Patient noncompliance

Patient noncompliance with prescription regimens is one of the most understated problems in the health care system. The effects of noncompliance have enormous ramifications for patients, caregivers, and health professionals. Compliance with medications is a worldwide problem, and measures that are effective in one country may not have work elsewhere. 

Bloom, D.L., "Facing the Next Challenge of Pharmaceutical Care Patient Noncompliance," Med.-lnterface, 9, 67-72 (1996). 

Patients noncompliance with doctors orders is a widespread phenomenon and well analyzed in the medical and social science literatures. While physicians, wedded to assumptions of rationality, often attribute noncompliance to poor communication between doctors and patients, sociologists are much more likely to stress the symbolic meanings attached to aspects of treatment, including medications. When our conversation turned to her repeated efforts to stop her medications despite the relief they were providing, Rachel contrasted psychotropic drugs with medications prescribed for physical ailments Swallowing pills to deal with emotional pain is a completely different thing. It s a much harder pill to swallow. ... 

In the Expert Consensus survey (Rush and Frances, 2000) the expert clinicians rated newer atypical antipsychotics highest for treatment of schizophrenic patients who are compliant with medication. Risperidone was rated highest of the atypicals, followed by olanzapine. In the case of patients with numerous failed trials with other antipsychotics, the experts voted for clozapine. For patients noncompliant with oral medication, respondents endorsed long-acting depot antipsychotics. Once again, these were impressions based on personal clinical experiences rather than hard empirical data. 

The directions for use (element [11]) must be both drug-specific and patient-specific. The simpler the directions, the better and the fewer the number of doses (and drugs) per day, the better. Patient noncompliance (also known as nonadherence, failure to adhere to the drug regimen) is a major cause of treatment failure. To help patients remember to take their medications, prescribers often give an instruction that medications be taken at or around mealtimes and at bedtime. However, it is important to inquire about the patient s eating habits and other lifestyle patterns, because many patients do not eat three regularly spaced meals a day. 

Compliance is the third patient-related factor contributing to medication errors. One study found a 76 percent difference between medications patients actually are taking when compared with those recorded in their charts as prescribed. Two factors that contribute to this high rate of discrepancy include confusion that may accompany advancing age and the increase in the number of prescribed medications (Bedell et ah, 2000). Another study demonstrated that patient noncompliance played a role in 33 percent of hospital admissions (McDonnell, Jacobs, and McDonnell, 2002). 

Patients noncompliant with twice daily dosing... 

Patients noncompliant with dietary restrictions, concomitant drug restrictions, and twice daily dosing after meals... 

Patients noncompliant with dosing with food... 

The fimdamental ubiquitous problem of patient noncompliance (therapeutic nonadherence) continnes to be significant in the management of ocular disease in ambn-latory ontpatients. Much time, effort, and expense are directed at diagnosis and the subsequent selection of drng therapy, but what transpires beyond that point in the patient s care depends on many fectors. 

Inadequate supplemental physical procedures Inadequate patient immune system response Patient noncompliance... 

Patient noncompliance is identified as a major factor in therapeutic failure in both routine practice and in scientific therapeutic trials but, sad to say, doctors, are too often noncompliant about remedying this. All patients are potential noncompliers " good compliance carmot be reliably predicted on clinical criteria, but noncompliance often can be. 

In these real life, or naturalistic, conditions the drug may not perform so well, e.g. minor adverse effects may now cause patient noncompliance, which had been avoided by supervision and enthusiasm in the early trials. These naturalistic studies are sometimes called pragmatic trials. 

The most important precaution during replacement and pharmacotherapy is to see the patient regularly with an awareness of the possibilities of adverse effects including fluid retention (weight gain), hypertension, glycosuria, h)q)okalaemia (potassium supplement may be necessary) and back pain (osteoporosis) and of the serious hazard of patient noncompliance. 

Didlake RH, Dreyfus K, Kerman RH, Van Buren CT, Kahan BD.1988. Patient noncompliance a major cause of late graft failure in cyclosporine-treated renal transplants . Transplant Proc. 20(Suppl. 3) 63-69. 

The importance of the execution model cannot be overemphasized. The execution model describes how the study is carried out and deviations from the protocol. There are deviations from the protocol that are done by the patient such as refusal to enter the study, dropouts, and patient noncompliance. Other deviations are due to practitioner behavior such as missing data, wrong recording of data, or improper preparation of doses. It must be decided whether the deviations are completely at random or if there is some influencing factor that may result in protocol deviations. For example, would patients experiencing adverse events have a greater tendency to drop out of the study ... 

The natural course of chronic PUD is characterized by frequent ulcer recurrence. Approximately 60% to 100% of ulcers recur within 1 year of initial ulcer healing with conventional antiulcer regimens. The most important factors that influence ulcer recurrence are HP infection and NSAID use. Other factors include gastric acid hypersecretion, cigarette smoking, alcohol use, a long duration of PUD, ulcer-related complications, and patient noncompliance. The cause of ulcer recurrence is most likely multifactorial. 

One of the most common obstacles to the success of dietary restriction is patient noncompliance due to the poor palatabUity and inconvenience. Regular counseling by a dietitian is essential to improve patient compliance. As kidney function declines, dietary restriction alone is usually inadequate to control serum phosphorus, and phosphate-binding agents are necessary (see section on pharmacologic therapy). 

The guiding principle for using drugs iu pauic disorder is to start low, use au adequate dose, aud treat for au appropriate period of time. Side effects with the autidepressauts, ofteu from too high au initial dose, may prevent achievement of an optimal dosage, compromise treatment response, and contribute to patient noncompliance. 

Dardick K. Educating travelers about malaria dealing with resistance and patient noncompliance. Cleveland Clin J Med 2000 69 469 79. 

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