Drug therapy: patient compliance

Compliance with drug therapy by epileptic patients

Fifty patients with epilepsy were randomly divided into three groups and given, respectively, oral information about the nature, purpose, appearances, functions, and unwanted effects of their medications at an initial interview; the same information supplemented by its presentation in written form for the patient to take home; and the same information by telephone contact only. Compliance with anticonvulsant therapy was assessed by interview and by drug levels. The amount of knowledge retained and the drug levels were measured again 4 weeks later. While no increase in serum levels could be detected over the mean values in the first interview, no reduction in levels could be documented either, although the drug information sheets had listed both the minor and the more serious unwanted effects of the drugs. The patients' information scores improved significantly in all three groups, but the combination of data presented at interview both orally and in written form was markedly superior to the other methods.

Improving patient cooperation with arthritis treatment regimens

This review of the literature on patient cooperation with arthritis treatment recommendations is categorized into 2 sections--involuntary and voluntary lack of cooperation. Extrapolating primarily from investigations of patients with other chronic diseases, 5 strategies for reducing involuntary patient noncooperation and 4 recommendations for improving voluntary patient cooperation are discussed. Although much remains to be learned about factors that influence patient cooperation with arthritis treatment recommendations, the application of existing knowledge can improve current levels. Determined efforts by health professionals are necessary if the excessive waste resulting from patient noncooperation is to be reduced. Shortcomings of past research and fruitful avenues for future empirical work in this important area are discussed.

Behavioral treatment of hyperlipidemia: techniques, results, and future directions

The present review examines the role of several target behaviors in the treatment of hyperlipidemia, including diet, exercise, cigarette smoking, Type A pattern, and medication adherence. Modification of the typical American diet (high in cholesterol, fat, and sodium) is emphasized in the treatment of hyperlipidemia since a multitude of laboratory, clinical, and epidemiological studies have shown that diet plays a crucial role in the pathogenesis of this condition and an increase in coronary risk. Factors affecting patient compliance such as health beliefs and family support are discussed in terms of their impact on behavior change efforts aimed at reducing plasma lipids through dietary and drug regimens. Intervention studies are reviewed in the behavioral treatment of hyperlipidemia. These programs have focused on diet modification, exercise, and medication adherence to reduce plasma lipids and coronary risk. The role of other target behaviors (i.e., Type A pattern and smoking) is explored not only in determining coronary risk but also in terms of their direct impact on plasma lipids. Further research is necessary to clarify the relationship between these target behaviors and plasma lipid levels and to investigate the effects of innovative family- and group-based intervention procedures in promoting and maintaining habit change related to coronary risk reduction.

Institutionalization and the defects of schizophrenia

Patients conforming to the Feighner criteria for schizophrenia who had been discharged from hospital were traced after 5-9 years. They were assessed in terms of mental state and cognitive, behavioural and neurological functioning; the results of these assessments were related to information obtained from casenotes. The findings of this study of 120 discharged patients were compared with those of an earlier study of 510 in-patients with schizophrenia. When factors of age and duration of illness were taken into account, there was no difference between the two groups in terms of positive or negative schizophrenic features or behavioural performance, although the in-patients performed less well on cognitive tests. This study indicates that the deficits of chronic schizophrenia are an integral feature of the disease process, and that any effects of institutionalisation are relatively small.

Evaluation and training of medication adherence counselors in a clinical trial: application of a skill inventory to video-recorded interviews

This report describes the procedures and feasibility of an integrated evaluation and training program developed at the Baylor-Methodist Lipid Research Clinic to examine the skills used by the clinic's professional staff in conducting medication adherence interviews with participants in the Coronary Primary Prevention Trial (CPPT). The specific aims of this project were to evaluate the staff's interviewing and counseling skills, identify strengths and deficits, provide needed training, and reexamine the staff's skills following this training. Each of five staff members conducted two 20-minute video-recorded interviews with two different simulated CPPT participants. A trained observer reviewed the video-recordings and evaluated, by an Inventory for Interviewing and Counseling Skills for Adherence to Medication (IICS-AM), each staff member's possession and frequency of use of 17 interviewing skills and 10 counseling skills. The 27 skills on the IICS-AM were selected from the literature as being most frequently recommended for effective interviewing and counseling for medication adherence. These rating data were used to design a 14-week training program to acquire and promote the use of these skills. Following training, the video-recorded interview procedure was repeated and the data analyzed to identify the effects of the training program. The integrated evaluation and training procedures used in this project offer a practical, objective method for examining, improving, and monitoring the skills of the adherence counseling staff in a clinic participating in a multicenter clinical trial.

