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Compliance is defined as “the extent to which a person’s behavior
coincides with medical or health advice.” Despite the importance of the
medication in treatment, disease prevention, and health promotion, compliance
rates range from 11% to 93%. The authors reviewed pediatric medication compliance
literature based on Medline searches of: medication compliance, patient compliance,
patient dropouts, or treatment refusal combined with 45 other terms including
drug therapy and specific formulations or methods of drug delivery. Additionally,
data were excerpted from an AAP Periodic Survey on primary care pediatricians’ views
on patient compliance with completing prescriptions for acute and chronic illness.
The authors noted a caveat regarding compliance data reliability: parental
reports of compliance have been shown to be markedly overrated (eg, in one
study, mothers reported 60% compliance with obtaining prescribed refills, compared
to only 12% according to pharmacy records).
The review yielded a number of principles pertaining to barriers to good
medical regimen adherence. Limits on the time the physician can spend
with each patient and family to negotiate a best-fit medication and discuss
their ability to comply with the prescribed regimen represents a significant
barrier. Lack of continuity of physician-patient interaction, particularly
between and within multi-personnel office settings, is a strong predictor of
poor compliance. Patient and family characteristics constitute additional
sets of factors influencing compliance: the patient’s and family’s
ability to understand the importance of following the prescribed treatment
is an important element. Factors affecting understanding include health literacy,
education, and culture. Patient/family knowledge, information, and misinformation
or perspectives from outside sources (including the Internet) influence compliance,
as can psychological function (eg, psychopathology). Such preexisting or emerging
problems necessarily require attention in order to enhance compliance.
Practice setting characteristics and specific physician behaviors can
influence compliance. Parents are more likely to be actively involved in the
communication process if they are not distracted by restless children, their
own time constraints, and annoyance over long waits. Enhanced communication
skills have been known to shorten visit duration, improve patient adherence,
and decrease the need for follow-up care.
Medication factors (eg, duration, schedule, formulation, palatability,
cost, and adverse effects) were clearly associated with compliance. Longer duration of
the medication regimen and increased complexity of the medication
schedule represented risk factors to adherence, with mid-day dosings being
particularly problematic. Personal preferences and aversions became evident
in relation to forms of medication and palatability. Children
expressed preferences for one form over another (eg, sprinkles vs syrup) whereas
parents preferred oral liquid to solid forms (eg, powder, tablets, capsules). Medication
cost for the uninsured or under-insured constituted an additional burden
leading to compromised compliance. Cost also drove drug formulary decisions
that restricted access to some useful medications that were more palatable
and/or facilitated the dosing schedule. Finally, adverse effects from medications decreased
compliance.
The authors outlined a set of General Principles to Enhance Medication
Compliance that include: (1) improving communication between physician
and patient/family, (2) modifying or negotiating regimens, (3) emphasizing
patient self-management of disease or illness, (4) using the simplest and
most effective regimen available, and (5) using technology and devices to
facilitate compliance. The authors stated the overriding issue for improved
compliance is developing a one-on-one relationship between “1 doctor
and 1 patient.”
Winnick S, Lucas DO, Hartman AL, Toll D. How do you improve compliance? Pediatrics. 2005;115:e718-724.
First Editor’s Comment: The term compliance is often
used interchangeably with adherence, as it has been in this paper. However,
compliance entails obedience to a directive from a physician (eg, “take
this medication 3 times a day”), whereas adherence implies that the patient
and family are active collaborators in the treatment process. The WHO defines
adherence as “the extent to which a person’s behavior—taking
medication, following a diet, and/or executing lifestyle changes, corresponds
with agreed recommendations from a health care provider.”1
The average adherence to medication recommendations is approximately 50%
in the pediatric population.2 Despite intuitive expectations, adherence can
falter even in life-threatening conditions such as type 1 diabetes (T1DM) and
congenital adrenal hyperplasia. Winnick et al emphasized the critical importance
of the one-on-one relationship between physician and patient as the key to
improving adherence. Improved delivery systems (eg, pumps, transdermal patches,
etc.) alone are unlikely to eliminate adherence problems. For example, a good
collaborative relationship associated with clear communication would facilitate
prompt discovery that the adolescent with uncontrolled T1DM has “broken” insulin
pumps because he is embarrassed that his peers can see the device. Another
example would be the young adult male with gonadotropin deficiency who fails
to adhere to recommendations because the testosterone replacement dose is inadequate
for normal erectile function. There is typically an explanation for poor adherence,
but the remedy presupposes strong lines of communication between the physician
and the patient and the family. The cost is time—the time to develop
and maintain a relationship. While technological advances can facilitate adherence,
when problems emerge, they cannot be confused with the solution.
Finally, the authors’ recommendation to “emphasize patient self-management
of disease or illness” should be interpreted cautiously. In the pediatric
context, one needs to know who assumes responsibility for various aspects of
medical care or how that responsibility is shared within the family.
David E. Sandberg, PhD
Second Editor’s Comment: Coincidentally, Osterberg
and Blaschke3 published a review article, “Adherence to Medication” which
denotes the importance of this issue across disciplines. As C. Everett Koop
said, “Drugs don’t work in patients who don’t take them.” The
problem is of particular importance to pediatric endocrinologists who treat
patients with chronic conditions requiring long-term therapy, complex regimens,
and frequent medication changes. Furthermore, patients are often asymptomatic
and cannot care for themselves. These patient characteristics are typical of
poor compliance and/or adherence to treatment. Lack of response to medication,
missed appointments, presence of psychological problems, and/or cognitive impairment
of the patient or caregiver may be indicators of poor adherence. High medication
costs and third-party payor requirements including high co-payments and frequent
refills compound the problem. These barriers are important and add to the time
required to obtain medications. Poor adherence contributes to worsening of
disease, increased costs of care, and even death. New cost-efficient technologies
that facilitate treatment adherence are needed to aid physicians and patients
in meeting the goals of therapy.
Fima Lifshitz, MD
References - (linked to  )
- World Health Organization. http://www.who.int/chronic_conditions/adherencereport/en/.
Accessed November 2, 2005.
- Matsui DM. Pediatr Clin North Am. 1997; 44:1-14.
- Osterberg L, Blaschke T. N Engl J Med. 2005;353:487-497.
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Current GGH - Vol. 24 No. 1
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