A manuscript by Mcdonald, et al published in JAMA in Dec 2002 reviewed all relevant published RCT of interventions to improve adherence to medications. In the analysis 49% of the interventions resulted in increased medication adherence and only 17% resulted in improved treatment outcomes. Many of the interventions to improve compliance involved phone calls, staff reminders and post-doctor visit counseling. Thus, most interventions were labor intensive and were not terribly effective in changing outcomes. In another review in Clinical Pharmacy and Therapeutics from 2001, Vermeire, et al found that factors related to poor compliance included psychiatric disorders, duration of treatment (longer duration results in decreased compliance), number of medications (and their cost) as well as the frequency of dosing. Not surprisingly, the complexity of the regimen was shown to predict poor compliance and the doctor-patient relationship really seemed to be an important variable in predicting higher adherence rates. Traditionally, physicians have taken a very paternalistic approach to counseling patients about treatment plans. Today, it is clear that there must be a shift to a “partnership” with shared responsibility between doctor and patient.
In this presidential election year, there is much discussion as to how best to reform healthcare in order to reduce cost and improve outcomes. Politicians have recommended sweeping changes to our healthcare system at high cost to taxpayers. Maybe more cost-effective changes to improve healthcare may be those that focus on improving compliance through strengthening the doctor-patient relationship. It is clear that lack of compliance results in poor outcomes, increased cost and lack of successful treatment. As physicians, we must understand that the doctor-patient relationship is central to solving this problem. We must involve patients in shared decision making and work to understand each individual patient’s perspective and circumstances that may impact adherence to a particular treatment plan. We must treat the patient as a partner in care. We must consider factors that may impede our ability to achieve high levels of adherence such as psychiatric illness, financial stress, family circumstances and support mechanisms. Most importantly we must individualize treatment plans and foster two way communication in order to promote success.