Psychological factors associated with severe abuse of the Hemodialysis diet

Thirty-one maintenance hemodialysis patients were observed for a six-month period. Seven of these patients (22.6%) were severe and persistent abusers of the hemodialysis diet. Because there are serious, even lethal, consequences of the sequelae of hemodialysis diet abuse such as fluid overload and/or hyperkalemia, this finding demands explanation. All seven severe abusers were men and, as a group, their current life situation was devoid of typical adult male gratifications. Their developmental histories indicated major difficulties with resolution of dependency/independency conflicts. Statistical analysis of demographic data and extensive psychiatric interviews support this. The author postulates that severe abuse of the hemodialysis diet results in part from the combination of unresolved dependency conflict, unfavorable current environmental circumstances, and a dependency-provoking treatment regimen. Severe abuse of the hemodialysis diet may serve an adaptive function by allowing at least some gratification in one area of the lives of these patients who suffers severe deprivation.

Comparative assessment of two booklets about rheumatoid arthritis, intended for use by patients

Increases in patient knowledge after reading booklets about rheumatoid arthritis demonstrated the effectiveness of written material as a teaching aid. Two groups of patients (35 and 37 in number) in a specialist hospital acted as their own controls. Group A, after reading a booklet produced by the Arthritis and Rheumatism Council, increased their scores by a mean of 21 per cent. Group B, after reading a booklet produced by the Leeds Health Education Service, and containing substantially more information, achieved a 45 per cent average increase, indicating that this is the more effective of the two. Overall low scores before reading indicate a need for more patient education.

Noncompliance with post-transplant immunosuppression

Two cases from an adolescent dialysis group are presented to illustrate the limitations of the generally used models of patient compliance and noncompliance with medical treatment. Understanding the noncompliance of these two young men required awareness of their psychological development and of the interpersonal matrix in which they lived. Their noncompliance was the result of a failure to master a transition from dependence to autonomy which probably could not have been predicted in advance, but which might have detected as it developed and might have been avoided through appropriate interventions with the patients and their families.

Increasing return compliance in a tuberculosis detection drive

This study explored the role of subject commitment as a variable for increasing compliance rates in a university-sponsored tuberculosis (TB) detection drive. Return rates for reaction readings were compared between those subjects who had made an overt commitment to return (either a verbal or a verbal plus written agreement) and those subjects who were exposed to a standardized, no commitment procedure. Return rates under both commitment conditions significantly increased. Contrary to expectation, subjects with a known family history of TB were found to be a high-risk group for noncompliance. For this group, obtaining both verbal and written agreement from subjects appeared to be the most efficacious procedure to increase compliance.

What makes persons "patients" and patients "well?

The transitions from person to patient and back represent social decision points rather than boundaries determined by shifting biological equilibria, as doctors so often suppose. Moreover, host resistance to pathogenic agents is weakened by social stress and strengthened by social support. Thus, the efficiency and effectivenss of medical care will be improved if the clinician, in assessing patient problems, systematically inquires into the social determinants of the decision to seek help. The probability of resolving the patient's difficulties will be enhanced by targeting treatment measures at the social components of the illness experience as well as at the pathophysiology of the disease process.

Causes and effects of noncompliance in cardiac patients

This study affirms that compliance with medical regimen in a university cardiac clinic favorably influences patient outcome. The multiplicity of factors influencing compliance are emphasized, as is the need for continuing physician evaluation of compliance, and attempts to favorably influence it.

