Between October and November 2009, Disruptive Women in Health Care analyzed the issues surrounding Drug Adherence and issued a series of posts from a variety of viewpoints and perspectives. In addition to our own pool of experts, Disruptive Women invited a number of guests to post on this complex public health topic. We compiled all the posts into an e-book. We hope you will find this a useful reference.

Please feel free to share, cross post and distribute with others who would find this of interest.

As always, we welcome your feedback and comments. All the posts remain on the blog and it’s not too late to comment on specific posts.

Download a free copy of the “Drug Adherence Throwdown” e-book.

The following guest post — part of Disruptive Women’s drug adherence series — is written by Valerie Fleishman, Executive Director, New England Healthcare Institute.

Patient adherence represents a rare “win-win” in health care, so it’s no surprise that all sectors have been busy seeking potential solutions. Technology companies have developed reminder gadgets, employers have redesigned benefit plans to remove cost barriers to chronic disease medications, pharmaceutical companies have developed combination drugs to simplify regimens, and providers have begun implementing new patient education and counseling techniques. However, efforts to date have remained largely sector specific and silo-ed. An earlier post by Janet Wright correctly pointed out that poor adherence is not the fault of patients, but rather the fault of the entire health care system. Ideally, we need to move beyond silo-ed efforts and develop a system-wide approach to the problem.

Recognizing that, the New England Healthcare Institute (NEHI) launched a multi-stakeholder initiative earlier this year to identify system-wide solutions to poor adherence. Several of these solutions have been mentioned in this series such as improved care coordination and the use of health information technology. However, I would like to highlight a fundamental system-wide change that has not yet been discussed in great detail, and was one of the critical findings from NEHI’s multi-sector expert roundtable and issue brief:  payment reform.

It is important to keep in mind that patient medication adherence is ultimately a quality issue.  As NEHI’s research shows, the link between medication adherence and improved health outcomes is clear.  Studies of chronic disease patients have shown that adherent patients have significantly lower hospitalization rates than nonadherent patients. Unfortunately, the current payment model is not designed to reward providers for patient outcomes – of which medication adherence may qualify as either a means toward that end or an endpoint itself. Either way, using payment reform to move away from rewarding volume of services and towards rewarding good health outcomes would go a long way to improving medication adherence and patient outcomes.

Performance-based reimbursements, global service payments, and Accountable Care Organizations are all being discussed as ways to reform our payment and delivery system. Performance-based reimbursements would reward providers for helping patients achieve measurable, positive health outcomes. Global service payments would give providers a lump sum to manage a group of patients as they see fit – with the expectation that the payment is used to achieve the best possible outcomes. Accountable Care Organizations are collaboratives within which a hospital, primary care physicians, specialists and other providers accept shared responsibility for the cost and quality of the care provided to a group of patients.

(more…)

The following guest post on the subject of drug adherence is written by Janet Wright, Senior Vice President, Science & Quality, at American College of Cardiology.

If the Disruptive Women series on medication adherence has shown anything, it’s that there is a nearly endless number of potential solutions to address the nearly endless number of reasons patients and their prescribed medications do not “stick.”. Over decades of practice in cardiology, I had a first hand view of the challenges patients face in adherence – inability to afford the prescription to incomplete understanding of a med’s value or benefit to overestimating the risk to unclear directions or complex instructions on how and when to take the drugs..

Now, in a staff role at the American College of Cardiology, I join others in the search for solutions to help other cardiologists and health care professionals improve adherence to complicated medication regimens. Successful medication adherence is not a failure on the part of the patient to take their medication, but rather a failure on the part of the health system – including patients, their providers, the reimbursement structure, the insurance companies, etc. – to make it easy and worthwhile for the patient to take his or her medicines..

In July a group of key stakeholders met to brainstorm potential solutions to improve medication adherence. The sponsoring groups represented the major players in improving medication adherence – the drug stores (National Association of Chain Drug Stores), the drugs (PhRMA, GlaxoSmithKline), the patient (National Consumers League) and the ACC representing the physician joined the coalition this fall. In addition to these groups, there were about 40 leaders in the field who shared their wisdom. With the knowledge gained from the discussion in July and in the context of the proposals being considered by Congress, the group is formally recommending five solutions that will improve medication adherence:

(more…)

The following guest post on the subject of drug adherence is written by Julie Murchinson, Founder, Health 2.0 Accelerator and Managing Director with Manatt Health Solutions.

