Researchers examine the issue of patient compliance

Ways to document compliance will be one result

Researchers who recently studied the working memory of pharmacists are now turning to the issue of patient compliance. Indicators show that pharmacists who make medication errors and patients who do not adhere to their medication regimens may share several individual characteristics, such as a lack of organizational skills and working memory.

As described in last month’s Drug Formulary Review cover story, a study showed that some pharmacists are predisposed to medical errors due to individual factors, such as a lack of working memory. The study compared the pharmacists mandated by a state board of pharmacy for misfill errors to a control group of pharmacists on computerized neuropsychological tasks and personality tests, offered by ExamCorp ( The three-year results found no differences in personality, but highly significant decrements for the medical error group for working memory, attentional control, and verbal organization when compared with the controls.

The 90-minute battery of tests is now being adapted to evaluate patients and their adherence to medication regimens. Not only should the tests indicate which patients are more likely to be noncompliant with their medications, the results also should provide pharmacists with a tool to document compliance, as well as give them ways to encourage these patients to take their medication as directed.

"There are a number of strategies to develop increased compliance," explains Robert O. Pihl, PhD, professor of psychology and psychiatry at McGill University in Montreal. Pihl, president of ExamCorp, helped develop the battery of tests.

"The majority of [these strategies] rely on gadgets or contracts or what is called education," he says. "These kinds of things can work if a particular relationship is developed between the provider and the patient. But unfortunately, the type of relationship that needs to be developed is not typical in any medical setting other than the psychotherapeutic setting. It takes a great deal of time, a great deal of listening, and a great deal of empathy, skills that are not necessarily inherent to professionals in our business."

Can you predict noncompliance?

To increase medication compliance, the researchers believe that there must be a procedure, such as a prospective screening test, that can determine important individual characteristics of patients who are likely to comply or not comply. The next step is to develop relatively automated interventions that will increase compliant behavior.

The types of measures that the researchers are suggesting are the same that they used successfully to discriminate pharmacists who made the medication errors. "We looked in particular at the functioning of the pre-frontal cortex," Pihl says. The measures evaluate how well people can plan and organize, and the degree of their working memory and attentional control.

We know that kind of functioning is important to compliance because the literature shows that noncompliant individuals tend to be less well educated and tend to have particular deficits in this area," he says. "For example, if you look at the problem with compliance in HIV patients, it’s really the difficulty of adjusting to the pill regimen. The major reason people don’t comply is that they forget. It takes a great deal of planning and organization."

The researchers then want to look at certain personality characteristics that have been used to some degree in this area, but without much success. The problem is that the personality characteristics, such as conscientiousness, have to be addressed in terms of both the patient and the provider, Pihl says.

"There are studies that show you can increase compliance if, for example, the pharmacist looks his or her patients in the eyes when explaining something. Compliant behavior can be doubled."

Pihl contends that the issue of compliance is the No. 1 medication error that exists. "Medicines won’t work if people don’t take them." Research shows, he says, that only one-third of patients comply with the medication regimen. One-third is partially compliant. One-third doesn’t even fill the prescriptions. "There are multiple reasons for this. It has to be an extreme dilemma to practitioners."

The ExamCorp research team recently received a grant to develop a compliance program suitable for all practitioners. The compliance program would include the testing procedure, the documentation processes of patient evaluation and education, as well as the reimbursement for services component. The team has partnered with several health care facilities for the research, but would be willing to work with others that are interested.