Education of independent elderly in the responsible use of prescription medications

A pilot study to test the effectiveness of medication instruction was carried out using 61 voluntary participants age 65 and older. They were interviewed regarding their medication taking, and instruction was individualized using one of four teaching modes: oral; written; oral and written; and oral and written combined with memory aids. Postinstruction interviews revealed no significant difference in compliance among all groups. The preinstruction mean compliance score of all subjects was 98.8 percent. Although compliance, judged specifically on the basis of the prescription label instructions, was extremely high both before and after instruction, drug-taking behavior and knowledge did change. The preinstruction compliance score does not necessarily reflect safe or desirable drug-taking behavior. There was no specific information given to clients with their prescriptions and prescription medications, indicating, for drug-therapy decision makers, a much broader problem than non-compliance.

An open comparison between free and a fixed combination of diuretic and beta-blocker in the management of essential hypertension

A total of 1,117 patients with inadequately controlled hypertension in spite of treatment with a combination of diuretic and beta-adrenergic blocker were studied. Treatment was changed to one or two tablets daily of Trasidrex (160 mg oxprenolol hydrochloride in a sustained release formulation and 0.25 mg cyclopenthiazide) with a subsequent improvement, 4 weeks later, in blood pressure control. Side-effects of treatment were uncommon and treatment was approved by the majority of patients. The majority of doctors participating thought a fixed combination would improve patient compliance with therapy.

An assessment of the clinical use of glyceryl trinitrate in a hospital outpatient population

Despite the availability of information on the use of glyceryl trinitrate (GTN) in standard texts, in practice many patients fail to obtain maximum benefit from GTN. This study of an Outpatient population, documents the patients' knowledge of the use and precautions which should apply to GTN and records the ways in which these patients took the drug. Fifty patients who regularly took GTN (greater than 5 tablets per week) were asked a series of questions by the same interviewer. Forty-nine of the 50 patients took GTN for the relief of chest pain, but only 34 patients knew that the drug could be used to prevent chest pain. Although 48 patients kept their bulk supply of GTN in the original container, over 40% transferred some or all of the tablets to other containers and locations. Seventy per cent of patients knew that GTN tablets deteriorate with time. However, knowledge of the factors which influence the rate of deterioration was lacking. Less than half the patients knew that the prompt relief of pain or the local effects on the buccal mucosa could be used as simple tests of the activity of tablets. It is recommended that all physicians should take more time to explain to their patients how to use glyceryl trinitrate correctly.

Compliance with medical regimens during adolescence

In summary, compliance behavior among adolescents is complex and imcompletely understood. Although the study of compliance is important for understanding the adolescent's stage of psychological development, relationships with authority figures, and the beginning of the youngster's career as a consumer of health care, its ultimate importance lies in the prospect of improving the likelihood that medication will be utilized appropriately. The first step in the process involves systematic monitoring of compliance rather than doing so only when noncompliance is clinically suspected. When compliance is found to be problematic for an adolescent, resorting to "scare" techniques or re-education is rarely effective. A more positive outcome may be achieved by determining the circumstances under which the youngster was successful in complying and attempting to tailor-make the regimen accordingly. Barriers to compliance, such as the presence of side effects, previous negative experience with the medicine, and lack of conviction about the diagnosis of appropriateness of therapy, should always be explored. Other potential intervention strategies for improving compliance have been discussed. In the final analysis, however, as Jonson has noted, all strategies aimed at improving compliance must provide the patient with insight into his own situation and himself, as well as his capability of doing something other than conforming when he judges it best.

Compliance with ocular therapy

Patient noncompliance with the physician's prescribed therapeutic regimen can present serious obstacles both to individual patient care and to the obtaining of information necessary for controlled drug trials. Unfortunately, the physician often is unable to determine whether and to what extent a patient is not complying with therapy. This article reviews the problem of patient noncompliance with particular emphasis on how and why noncompliance occurs, and methods of predicting, detecting and coping with the defaulting patient.

Blunting of exercise-induced tachycardia and renin release 24 hours after a single dose of sotalol

Sotalol significantly reduces resting and exercise-stimulated heart rate and plasma renin activity 2 hours and to a lesser degree also 24 hours after oral administration of a single 200-mg dose in healthy volunteers. Because of this 24-hour beta-adrenoceptor blocking effect, sotalol should be suitable for once-daily dosing in clinical practice.