The tools are coming! The tools are coming! For a while now, tools to manage drug adherence have been developed, many designed to enable the patient to self-manage in the context of and in collaboration with the health care system from a specifically designed device or heavy application. Patient adoption, however, has been slow and the vision for self-management of drug adherence not yet reality. But recently from the budding Health 2.0 space, we are seeing tools built on more accessible web and mobile platforms that allow patients to manage when and where they want to with their mobile device (e.g. iPhone, Blackberry, cell phone). So, in much the same way many people’s lives have changed as a result of being able to use Facebook or Twitter, or read the Washington Post from their phones on the bus or out at lunch, patients who have previously required proximity to their home device or desktop to log medications taken can now not only track on their phone what they take from their pill box, but also take advantage of glow cap or smart label technologies that can technically interact with a phone-based mobile application.

It was one thing when the Brazilian government was sending text messages to remind women to take their birth control pills (which, by the way, has been highly effective), but we are in a new age of both passive and active patient engagement with mobile platforms. There are iPhone accessible apps like Polka and TheCarrot.com that enable patients to schedule and track their medications taken along with a number of other health topics including sleep, exercise and mood, among others. Medic8Manager provides an iPhone solution that goes a few steps deeper on drug adherence for managing scheduled medications with reminder functionality, refill tracking, missed dose alerts, as-needed meds and discontinued medications. A similar application in development from Informediq even uses the tagline, “enabling healthcare anywhere”. While some products are typically used solely by patients without involvement required from a physician or other caregiver, we are starting to see more user-friendly tools that originate from the physician-patient care process, while allowing for more consumer-friendly adherence tracking, a good example of which we are seeing from the new AdhereTx product. The next step in innovation can be seen from eMedMobile which facilitates a phone working with “smart labels” on prescription medication bottles that store drug data and send alerts to caregivers when a drug is missed.

(more…)

For those of you who are visiting our blog for the first time, you will notice several blog posts on the topic of drug adherence.  From time to time Disrutpive Women tackles a particularly vexing issue and runs a series of posts that we then compile into an e-book.  

If you are interested in an overview of our current series, please read my first post.

I invite you to take a look at our adherence posts–but don’t stop there.  Explore the archives and recent posts listed on the left hand side of the blog.  Read the bios of our authors and join in the conversation.

My initial enthusiasm for blogging on the subject of adherence policy “carrots and sticks” faded the more I contemplated the disputes that would arise by suggesting “sticks,” so mostly I’ll – pardon the pun – “stick” to “carrots.”

In recent weeks these blog pages have been filled with ways to support patients: reviewing insights about human behavior, the young, the old, reminder systems, games and team care. In fact, this series could have continued all month and we’d not have exhausted the ways in which patients are supported, encouraged and cajoled to be adherent.

Yes, we’ve dispensed plenty of sugar to make the medicine go down, but we’ve not proposed any “sticks” in the event it does not. Let’s face it; we’re not ready for the outrage in the public policy world if we seriously suggested that patients somehow should be held accountable.

In the private sector, some accountability-style policies exist (though not to my knowledge regarding medicines). For example, one major company warns employees that if they have an automobile accident requiring hospitalization and committed a moving violation or failed to wear a seat belt, they’ll be responsible for paying an additional $1,000 deductible. It’s a policy that requests responsible behavior in return for a benefit. I don’t sense that we’re ready for that same kind of “tough love” talk with patients. Not yet.

I liked Joyce Cramer’s notion of the “patient as willing partner” and wonder if we, as patients, sit at one side of the partnership table, what does “the other side” offer us?

In fact, it offers us a lot in the way of benefits, opportunities and “carrots” regarding our medication needs.

