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Executive Summary

Rx DRUG NONCOMPLIANCE RESPONSIBLE FOR 23% OF NURSING HOME ADMISSIONS and 10% of hospital admissions, according to a just-released report by the HHS Inspector General report entitled "Medication Regimens: Causes of Noncompliance." The IG report is based on a review of the literature available on the issue of patient noncompliance and is related to the IG's April 1989 report on drug utilization review, which was conducted in preparation for the since defunct Medicare Catastrophic Coverage Act. Conducted "to determine why elderly people fail to follow prescription medication regimens," the study notes that "prior research indicates that 55% of the elderly fail to comply in some way with their medication regimens." The report acknowledges, however, that "rates of medication compliance are difficult to generalize. An individual patient's compliance behavior may not be consistent. A patient may comply with one medication but not another. Compliance behavior may change over time due to the patient's perceptions of efficacy of treatment and other factors." In addition, "methodological difficulties associated with conducting compliance studies may lead to an underestimation of the extent of the compliance problem." The report attributes medication noncompliance among the elderly to a combination of physiological, behavioral and treatment factors, as well as a lack of interaction between the health care provider and patient. Physiological factors noted include sensory impairments, such as poor eyesight or hearing, that can interfere with understanding instructions from a physician or pharmacist; memory loss; depression; and cognitive impairment. The nature of the disease being treated can also affect compliance. According to the report, compliance is worst among patients with chronic diseases when the medicine is taken preventatively, the patient is asymptomatic, or there are no immediate negative consequences of noncompliance. Behavioral factors cited by the study include social isolation; social and health beliefs that may be based on misconceptions or faulty information; and economic conditions that may make expensive prescription drugs unaffordable. Treatment factors that can cause noncompliance include the type of medication and its side effects, the patient's perceptions of the effectiveness of medication based on the form, size and color of the medication, and the duration and complexity of treatment. Addressing the issue of patient/physician interaction, the report insists that "compliance is the physician's responsibility as well as the patient's. According to the study, "physicians generally underestimate the levels of noncompliance among their own patients. They have also been shown to be unreliable predictors of whether or not individual patients will comply." The report maintains that the traditional patient/physician encounter is "ill-suited for learning to take place" because of anxiety, the large amount of information transmitted, the potentially upsetting nature of diagnosis and advice, and the physician's use of technical language. In addition, noncompliance can result from problems resulting at the pharmacy level. The report notes that medication labeling prepared by the pharmacist may contain discrepancies with what the prescribing physician intended, and that time for consultation between the pharmacist and patient may be limited. The report concludes that "education is the best way to improve compliance." The report recommends the use of public education programs and compliance aids such as refill reminder cards, large type instructions, the compilation of medication histories, simplified regimens and the involvement of family members in supporting or supervising correct medication compliance.

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