A placebo-controlled multicenter trial of Limbitrol versus its components (amitriptyline and chlordiazepoxide) in the symptomatic treatment of depressive illness

In a multicenter, placebo-controlled, clinical trial, the efficacy of Limbitrol was compared with that of its components, amitriptyline and chlordiazepoxide. All patients had a diagnosis of primary depression. Data from 279 patients were evaluated using the Hamilton depression scale, the Beck depression inventory, and physician and patient global change measures. Statistically significant differences favoring Limbitrol occurred after 1 week of treatment, and a trend in favor of Limbitrol continued throughout the remaining 3 weeks. In most efficacy comparisons, the combination was as good as, or better than, amitriptyline alone. It was superior to chlordiazepoxide alone after 2 and 4 weeks of treatment. Each component produced an independent contribution to the total therapeutic effect: the chlordiazepoxide effect was more prominent in the first 2 weeks and the amitriptyline effect in the latter 2 weeks. A trend favoring amitriptyline over chlordiazepoxide was evident by week 4. The overall incidence of side effects was comparable in both Limbitrol- and amitriptyline-treated groups. Limbitrol-treated patients exhibited more sedation, but significantly fewer Limbitrol patients discontinued treatment prematurely because of side effects.

Factors influencing mothers' compliance with a medication regimen for asthmatic children

This study lends support to the utility of a compliance-adapted health belief framework for exploring mothers' differential adherence to medication regiments prescribed for their asthmatic children. Most of the Model components behaved as hypothesized in predicting mothers' drug administration. The findings offer empirical evidence which can be applied to the purposes of identifying potential noncompliers and designating those specific, health-related orientations of the mother which are related to poor cooperation with therapy. Based on an educational diagnosis, the clinician may thus intervene to alter inappropriate health beliefs in order to enhance the likelihood of compliance for the asthmatic patient.

Prevention by bedtime cimetidine of duodenal-ulcer relapse

45 patients with healed duodenal ulcers completed a six-month double-blind trial to compare the effects of cimetidine and placebo on the prevention of duodenal-ulcer relapse. A single bedtime dose of cimetidine (800 mg) was given and ulcer relapse was assessed endoscopically at regular intervals. At the end of the six-month trial, 16 of the 21 (76%) cimetidine-treated patients remained ulcer-free compared with only 3 of the 24 (12.5%) placebo-treated patients. No untoward effects of this treatment were observed.

A multicentre evaluation of sustained release oxprenolol in the management of hypertension in hospital out-patient practice

One hundred and two patients with essential hypertension, managed in hospital out-patient clinics in the United Kingdom on a drug regime of beta-receptor antagonist alone, or in combination with a diuretic were successfully transferred to once daily sustained release oxprenolol. Where a diuretic was prescribed the dose remained unchanged. Improved control of blood pressure was recorded in the majority of patients with one or two morning tablets of sustained release oxprenolol. Preference for once daily therapy, enthusiasm for the calendar pack, and a net increase in the mean daily dosage of a beta-receptor antagonist were the probable factors contributing to the improvement recorded. Once daily sustained release oxprenolol would appear, in most hypertensive patients, to be an effective substitute for multi-dose treatment with beta-receptor antagonists in conventional formulation.

Dentists' perceptions of their patients relation to quality of care

This study investigates dentists' perceptions of their patients and the relation of these perceptions to measures of actual quality of restorative treatment. The results indicate that 1) though the dentists see their patients as "cooperative," they perceived a substantial number of "problems," i.e., willingness to pay for optimal care or follow professional recommendations; and 2) there are significant associations between dentists' perceptions of patients and measures of the quality of restorative treatments; higher quality scores were associated with perceptions of a more cooperative patient.

Experience with a sustained-release formulation of oxprenolol in the management of angina pectoris in hospital out-patient departments

One hundred and two patients with angina pectoris under treatment with beta-receptor antagonists prescribed on a multi-dose basis were openly switched to treatment with once-daily sustained-release oxprenolol (160 mg per tablet). Eighty-eight patients were successfully managed on once-daily oxprenolol and 70% achieved significant benefit with a single morning dose of 160 mg. The mean number of anginal attacks and the mean glyceryl trinitrate consumption were both significantly reduced. It is concluded that once-daily treatment with oxprenolol in sustained-release form offers the advantage of reduced tablet ingestion without symptomatic detriment in the management of angina pectoris.