• Availability. More medications are available today than ever before, brought to us by public funding and policies that underwrite the cost of basic biomedical research, science education and advanced graduate training. Public policies also provide intellectual property protection to those who successfully innovate to produce new medicine solutions and then – after a time – allow that intellectual property to be used by others to produce cheaper, generic copies of those once-innovative products.
• Assurances. Medications are studied, reviewed and regulated virtually continuously, by regulatory agencies and major health care systems to assure safety, effectiveness and appropriate use. We can report side effects and are encouraged to do so. Those data are monitored and used to further improve pharmaceutical care.
• Accessibility. Medications are more accessible than ever. There is a pharmacy – on average – at every square mile in the US, each one staffed by experts in the use of medications and the management of complex combinations of multiple products for those of us with multiple chronic conditions. These experts can generally tell “in a heart beat” if the side effect we suspect is the medication or the way we’re taking it. For those locations where the “on average” does not apply, mail order pharmacies fill the gap.
• Affordability. Medications are more affordable than ever. The range of generic and therapeutic substitution options allow clinicians and patients to consider the cost of medicines and to pick affordable choices for the vast majority of conditions treated today. Public and private sector coverage for medicines has never been better and every company has a patient assistance program for those who do not have coverage or cannot otherwise afford the medications.
• Alternatives. In this chronic disease epidemic era a large share of the medications we take are intended to treat conditions that could have been prevented. Public policies have invested in understanding the drivers of preventable illness and educating us on everything from nutrition and exercise to stress management and back-injury prevention. Surely not everyone, but many people can practice the alternatives if they choose.
• Accountability. Those who develop, manufacture, prescribe and dispense medications are held accountable for their mistakes. A company that misrepresents the safety, efficacy or indications for their product is subject to legal sanctions and litigation. Clinicians who inappropriately prescribe or pharmacists who inappropriately dispense are subjected to similar consequences. Preventable errors in hospitals are reported and related care is not reimbursed.

Each of these is important and as patients we’d want nothing less. Can we legitimately ask for more? In some cases, yes.

Those with multiple or serious chronic conditions requiring some of the newest biotechnology solutions face great financial burdens. They can legitimately ask for relief. The same is true for people who suffer from cancer and some rare diseases with very expensive therapies. Then, there are those with currently incurable conditions; they can legitimately ask – if not for a cure – then at least for a treatment.

In return for what we have been given, can something be asked of us as patients? I’d like to think so, but I know of none that would gain traction in today’s debates. Are we ready to suggest that the non-adherent hypertensive patient be charged more for heart attack or stroke care? I don’t think so.

Until we are, we may as well ramp up the “carrots,” so many of which have appeared in these pages, stop the handwringing about the cost of non-adherence and haul out our collective checkbooks.

I’ve always been someone who (pretty much) does what I’m told. When my parents or a doctor told me “Take your medicine”, I complied. However, I remember a number of years ago when I was taking an antibiotic for a bad kidney infection; I started to feel better and I wondered why I should continue to take the drug. It wasn’t until someone explained to me that by not taking all the medication, or even skipping a few pills, the bacteria-causing infection could become resistant to future antibiotic treatment – they’d be bigger, “badder”, bacteria. This tidbit of information made perfect sense to me and I’m pleased to report that today, I take all my medications as prescribed, even when I might not have any symptoms.

Based on my personal experiences, I was very surprised to learn what an extreme problem drug adherence is to the health care system. It appears that many, many people are not listening to their health care professionals about taking their medicine as they should.

Before looking at possible solutions to this national epidemic, let’s identify a few reasons patients don’t take, or sometimes, even fill, their prescriptions. One common reason is a lack of understanding about the disease or diagnosis for which the prescription was written. Other reasons may be concerns about the drug’s effectiveness, fears related to medical side-effects, lack of belief that they can control the disease, or like me with the antibiotic, they stop taking the medication because they are feeling better and don’t realize the side effects of not taking all of the prescription. It seems to me that many of these reasons for non-adherence can be addressed if people were provided with more information about both their medical conditions and how their medications can be of benefit.

One possible emerging solution to this information/education problem is the application of healthy games – multimedia experiences that are fun and deliver health benefits. Healthy games hold the potential for many benefits, including improving health literacy, physical fitness, cognitive fitness, condition management and motivating behavior change (like increasing the likelihood of drug adherence).

iConecto, a company working to empower personal health and organizational performance though healthy games, gaming technologies and social media, has collected the largest database of healthy games for consumers and professionals. In addition, iConecto is tracking the evidence and experience of the benefits of these games. Currently, there are over 35 documented studies which show that well-designed games can help engage and empower consumers health behaviors leading to higher treatment regime adherence, better overall health, and more clarity in communication with others about their conditions. These clinical studies have focused on a variety of areas, including cancer, asthma, diabetes, cystic fibrosis, exercise/weight loss and brain games. This blog post will focus on a few examples related to improving drug adherence through the use of healthy games.

(more…)

The following post – part of Disruptive Women’s Drug Adherence Series – is by Stacey Irving of McKesson Patient Relationship Solutions.

