Letters

Enhancing patients' compliance

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7128.393b (Published 31 January 1998) Cite this as: BMJ 1998;316:393

Electronic monitoring approaches should be more widely used

  1. Peter A Meredith, Reader in clinical pharmacologya
  1. a University of Glasgow, Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow G11 6NT
  2. b Avon Health Authority, Bristol BS2 8EE
  3. c National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO1 5DD

    Editor—Giuffrida and Torgerson's paper focuses attention on a problem that is widely recognised but largely ignored—namely, compliance.1 Any measure that seeks to improve compliance with a prescribed regimen should be encouraged. As the authors concede in their introduction, however, the main challenge is identifying the patients whose compliance is considered to be inadequate.

    Assessment of compliance should focus on the individual patient, and thus any approach that is targeted in a general manner at unselected populations is unlikely to be cost effective. The fundamental problem is that the prescribing clinician is unable to readily identify inadequate compliers and to distinguish them from poor responders or non-responders. This is not surprising as there is considerable evidence to indicate that compliance with a treatment regimen is not determined by age, sex, income, social status, level of educational achievement, or any other readily determinable factor. Thus before considering financial incentives to improve compliance we need to identify a reliable method to identify which patients to target.

    It is now generally accepted that counts of returned tablets and patients' diaries are inadequate methods of assessing compliance and generally overestimate consumption of drugs.2 Measurement of drug concentrations in blood, urine, or saliva may provide a limited insight into compliance but is relatively expensive, not instantaneous, and often misleading as, for many drugs, improvement in compliance immediately before a clinic visit will mask a potential underlying problem.

    Electronic monitoring approaches, which depend on the use of devices incorporated into the drug dispensing system (that is, electronic caps on drug containers or electronic recording devices incorporated into inhalers),3 are not entirely foolproof but are vastly superior to any other available monitoring approach. In addition, these devices offer the opportunity to extend our understanding of compliance in an individual patient from simply being a yes/no or adequate/inadequate phenomenon to one that recognises that compliance has dimensions of both time and quantity. To date such devices have proved to be too expensive for application in routine patient care. Undoubtedly, however, with more widespread use, economies of scale in production and cost would apply. This would allow greater emphasis to be placed on monitoring compliance, and a more rational approach could then be adopted to identify individual patients who are most likely to derive benefit from interventions designed to improve compliance.

    References

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    Financial inducements are equivalent to coercion

    1. A E Raffle, Consultant in public health medicineb,
    2. K Morgan, Director of public healthb
    1. a University of Glasgow, Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow G11 6NT
    2. b Avon Health Authority, Bristol BS2 8EE
    3. c National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO1 5DD

      Editor—What is happening to health care? We in Britain are shocked when we look back at the sterilisation of Swedish women without consent.1 Yet a paper in the BMJ describes a systematic review of studies of financial inducements to patients without mention of autonomy or coercion.2 Giuffrida and Torgerson seem to draw no distinction between two very different situations. One is where an individual is offered personal advice, treatment, or preventive interventions for the benefit of that individual alone. The other is where, for reasons of public protection, enforced management is contemplated because, for example, an untreated patient with tuberculosis threatens the safety of others. The liberty of one person is disregarded because of the risk to others. Giuffrida and Torgerson simplistically imply that coercion by means of payment or gifts can always be justified because it is for the patient's own good, as well as for the good of society at large. Presumably the same arguments were used for ignoring the need for consent by the Swedish women.

      There are many ways whereby we try to make services accessible and easy to use, and room for improvement exists. We try to minimise financial obstacles by providing free health care and by reimbursing travelling expenses for those with low income. Here in Bristol we have our share of problems in communicable disease control. Kindness and sympathy, home visits, the offer of a change of hospital team, and the offer of being taken to hospital by a member of staff whom the patient trusts often succeed in ensuring that patients do not endanger others by refusing treatment. In some cultural groups, particularly our Somali population, the usual approach often fails. We have contemplated using financial incentives but have decided to try even harder with a supportive approach.

      It is unacceptable to assume that coercion can be justified solely for an individual's own good or for any supposed economic benefit to society. The way people feel about, and benefit from, health care involves far more than the specific remedies with which they are treated.3 People must be supported in deciding for themselves whether the benefits they may receive from a specific remedy or preventive intervention outweigh any side effects they experience or any possible adverse consequences they may worry about. If benefits to the patient are so self evident, why are payments or gifts thought to be necessary?

      References

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      Authors' reply

      1. Antonio Giuffrida, Research fellowc,
      2. David J Torgerson, Senior research fellowc
      1. a University of Glasgow, Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow G11 6NT
      2. b Avon Health Authority, Bristol BS2 8EE
      3. c National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO1 5DD

        Editor—Meredith is correct that blanket use of any method of improving compliance is unlikely to be cost effective; the studies in our review, however, were conducted among selected or uncommon groups of patients (for example, homeless people with tuberculosis).

        We are surprised that Raffle and Morgan think that we advocated coercion to make patients comply with treatment. While we would have liked to discuss in more depth some of the issues that our review raised, we did not have space to do so. Also, linking our review with enforced sterilisation of Swedish women is somewhat extreme. We would not support the use of coercion; in our view, however, financial incentives are not coercive. Financial incentives allow more choice and autonomy than does having a healthcare worker try verbally to “persuade” (intimidate?) a patient to attend hospital. To some people, having a member of hospital staff arrive outside their home to take them into hospital might be deemed more coercive than the simple offer of a small payment.

        We are pleased to learn that Raffle and Morgan have a supportive service for those patients who need treatment with minimal barriers to access. As these authors admit, however, their methods fail among some groups of patients. Treatment failure among patients with an infectious disease means that their children, spouses, friends, and other members of the public are at risk of infection. Whose autonomy is now threatened? In addition, the methods used by Raffle and Morgan are probably relatively expensive, and it might be more cost effective and equitable to pay patients to attend. Assuming that it takes an hour of a health worker's time to travel to and collect a patient, this would cost at least £15—a far greater sum than was shown to be effective in one of the studies identified in our review.1 Rather than pay this money to a middle class professional healthcare worker, some might deem it to be a fairer use of our taxes to pay someone who is ill and poor and cannot afford the decent diet to fight the very disease that is being treated.

        Finally, in this era of evidenced based medicine, we assume that the strategies to maximise compliance used by Raffle and Morgan have been shown to be effective (and cost effective) in randomised controlled trials.

        References

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        View Abstract

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