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Compliance in Healthcare and Research FREE TO VIEW

Larry C. Kuo, MD
Author and Funding Information

Medical Director, Clinical Process Improvement, Lovelace Health Systems Inc, Albuquerque, NM

Chest. 2001;120(4):1428. doi:10.1378/chest.120.4.1428
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By Lora E. Burke PhD, MPH, RN, and Ira S. Ockene MD, eds. Armonk, New York: Futura Publishing Company, Inc, 2001; 354 pp; $49.00

“The real challenge of the new millennium may indeed be to strike an appropriate balance between the pursuit of exciting new knowledge and the full application of strategies known to be extremely effective, but considered underused,” begins the concluding chapter of this newly released book. In the last few decades, multiple, primarily pharmaceutical, therapies have been developed and then convincingly proved to effect large reductions in morbidity and mortality across the heavily populated spectrum of cardiovascular diseases. This American Heart Association (AHA) monogram shines a spotlight on a traditionally less publicized component of the relentless advancement of medical science, namely, patient and provider compliance with (or adherence to) medical advice. This 21-chapter book, edited by Lora E. Burke, PhD, MPH, RN, and Ira S. Ockene, MD, benefits from 45 contributing authors. As befits this intuitively multidisciplinary topic, more than two thirds of the contributors are not medical physicians. Reflecting the diverse perspectives presented throughout the book, contributors include PhD researchers, nurses, nutritionists, behavioral psychologists, pharmacists, and epidemiologists. Given the AHA sponsorship and the expected readership, there is a bias toward cardiovascular disease in the discussions.

Large treatment gaps (often reported in the 25 to 50% range) exist for coronary disease, heart failure, and dyslipidemia, due to the underutilization of proven therapies. Then, when appropriate therapy is prescribed, the literature reports equally appalling rates of patient nonadherence to treatment. The obvious adverse multiplicative effect of both forms of noncompliance still underestimates the magnitude of a missed health-care opportunity, as the literature-reported benefits of most therapies are probably blunted by noncompliance within the clinical trials themselves. These and other key facts and principles are analyzed cogently in the excellent introduction (by R. Brian Haynes, MD, PhD) and an excellent final chapter (by Neil B. Oldridge, PhD). Unfortunately, as Dr. Haynes notes, adherence research has been fragmented, unimaginative, largely impractical in clinical settings, and typically shows unimpressive benefits. In published studies, compliance criteria and metrics are highly variable, further complicating the ability to compare studies or to formulate convincing conclusions. Dr. Oldridge concludes the monograph with a compelling reminder of the necessity for multilevel compliance strategies targeting patients, providers, and health-care organizations.

The intervening chapters are organized into seven parts, which are titled as follows: “Factors and Interventions Affecting Compliance”; “Multi-Level Organizational Approaches to Compliance”; “Measure of Compliance”; “Issues in Special Populations” (ie, children, minorities, and obese populations); “Issues Across Settings”; “Special Topics”; and “Future Directions.” These chapters generally were not presented as continuous a stream of new information or insight as the introduction and last chapter, but they comprise a useful overview and review of the study of health-care compliance, albeit with noticeable overlapping. Given the relative lack of reproducible, efficacious clinical trial data, several authors presented possible models for compliance research and implementation, as well as a proposal for leveraging the technology of the Internet.

Today’s health-care professionals have increasing numbers of highly efficacious treatments for our most common and most deadly diseases, reaping the rewards of highly productive research and clinical trials. However, patients, providers, and medical organizations collectively are woefully inadequate in their compliance with and application of these therapeutic successes. Compliance in Healthcare and Research provides an all-too-rare discussion of what is arguably one of most important challenges for today’s health-care systems. This monograph should be useful to all health-care professionals and administrators, especially if they treat patients with chronic medical conditions or conduct disease-management programs.




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