Poor medication adherence affects all of us in healthcare — it’s a problem that our entire industry is trying to tackle. By many estimates, more than 50% of patients aren’t taking their medications as prescribed. And that’s a real problem: it’s adding $177 billion in additional healthcare costs and contributing to sicker patients. Reports associate lack of adherence with 10% of hospital visits and 40% of nursing home admissions.

At McKesson, we’re trying a new approach. We’ve partnered with pharmaceutical manufacturers to sponsor programs that get community pharmacists involved in promoting medication adherence. Independent and small-chain pharmacies, including McKesson’s chain of Health Mart pharmacies, have a reputation for building strong relationships with their customers and delivering excellent service. By getting pharmacists to spend time counseling patients about their medications, we’re helping patients become more informed, more confident, and more motivated to adhere to their medication regimens.

In one of our first programs, the Pharmacy Intervention Program, we’ve trained hundreds of pharmacies in motivational interviewing and other key health behavior change techniques — asking patients open-ended questions and having a true discussion about the patient’s knowledge, feelings, beliefs, goals and expectations. This patient-centered approach to counseling helps pharmacists be as effective as possible in providing education and support to patients.

Here’s how it works: when patients come to pick up their prescription for one of the sponsored medications, the pharmacy’s computer system alerts the pharmacist or pharmacy technician that the prescription is eligible for counseling. Before the patient leaves the pharmacy, a pharmacist begins a conversation with him or her about the medication and provides the patient with literature to take home. Pharmacists are reimbursed financially for the 5 minute counseling time — something they ordinarily do for free — further encouraging them to take the time to promote patient adherence.

(more…)

For many years I was a caregiver and advocate for my family and friends. I discovered that taking their medications correctly was one of the main problems.  The struggle occurred mostly because they were often taking multiple medications prescribed by numerous physicians, and using various pharmacies to fill their prescriptions.

This resulted in either missing medications, or taking them incorrectly, to simply becoming frustrated and not taking them at all.  This was especially true for my mother who was on 16 prescription and 6 over-the-counter medications when I decided to design a medication chart to assist her. That developed into a healthcare and medication  system, easy-to-use spiral notebook.  This can be seen on www.mymedmanager.com or on www.youtube.com/mymedmanager.

Medications can be very beneficial, but to get the most benefit, they must be taken properly.  Following instructions from the prescribing physician is extremely important, but reading and understanding the warning labels placed by the manufacturer is just as important.

For example, many people think if the warning label says, “take with food,” it is to prevent getting an “upset stomach.” Therefore, many will ignore that warning label and take it on an empty stomach because they believe they have stomachs “made of steel.”   What they may not realize is, in many cases, food helps to increase the absorption of the medication.  There are numerous examples of this type of confusion.

(more…)

As our population ages the importance of one’s ability to remain independent as long as possible will become even more important than it is today. One of the leading causes for the placement of a frail adult in a nursing home is due to non-adherence to medication regimes. In fact, 10 to 25 percent of hospital and nursing home admissions annually are because of an individual’s lack of adherence.

The American Academy of Nursing working with the Agency for Healthcare Research and Quality has published practice guidelines for nurses working with the older adults in the community on the management of their medication. There are many risk factors that affect the individual’s adherence from physical ability to depression and beyond.

We know that nursing interventions and evidenced based transitional care innovations where an advanced practice nurse leads an interdisciplinary team can help the patient and their caregivers prevent non-intentional and/or intentional non-adherence of medications.

(more…)

If medication adherence is a problem for adults, consider how difficult it is for young people with chronic medical conditions.

Alternate flavorings, formulations, and suspensions can help the medicine go down in children.  But what is the solution when taste is not the problem?  One approach we need to take is to put the young person center and first.  Talking past the child to the parents is a practice that continues today and even with many young adults patients.  If we want young people to succeed in self-medication management, they must be the drivers of their care.

Child-centered care:

 Psychoeducation: As soon as the child is able to participate, he needs to be educated about his condition and medication regimen so he understands what his happening to his body.  Participating in the decision-making process, e.g., whether to take the morning medicine after brushing teeth or at breakfast, protects the child’s autonomy and sense of control.

Contracts help in getting the young person to take ownership, and patient records are an age-old but effective method of monitoring adherence.  Children can check boxes on printed forms, manually or computerized; parents can help by incentivizing adherence with tokens or rewards.  Encouraging the child to share the record in the next medical visit further increases his autonomy – a critical issue when one loses the sense of control over one’s body.  Physician follow-up is critical to promoting adherence, e.g., counting pills, checking records.

