Patient Noncompliance: Subset Analysis
Owens, Norma J., Drug Topics
To measure accurately the degree to which a patient adheres to a therapeutic regimen, it may be necessary to use a combination of electronic monitoring, drug assays, and interviews. However, understanding the principles underlying noncompliance and partial compliance may also help physicians develop effective interventions that will aid their patients in achieving acceptance of therapeutic regimens.
Patients who fail to adhere to a prescribed regimen send a clear signal to the health care provider that something has gone wrong. To understand a patient's behavior better, it may be helpful to examine how compliance is affected by the patient's values, beliefs and circumstances, physician/patient interactions, and disease state. Insight into how these variables interact will enable physicians to convince their patients of the importance of complying and of the worth of behavior modification for their benefit.
The health belief model may help to explain a patient's behavior (Fig 1). (Figure 1 omitted) Becker and Maiman suggest that understanding a patient's risk of noncompliance with a medical regimen will do little to help alter the situation and does not explain what factors help to motivate the larger group of patients who do comply, even in the face of inconvenience and adverse reactions.(1) The use of a value expectancy model to explain behavior under conditions of uncertainty can serve as a consistent framework in which to compare different groups of patients. Behavior may be predicted by understanding the value of an outcome to an individual and from that person's belief that a given action will result in a particular outcome. The patient subsets addressed will he stratified by age to provide a range of disease types, and three models will be discussed.
MODEL 1: ACUTE REVERSIBLE DISEASE VS CHRONIC COMPLEX DISEASE
Children with acute otitis media are a subset of patients who present with an acute disease in which there is little doubt about the accuracy of the diagnosis, the probability for cure is high, and the barriers to treatment are low. Data from this population suggest that compliance is high in the initial phase of treatment but decreases as the patient's symptoms abate. The compliance rate for treatment on day 5 or 6 of a 10-day antibiotic regimen is only 20% to 30%.(2) However, little evidence suggests that the success of treatment of otitis media is affected adversely by this decrease in compliance.(3)
The treatment of insulin-dependent diabetes mellitus in the adolescent presents a very different challenge to the practitioner. These patients must accept a complex and chronic disease during a time of confounding social and psychological variables. They must learn new patterns of diet and exercise, manage the medication, and become familiar with monitoring methods and means of preventing physical deterioration (Table 1). (Table 1 omitted) These tasks must be timed and integrated appropriately to achieve a favorable outcome. The rates of compliance with the different components of a diabetes regimen vary: in general, compliance is higher with the medical components of the regimen than with the life-style modification components.(4,5)
Psychological variables that affect compliance in patients with diabetes include mood,(6) coping skills, and feelings of worth or self-esteem.(7) The involvement of family members and continuity of care by the health care provider are factors that may have a positive effect on compliance in these patients. Including the patient in the design of a therapeutic regimen may also encourage cooperation and acceptance of a regimen. Recently, some of the barriers to compliance among diabetic patients have been lowered by advances in pharmacologic dosing methods in the form of insulin syringe "pens." This new dosing form allows a patient to dial the proper dose and self-inject premixed insulin suspension, isophane, and regular insulin preparations without the additional steps needed in the traditional vial and syringe systems. …