DƯỢC LÍ Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th, 2010

Even the most carefully prepared prescription for
the ideal therapy will be useless if the patient’s level of
compliance is not adequate. Noncompliance may be
manifest in drug therapy as intentional or accidental
errors in dosage or schedule, overuse, underuse, early
termination of therapy, or not having a prescription
filled (Hagstrom et al., 2004); therapeutic failures can
result (Hobbs, 2004). Noncompliance always should be
considered in evaluating potential causes of inconsistent
or nonexistent response to therapy. The reported
incidence of patient noncompliance varies widely but
usually is in the range of 30-60% (Zyczynski and
Coyne, 2000); the rate for long-term regimens is ~50%
but can be impacted by pharmaceutical care management
(Klein et al., 2009).
Hundreds of variables that may influence compliance
behavior in a specific patient or condition have
been identified. A few of the most frequently cited are
discussed here, along with some suggestions for
improving compliance, although none provides 100%
compliance (Table AI–2).
Table AI–2
Suggestions for Improving Patient Compliance
Provide respectful communication; ask how patient takes
medicine.
Develop satisfactory, collaborative relationship between
physician and patient; encourage pharmacist involvement.
Provide and encourage use of medication counseling.
Give precise, clear instructions, with most important
information given first.
Support oral instructions with easy-to-read written
information.
Simplify whenever possible.
Use mechanical compliance aids as needed (sectioned
pill boxes or trays, compliance packaging, color-coding).
Use optimal dosage form and schedule for each individual
patient.
Assess patient’s literacy, language, and comprehension, and
modify educational counseling as needed. Be culturally
aware and sensitive. To improve compliance, don’t rely
on patient’s own knowledge of disease alone.
Find solutions when physical or sensory disabilities are
present (use nonsafety caps on bottles, use large type on
labels and written material, place tape marks on syringes).
Enlist support and assistance from family or caregivers.
Use behavioral techniques such as goal setting, selfmonitoring,
cognitive restructuring, skills training,
contracts, and positive reinforcement.
The Patient–Provider Relationship
Patient satisfaction with the physician has a significant
impact on compliance behavior and is one of few factors
that the physician can directly influence. Patients
are more likely to follow instructions and recommendations
when their expectations for the patient–provider
relationship and for their treatment are met. These
expectations include not only clinical but also interpersonal
competence, so cultivating good interpersonal and
communication skills is essential. Cultural sensitivity
is of growing importance, as healthcare providers see
more patients from countries and cultures different
from their own.
When deciding on a course of therapy, it can be
useful to discuss a patient’s habits and daily routine as
well as the therapeutic options with the patient. This
information may suggest cues for remembrance, such
as storing a once-daily medicine atop the books on
the bedside table for a patient who reads nightly, or in the
cabinet with the coffee cups if it is to be taken in the
morning (noting that the humid environment of a bathroom
can be the worst place to store a medication in
terms of its physical and chemical preservation). The
information also can help tailor the regimen to the
patient’s lifestyle. A lack of information about a
patient’s lifestyle can lead to situations such as prescribing
a medication to be taken with meals three times
daily for a patient who only eats twice a day or a medication
to be taken each morning for a patient who
works a night shift and sleeps during the day. Rarely is
there only one treatment option for a given problem,
and it may be better to prescribe an adequate regimen
that the patient will follow instead of an ideal regimen
that the patient will not. Involving patients in the control
of any appropriate aspects of their therapy may
improve compliance, not only by aiding memory and
making the dosage form or schedule more agreeable or
convenient, but also by giving patients a feeling of
empowerment and emphasizing their responsibility for
the treatment outcome.
It is not unreasonable for the physician to ask the
patient whether he or she intends to adhere to the prescribed
therapy and to negotiate to get a commitment to
do so. Attempts should be made to resolve collaboratively
any conflicts that may hinder compliance.
Patients and Their Beliefs
Behavioral models suggest that patients are more likely
to be compliant when they perceive that they are susceptible
to the disease, that the disease may have serious
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APPENDIX I
PRINCIPLES OF PRESCRIPTION ORDER WRITING AND PATIENT COMPLIANCE