Communication skills and understanding the young person’s perspective are key ingredients to building trust. A non-judgmental attitude along with a willingness to negotiate and temporarily modify medications can help a young person understand the need to adhere to a regimen.

Problems may surface when the child enters adolescence and considers engaging in risk-taking behaviors.  This is also the time to foster health self-management and start the transition process to adult-oriented health care.  As the teen matures, he must be educated and encouraged to learn about his condition and management. The physician should work with the family to develop a step-wise approach to increase responsibility, e.g., first succeed at level 1 for x months before moving up to level to 2.  For example:

1. Monitor patient-recorded adherence chart
2. Make doctor’s appointments and record on chart (physician visits are associated with adherence)
3. Order prescriptions and record on chart
4. Fill medication trays

(more…)

Mary R. Grealy is president of the Healthcare Leadership Council, a coalition of chief executives of the nation’s leading health care companies and organizations.  She is also the author of Prognosis:  A Healthcare Blog which explores the nexus at which healthcare policy meets healthcare practice.

If only it were an urban legend that senior citizens in the United States were cutting their physician-prescribed pills in half or ignoring their medications altogether in order to have enough money for food and utilities, but one doesn’t need academic studies to know that this kind of economically-forced non-adherence has too often been the case in our country.

After Congress passed the Medicare Modernization Act (MMA), creating the Part D prescription drug program, the Healthcare Leadership Council – an advocacy group comprised of chief executives of healthcare companies and organizations from all health sectors – literally took its show on the road. Having worked for passage of the MMA, we felt a responsibility to ensure that the new Part D program was implemented successfully and that seniors knew how to take advantage of the new benefit.

In community meetings across the country, I met with scores of elderly men and women who told me heart-wrenching stories of the hard choices they had to make between medications and other necessities, knowing they were putting their health at risk.

Has the Medicare Part D prescription drug program made a difference in drug adherence within this vulnerable population? The results are quite positive but they also show that further improvements remain necessary.

The impact of Part D on drug adherence among the elderly is unquestionable. A survey in April of this year by KRC Research (commissioned by Medicare Today, a coalition of local and national organizations we founded to provide reliable Part D information to seniors) found that three of every 10 Medicare beneficiaries reported that they are now taking medications that they had previously either skipped or rationed.

(more…)

The following guest post — part of our Drug Adherence series — is by Elizabeth Sozanski, who is currently Senior Director, Global Brand Strategy, and is the former Adherence Leader for AstraZeneca. In that role, she was responsible for building the adherence strategy and initiatives in support of 5 largest brands; had a leading role in developing adherence-related partnerships with multiple healthcare partners; and served as the main interface to the organization for adherence best practices aimed at improving appropriate care and healthcare outcomes.

In the many years that I’ve been with the pharmaceutical industry, few issues have been both as divisive and unifying the way medication adherence has, all at the same time. It’s divisive because various stakeholders in the healthcare space each own a different—and often seemingly conflicting—component of this common yet complex problem. It’s unifying because not a single one of those stakeholders can solve the issue on their own. The unique opportunity this situation creates is that, to address this costly and serious challenge with the price tag of $100 billion each year, we all have to come together and work across our boundaries and individual interests.

When I talk about healthcare stakeholders, I certainly include the manufacturers, but also a whole host of other key players in the healthcare space: starting with patients, doctors and nurses, and including managed care organizations, insurance companies, employers, public health organizations, policy-makers and regulatory bodies such as the FDA or EMEA.

As manufacturers, our hope is that patients who use our medicines benefit from their full value by using them appropriately. As an industry, we put so much effort into discovering and developing new medicines for patients—the therapeutic benefit of these medicines is clearly compromised unless an appropriate doctor-prescribed regimen is adhered to.

There are as many theories as they are people as to why patients deviate from their doctors’ guidance, and choose to “prescribe” their own treatment regimen instead. I won’t go into them because they have been very well covered already in this debate.

So what can a manufacturer do to address the issue? While no pharmaceutical company can single-handedly remove all of the underlying issues which drive patient adherence (in fact, none of the other healthcare stakeholders can either), there are many things we can do as an industry, and even more we can do if we partner with others in this challenging mission.

