, etc)

This diversity and the large number interventions precludes an exhaustive critique of each. Some generalizations are, however, possible:

• As is the case for the theoretical models, many of these interventions depend on a cogent, rational patient
• A large proportion of the interventions are based on the notion that noncompliance is the result of a lack of understanding and is best addressed by education. Research findings and clinical experience, however, indicate that education, even when successful, is often insufficient to correct noncompliance.
• Similarly, many interventions are reminders, designed to combat forgetfulness, inattention, and absent-mindedness. Even when these are significant problems, reminders are no panacea.
• Perhaps the strategy receiving most attention is reorganizing the clinician-patient relationship such that the patient’s role is more assertive, collaborative, and proactive. This has proved a difficult for both clinicians and patients, and the results are not universally positive.

Next: Patient Behavior: Good Patients, Bad Patients, Economic Man, & Other Nonexistent Species

PDF Download
The State Of The Art Section, which includes The Verdict, Current Models, Current Programs, and Patient Behavior subsections and all citations is available in PDF format for download at ~State Of The Art~

Footnotes

1. Links to many such devices can be found in the AlignMap FURL Archive under the Category, Enhancement Of Compliance. [back]