E-drug: TBnet (00230) Q&A: Improving compliance (cont'd)
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In answer to Richard Laing's forwarded question about improving
compliance with anti-tb drug regimens...
A very simple, practical starting point is the method described by
Cramer and Rosenheck from Yale, in the January 1999 issue of J
Nervous & Mental Diseases. Here's the reference: Cramer JA,
Rosenheck R. Enhancing medication compliance for people with
serious mental disease. J Nervous Mental Dis 187: 53-4, 1999.
Those interested in more details can contact Joyce Cramer at:
joyce.cramer@yale.edu
Basically Cramer and Rosenheck started with a very unpromising
group of patients, selected by the fact that their compliance,
measured by electronic monitoring, was in the range described as
'partial compliance', i.e. they were omitting one-third to two-thirds of
prescribed doses of medicines deemed medically crucial for their
clinical situation. Cramer and Rosenheck then reviewed with the
patients, in a simple interview, details of their daily lives, searching to
identify the most robust of these patients' daily routines. Having
selected one or more robust routines, they then endeavored to show
the patient how to link the dosing to the routine in question. They
reported that the whole thing can be done in less than 15 min, and
does not require elaborate skills on the part of the interviewer.
A key point is that they continued using the electronic monitoring to
verify whether the linkage to robust routines maneuver actually
improved compliance, and, if not, they went at it again with the
patient. The principle of 'measurement-guided management' is of
course a very basic tenet of management in other areas of human
endeavor, but has been the exception rather than the rule in attempts
to improve patient compliance with prescribed drug regimens.
Cramer and Rosenheck were able to get about 80% of the patients in
their study up to a level of compliance that was probably good enough
to enable them to get a good therapeutic result from all but the least
forgiving prescription drugs.
That conclusion of course begs the question "how much compliance is
enough?", which is a drug-specific issue. It is often said that 'good
compliance' consists of taking 80% or more of prescribed doses, but
that statement is uninformed by even the most basic clinical
pharmacologic considerations. It is manifestly untrue, for example, for
the combined oral steroidal contraceptives, which are in the
prescription drug class with which we have the longest-running, most
extensive use-experience, and for which the question 'how much
compliance is enough?' is clearly answered and translated into labeling
in both the US and the UK. The kinds of studies which support that
labeling need to be run on other chronic-use drugs, where feasible.
The Cramer-Rosenheck method is not a panacea, for it clearly left
about 20% of the original group in more or less the same low level of
compliance. But it improved a substantial majority, and, as such,
represent a considerable overall improvement, despite its manifest
simplicity. In their hands, the effects of their intervention persisted for
at least 6 months, but it would be unwise to assume that some
reinforcement from time to time isn't necessary.
In my experience in discussing these results with various caregivers,
the one group that seems to resist the simple conclusions of Cramer
and Rosenheck are those with a strong bent towards behavioral
sciences. There seems to be a feeling that something so simple cannot
be effective. Clearly the work needs to be repeated and expanded to
other types of clinical problems than those of the original study.
Moreover, it may well be, in the special circumstances of TB, which
often includes a large proportion of homeless patients, that the 'robust
routines' idea is not very useful. Time and future studies will tell the
tale.
John Urquhart, MD, FRCP(Edin)
Professor of Pharmaco-epidemiology
Maastricht University, Maastricht, Netherlands
Chief Scientist, AARDEX Ltd/APREX Corp,
Zug CH & Union City, CA USA
Professor of Biopharmaceutical Sciences, UCSF, San Francisco
home office: 975 Hamilton Ave, Palo Alto, CA 94301 USA
e-mail: urquhart@ix.netcom.com
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