Mastergeriatria.it

Helping Patients Follow Prescribed Treatment: Clinical
Applications
R. Brian Haynes; Heather P. McDonald; Amit X. Garg JAMA. 2002;288(22):2880-2883 (doi:10.1001/jama.288.22.2880) Patient-Physician Relationship/ Care; Treatment Adherence; Drug Therapy;Adherence Interventions to Enhance Patient Adherence to Medication Prescriptions: Scientific CLINICIAN’S CORNER
Helping Patients Follow Prescribed Treatment
Clinical Applications
R. Brian Haynes, MD, PhDHeather P. McDonald, BSc Low adherence to prescribed medical regimens is a ubiquitous problem. Typi-
cal adherence rates are about 50% for medications and are much lower for
lifestyle prescriptions and other more behaviorally demanding regimens. In
MEDICALRESEARCHDUR- addition,manypatientswithmedicalproblemsdonotseekcareordropout
of care prematurely. Although accurate measures of low adherence are lack-
ing for many regimens, simple measures, such as directly asking patients
and watching for appointment nonattendance and treatment nonresponse,
will detect most problems. For short-term regimens (Յ2 weeks), adherence
ingly, these treatments can be self-administered. Unfortunately, low to medications is readily achieved by giving clear instructions. On the other
hand, improving adherence to long-term regimens requires combinations of
information about the regimen, counseling about the importance of adher-
ence and how to organize medication taking, reminders about appoint-
ments and adherence, rewards and recognition for the patient’s efforts to
follow the regimen, and enlisting social support from family and friends. Suc-
cessful interventions for long-term regimens are all labor-intensive but ul-
timately can be cost-effective.
who enter the medical care system,more than a third may drop out, espe- cially during the first few months.
While in care, the average consump- adherence, with a specificity of 87%.
fluids (blood, saliva, urine) can help in tion is “Have you missed any pills in the Author Affiliations: Department of Clinical Epidemi-
ology and Biostatistics and Department of Medicine,McMaster University Faculty of Health Sciences (Dr Haynes), and Health Research Methodology Pro- timation of adherence by patients is dif- gram, McMaster University School of Graduate Stud- ies (Ms McDonald and Dr Garg), Hamilton, Ontario.
Corresponding Author and Reprints: R. Brian Haynes,
MD, PhD, Department of Clinical Epidemiology and Biostatistics, McMaster University Medical Centre,Room 2C10B, 1200 Main St W, Hamilton, Ontario, Canada L8N 3Z5 (e-mail: [email protected]).
suring adherence is presented in BOX 1.
Scientific Review and Clinical Applications Section
Editor: Wendy Levinson, MD, Contributing Editor.
We encourage authors to submit papers to “Scien- tific Review and Clinical Applications.” Please con- tact Wendy Levinson, MD, Contributing Editor, JAMA;phone: 312-464-5204; fax: 312-464-5824; e-mail: See also p 2868.
2880 JAMA, December 11, 2002—Vol 288, No. 22 (Reprinted)
2002 American Medical Association. All rights reserved.
Is This Patient Following the
Treatment as Prescribed?
If Not, What Can I Do About It?
dants that can prevent heart disease.
checked at the visit and found to be giv- ing falsely low readings. Recent tests in- can also be helpful in a health care sys- 2 to 3 times a night, but otherwise feels Box 1. Measures of
Adherence*
ing to improve patient adherence.5,6 First, zide daily, 20 mg of simvastatin at night, 10 mg of glyburide twice daily, and a re- correctly established. Second, the treat- been able to lose weight despite attempt- efficacy for this diagnosis and appropri- ing to follow a calorie-restricted diet and ate for the patient’s circumstances. Third, lished effectiveness (or otherwise will be a waste of resources, at best). Fourth, the Box 2. Increasing Adherence
patient’s right to refuse treatment must With Short-term Treatments*
be respected at all times. Attempts to co- copy, and decreased sensation in his feet ety levels simply withdraw from carewhen threatened.7 Box 3. Increasing Adherence With Long-term Treatments*
Simplifying the regimen (eg, less frequent dosing, controlled release dosage forms) tions.8 In the Scientific Review,8 so few studies of short courses of treatment re- Reminders (manual and computer) for medications and appointments Reinforcement and rewards (eg, explicitly acknowledging the patient’s efforts tions are summarized in B
Self-monitoring with regular physician review and reinforcement OX 2 and BOX
Involving family members and significant others 3 and we discuss their applications in the
context of questions that commonly arise
2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, December 11, 2002—Vol 288, No. 22 2881
This patient’s difficulties include low written instructions of what to start and Has This Patient Dropped
Out of Care?
adverse effects from her medication.
moglobin A1c, as well as infrequent self- tes control.14,15 Rather, it follows the evi- even be seen as transient relief from the speculate that the patient forgot the ap- ence2 and that simplification of the regi- tor’s practice. Missing appointments is a regimen closely for any length of time.
tance of high adherence, negotiating pri- up by the clinic if ongoing care is clini- ter or telephone, by contracting with pa- be shared with nurses, specialists, phar- tors that are aggravating his diabetes.
patient and his significant others are will- if he will agree and the glyburide, which which can increase insulin resistance.
his cardiovascular risk. In fact, the sugar Conclusions
ferred until the blood glucose is brought cal therapies, better, more effective, and 2882 JAMA, December 11, 2002—Vol 288, No. 22 (Reprinted)
2002 American Medical Association. All rights reserved.
tance of high adherence at each visit will many patients to follow their regimens.
health care professionals. If needed, and with the patient’s permission, the help sistent effects on clinical outcomes. Per- can have adverse effects especially if it ence intervention was cost-effective.
ing the regimen as simple as possible, ne- gotiating priorities with the patient, pro- Funding/Support: Ms McDonald was supported by
a Population Health Information Project studentship and Dr Garg was supported by the Canadian Insti- daily with 10 mg of enalapril twice daily tutes of Health Research/Kidney Foundation of Canadaand Associated Medical Services/Wilson Postgradu- REFERENCES
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2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, December 11, 2002—Vol 288, No. 22 2883

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