COMPLIANCE WITH ANTIHYPERTENSIVE DRUG THERAPY: GENERAL DISCUSSION

L. TOBIAN (University of Minnesota Hospitals, Minneapolis, Minn.) : All the things that did not work were mentioned. Was any one single thing dis- covered which did increase compliance?

D. W. TAYLOR (McMaster University Health Sciences Centre, Hamilton, Ont., Canada): The one strategy that has consistently improved patient com- pliance has been an increase in patient supervision of one type or another. Unfortunately the benefits of such programs have always been short-lived. Long-term followup after termination of increased supervision programs has always revealed substantial or total deterioration of the benefits achieved during the program. We are simply not very far along in the development of adequate self-management techniques. If one wishes to pursue the increased patient super- vision strategy, we must identify the most cost effective way of delivering such supervision on a long-term basis.

M. MOSER (New York Medical College, Valhalla, N . Y . ) : Were repetitive educational efforts better than the oneshot concentrated education?

D. W. TAYLOR: Our 6-month educational program provided no improve- ment in patient compliance. I am not aware of any studies which have examined patient compliance during very long-term educational programs.

R. STAMLER: I would just like to make three very brief points. I was delighted to read the Task Force report on treatment of the hypertensive and not come across the word “compliance” once; rather “adherence” and “patient participation” were used. We should keep this in mind since compliance implies compulsion and this just seems bound not to work.

We do need to investigate all strategies that might improve patient adherence; however, let me caution against the conclusions to be drawn from a negative experience. Thus, the fact that a one-shot or short-term education program by itself does not overcome all the problems, does not mean that patient education as part of a decent treatment program is useless.

Finally, one of our most important correlates in increasing patient adherence involves the nature of the treatment itself. Obviously a patient will have more problems adhering to a drug program which creates many major side effects and very serious personal problems than in accepting a drug which does not create such problems. Treatment has to occur in a maximally supportive atmosphere with the person dispensing the medication and monitoring the pressure checking for such problems and helping the patient solve them.

C. MOSES (Medicus Communications, Inc., New York, N . Y . ) : I share Rose Stamler’s comments about “compliance.” I think all of us are indebted to Mr. Taylor and Dr. Sackett and their group for trying to move compliance or adherence into the realm of scientific observation.

Everybody is knocking the value of education in increasing compliance, and that is probably realistic, especially when we consider that physicians (who really are educated about health problems and the hazards of a heart attack) take three times as long as laymen to call for help when they develop symptoms of a heart attack.

I was disturbed by the clear demonstration that there was no relationship between the development of side effects and compliance. I think we need addi-

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tional documentation since the influence of the side effects can be quite subtle and yet persuasive, for example, the young man with hypertension whose fear of impotence, real or imagined, precludes his maintenance therapy.

M. MOSER: The just concluded National Health Survey of over 4500 pa- tients by Graham Ward's group revealed 60% had stopped their medication because: (1 ) they perceived that they were cured, which is a health education function on the part of the physician, or (2) they were told to stop the medica- tion. Less than 596, as was pointed out, stopped because of side effects.

D. W. TAYLOR: I am concerned that the term compliance has so many negative connotations. Certainly, we do not subscribe to a totalitarian attitude towards the treatment of patients, in which you force things down people's throats. The term compliance, however, has recently been accepted by Index Medicus, and it is therefore the term under which we will have to look up papers that are published in the area. Thus, it will be very difficult to switch to adherence or therapeutic alliance. Perhaps, we should try to divest ourselves of the negative connotations of the word compliance.

Our side effects data came from patients who had been on treatment for at least a year. We found no difference in compliance between those who reported having side effects and those who reported that they were not having side effects. These data, of course, do not tell us whether side effects are important to indi- viduals who stop treatment and leave the treatment setting. Moreover these data do not mean that we should simply ignore the side effect issue. There may be some patients for whom side effects are the major hinderance to compliance. Our data simply suggest that side effects do not constitute a major barrier to compliance with antihypertensive drugs for most patients.

S . KRUG (University of Connecticut Health Center, Farmington, Conn.) : There is a great deal of material in the sociological, psychological, and medical literature on the relationship between socio-economic status and compliance and on the relationship between socioeconomic status and many of the variables which were mentioned in the presentation, namely health beliefs, doctor-patient communication, quality of doctor-patient relationship, and the like. Which socioeconomic factors do you think are important?

D. W. TAYLOR: Our review of the compliance literature indicates that socio- economic factors are not as important as you suggest. There may be situations in which the cost of the clinic visit or of prescribed medication may hinder compliance; however, when all of the studies in this area are considered, no consistent relationships emerge between socioeconomic status and compliance. It would be important in studies looking at the relationship between socio- economic status and compliance to control for other variables like the health beliefs. We may find for example that apparent relationships between socio- economic status and compliance are really mediated by differences in patient perception of their susceptability to illness and the value of treatment.