There are three key areas where we can bring particular value to this challenging issue:
(more…)

Last term, my Program Planning for Health Behavior Change workgroup was charged with using theory to help explain a health behavior and design a targeted intervention.  With several MDs in my group, we chose improving warfarin adherence to reduce risk of stroke in elderly patients with atrial fibrillation.

2.2 million Americans suffer from AF, a condition that causes a 4 to 5 fold increased risk for stroke. What is worse is that 5% of those ages 65+ have AF.  Luckily, warfarin is an inexpensive, generic drug that, if taken consistently and with regular physician monitoring, can reduce the risk of stroke for AF patients.   However, compliance is a problem and as a result non-compliant AF patients remain at risk for stroke.

My group utilized a PRECEDE/PROCEED framework to conduct a hypothetical needs assessment and identify the underlying causes of the problem that our resulting intervention would address.  This framework provides a conceptual way of organizing multiple levels of factors that explain prescription regimen noncompliance and identify places where an intervention may be effective.  Utilizing our course textbook, Health Behavior and Health Education: Theory, Research, and Practice by Glanz, Rimer, and Viswanath, we found that examining the following factors was particularly important in explaining whether one is adherent:

• Predisposing factors – the motivation or rationale for behavior and include one’s attitudes, beliefs, preferences, skills
• Reinforcing factors – the reward or incentive for persistent behavior such as social support, modeling, peer influence
• Enabling factors – direct or indirect antecedents that allow motivation to be realized, including environmental and structural factors

We also used social cognitive theory, which focuses on the individual as a health behavior change agent, and its theoretical constructs.  In reviewing the literature, we found that elderly AF patients may:

(more…)

The following guest post on the subject of drug adherence is written by Joyce A. Cramer. Joyce is Associate Research Scientist at Yale University School of Medicine as well as President of Epilepsy Therapy Project, a 501-c-3 organization accelerating new therapies for people with epilepsy.

“Drugs don’t work in people who don’t take them” said former Surgeon General C. Everett Koop. While performing research on this topic since the 1980s, I have been continually surprised that the results are uniform: People take, on average, three-fourths of medication as prescribed¹. This has held true across many diseases and types of medications. There seems to be no consequence so severe that everyone with that disorder takes all doses (e.g., organ transplantation, epilepsy, asthma, etc.).

One of the first studies I published included extensive neuropsychological testing. It showed that not taking all doses does NOT relate to intelligence². There are numerous studies showing the ineffectiveness of health education. Many people get good scores on knowledge linking disease control/management with medication, but do not carry-through by taking all doses.

Interviewing lots of people led me to realize that the main reason is forgetfulness (on a daily basis or during a disrupted schedule). I then developed a simple system to teach people skills on HOW to take their medication. It consists of asking the person (a) what is the best time of day to remember a dose, and (b) what daily activity can you link this to as a reminder³? Typical responses are the best time is in the morning (ask to set a range of time, i.e., 7-8 am), and link it to making coffee, taking the dog for a walk, etc. Only the person who is taking the medication can select the most convenient time and the personalized cue. The “Cramer Method” does work, as demonstrated in several studies.

The system works only when the person has accepted the diagnosis and need for treatment.

On the medical side, I teach doctors to ask whether the person is willing to take the medicine, then proceed to teach them how to set time and personalized cues. Explain that if the first cue does not work well, select another cue.

I often hear that someone had an exacerbation of symptoms after missing doses or discontinuing treatment. Sometimes the same person has multiple episodes until the personal lesion is learned. That’s human nature. I do not look at medication adherence as a complex behavior mediated by psychological issues. Much of it is a straightforward personal commitment based on choice, coupled with acceptable tactics to do what is being asked. Diseases differ in requirements, ranging from one tablet daily for hypertension to diet, exercise and oral or insulin treatments for diabetes. People differ in their willingness to perform health-related tasks – changing over time based on other priorities in their lives⁴. Yes, people make choices for which they are responsible, both actions and inactions. The doctor can’t make it happen without a willing partner.

1. Claxton & Cramer. Medication compliance: the importance of the dosing regimen. Clin Therapeutics 2001; 23: 1296-1310.
2. Cramer et al. How often is medication taken as prescribed ? A novel assessment technique. JAMA 1989; 261:3273-3277.
3. Cramer & Rosenheck. Enhancing medication compliance for people with serious mental illness. J Nervous Mental Dis, 1999; 187: 52-54.
4. Cramer et al. Compliance declines between clinic visits. Archives of Internal Medicine, 1990; 150:1377-1378.