drugs, undefined, though progress is being made
with studies that define these limits. The key, of
course, is to know the drug’s forgiveness. The
difficulty is the measurement of drug action.
In this effort, the patient holds a key position, as
his/her ability to cope with the prescribed regimen
is crucial for good compliance and, through good
compliance with rationally prescribed medicines,
good outcomes. Health professionals have an
important role to play in helping patients comply
properly and thus get the fullest possible benefit
from their prescribed medicines. When compli-
ance is insufficient, the outcome of the treatment
is put in jeopardy and the costs of care rise due to
the needless addition of second or third agents,
dose escalations or diagnostic tests to ascertain
the nature of a clinical problem that has been
created by persistent, clinically unrecognized
poor compliance.
Many studies have shown that patients under-
going long-term treatment in particular do not
succeed in taking their medication correctly over
a long period of time (Joneset al., 1995; Caroet al.,
1999; Catalan and LeLorier, 2000; Benneret al.,
2002).
Some figures may serve to demonstrate the
dimensions of this problem:
Fifteen percent of the prescriptions of general
practitioners are not dispensed at the pharmacy.
Fifty percent of all patients do not take the pre-
scribed medication or do not take it correctly,
mostly due to early, complete discontinuation of
dosing, otherwise known as short persistence.
Seven to eight percent of hospitalizations have
been attributed to noncompliance; but on close
review, this turns out to be hospitalizations for
excessive drug intake. We now know that there
are four times as many errors of dose omission
than errors of excess dosing, which can result in
clinical complications that mimic worsening
disease. Thus, there is probably a higher percen-
tage of hospitalizations attributed to noncompli-
ance, but these are usually misinterpreted
clinically as a worsening of the patient’s dis-
ease(s). We do not yet have good studies
to quantify this aspect of the noncompliance
problem.Many patients fail to realize that it is important to
take medication regularly and that they can make
hazardous mistakes in the application of their med-
ication. Moreover, many patients are for various
reasons prejudiced against the prescribed treat-
ment measures, including the prescribed medica-
tion. Problems with incomprehensible or
disturbing package leaflets are only one of the
aspects. The compliance of the patient is influ-
enced by a large number of different factors. It is
not a static process but a dynamic one, yet two
groups have recently presented evidence that
future compliance can be modeled and faithfully
simulated during future months, based on 30–60
days of electronic monitoring data on the patient
(dosing history). Such simulations may be suffi-
ciently reliable at the group level to be useful for
predicting group results in trials, but they cannot
predict actual day-to-day dosing patterns in indi-
vidual patients. Thus, they are not helpful for the
practitioner, who inevitably deals with individual
patients, one at a time.
The quantitative, objective analysis of the con-
duct of the patient in taking medication is
obviously a first step toward an effective improve-
ment of compliance, for reliable measurement is
the keystone of effective management.27.12 Improve compliance:
but how?The crucial step is to use the objective record of the
patient (prior dosing) as a management tool to
allow the patient to see what errors were made
and to discuss options for how to avoid such errors
in the future. This step is wholly new, for prior
efforts to improve compliance have relied on
patients’ self-reported compliance, which is sub-
ject to errors due to imperfect memory, mixed
feelings about the treatment program and a desire
to please the physician.- If the results of treatment are unsatisfactory, the
following questions must be answered:
364 CH27 PATIENT COMPLIANCE: PHARMIONICS, A NEW DISCIPLINE