detection of poor compliance will improve as the
use of electronic monitoring expands. There have
been many examples in the past of how increasing
use of a new, objective measurement resulted in a
concomitant improvement in doctors’ abilities to
recognize problems on clinical grounds alone. A
more uncertain matter is how physicians can best
intervene to improve compliance, or whether they
will allow this problem to pass into the hands of
other health professionals, as occurred, for exam-
ple, with glucometry in IDDM.
Pharmacists
Compliance management opens up a potential
opportunity for pharmacists to become directly
engaged in pharmaceutical care and not allow the
linkage between measurements and care to default
to another professional group, as occurred in
IDDM. If pharmacists correctly position their com-
pliance-related activities, they could develop a
much stronger partnership with the prescriber,
though it will require a clear definition of the
roles of the physician and the pharmacist (Me ́try
and Meyer, 1999).
Transition from in-hospital
to in-home care
Medication monitoring can help smooth the transi-
tion from the hospital to the home, to be sure that
the patient is able to cope with the prescribed regi-
mens at home. It will require a close link between
hospital and community pharmacies.
SIAC: systems integration
in ambulatory care
Several published RCTs show that frequent tele-
phone contact with patients considerably reduces
resource utilization in CHF and other chronic con-
ditions. Thus far, however, the phone maneuvers
lack an objective measure of the patient’s dosing
history, which, in most instances, is the most
important variable in disease management.
How much more efficient would these interven-
tions be, if one could confidently rule in or out drug
regimen noncompliance as the main focus for
intervention? Hence, the SIAC program. SIAC
provides a convenient upload link from the
patient’s electronic dosing monitor(s) to a website,
where the dosing history is analyzed and a specific
plan formulated to guide the patient toward punc-
tual dosing. Analysis and plan are downloaded to
the prescriber, pharmacist or phone-interventionist
for implementation. The cycle can occur dailyvia
automatic downloading of dosing data from an in-
home modem link, or at weekly/monthly intervals
from downloading in the pharmacy or clinic. Class
III and IV CHFs need daily review, but in other
conditions, the complications of noncompliance
are slower to occur, allowing weekly, monthly or
quarterly analyses.27.17 What will be the reaction
of third-party payers?Studies will be needed to provide data on the cost-
effectiveness of such approaches. One must
approach these cautiously, because there is much
to be learned before engaging in the kinds of con-
firmatorystudiesthatcandefinetheactualeconomic
value of a new approach. Studies done prematurely,
before the ‘learning curve’ has been substantially
traversed, will only confuse and delay matters. A
key step, as emphasized earlier, is the targeting of
high-risk patients, whose well-being depends very
directly on maintenance of the dosing schedule.
Moderate–severe congestive heart failure appears
to be one such situation; chronic hormonal receptor
blockade in hormonally dependent tumors is prob-
ably another. Still another is immune suppression in
organtransplant recipients. Yetanotherismoderate-
to-severe epilepsy, especially at the time the patient
is being evaluated for escalation from monotherapy
to two-drug therapy, or from two-drug to three-drug
therapy, to be sure that seizure recurrences are the
consequence of inadequate drug action, not inade-
quate drug dosing.
The field of therapeutics is vast and complex,
with many areas in which special problems arise370 CH27 PATIENT COMPLIANCE: PHARMIONICS, A NEW DISCIPLINE