Low compliance to prescribed medical interventions is an ever present and complex problem, especially for patients with a chronic illness. With increasing numbers of medications shown to do more good than harm when taken as prescibed, low compliance is a major problem in health care. Relevant studies were retrieved through comprehensive searches of different database systems to enable a thorough assessment of the major issues in compliance to prescribed medical interventions. The term compliance is the main term used in this review because the majority of papers reviewed used this term.Three decades have passed since the ®rst workshop on compliance research. It is timely to pause and to re¯ect on the accumulated knowledge. The enormous amount of quantitative research undertaken is of variable methodological quality, with no gold standard for the measurement of compliance and it is often not clear which type of non-compliance is being studied. Many authors do not even feel the need to de®ne adherence. Often absent in the research on compliance is the patient, although the concordance model points at the importance of the patient's agreement and harmony in the doctor±patient relationship.The backbone of the concordance model is the patient as a decision maker and a cornerstone is professional empathy. Recently, some qualitative research has identi®ed important issues such as the quality of the doctor±patient relationship and patient health beliefs in this context. Because non-compliance remains a major health problem, more high quality studies are needed to assess these aspects and systematic reviews/meta-analyses are required to study the effects of compliance in enhancing the effects of interventions.

BackgroundThe problem of poor compliance/adherence to prescribed treatments is very complex. Health professionals are rarely being asked how they handle the patient's (poor) therapy compliance/adherence. In this study, we examine explicitly the physicians' expectations of their diabetes patients' compliance/adherence. The objectives of our study were: (1) to elicit problems physicians encounter with type 2 diabetes patients' adherence to treatment recommendations; (2) to search for solutions and (3) to discover escape mechanisms in case of frustration.MethodsIn a descriptive qualitative study, we explored the thoughts and feelings of general practitioners (GPs) on patients' compliance/adherence. Forty interested GPs could be recruited for focus group participation. Five open ended questions were derived on the one hand from a similar qualitative study on compliance/adherence in patients living with type 2 diabetes and on the other hand from the results of a comprehensive review of recent literature on compliance/adherence. A well-trained diabetes nurse guided the GPs through the focus group sessions while an observer was attentive for non-verbal communication and interactions between participants. All focus groups were audio taped and transcribed for content analysis. Two researchers independently performed the initial coding. A first draft with results was sent to all participants for agreement on content and comprehensiveness.ResultsGeneral practitioners experience problems with the patient's deficient knowledge and the fact they minimize the consequences of having and living with diabetes. It appears that great confidence in modern medical science does not stimulate many changes in life style. Doctors tend to be frustrated because their patients do not achieve the common Evidence Based Medicine (EBM) objectives, i.e. on health behavior and metabolic control. Relevant solutions, derived from qualitative studies, for better compliance/adherence seem to be communication, tailored and shared care. GPs felt that a structured consultation and follow-up in a multidisciplinary team might help to increase compliance/adherence. It was recognized that the GP's efforts do not always meet the patients' health expectations. This initiates GPs' frustration and leads to a paternalistic attitude, which may induce anxiety in the patient. GPs often assume that the best methods to increase compliance/adherence are shocking the patients, putting pressure on them and threatening to refer them to hospital.ConclusionGPs identified a number of problems with compliance/adherence and suggested solutions to improve it. GPs need communication skills to cope with patients' expectations and evidence based goals in a tailored approach to diabetes care.

BackgroundResearch suggests adherence to treatment recommendations is low. In type 2 diabetes, which is a chronic condition slowly leading to serious vascular, nephrologic, neurologic and ophthalmological complications, it can be assumed that enhancing adherence to treatment recommendations may lead to a reduction of complications. Treatment regimens in type 2 diabetes are complicated, encompassing lifestyle adaptations and medication intake. ObjectivesTo assess the effects of interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Search methodsStudies were obtained from searches of multiple electronic bibliographic databases supplemented with hand searches of references. Selection criteriaRandomised controlled and controlled clinical trials, before-after studies and epidemiological studies, assessing changes in adherence to treatment recommendations, as defined in the objectives section, were included. Data collection and analysisTwo teams of reviewers independently assessed the trials identified for inclusion. Three teams of two reviewers assessed trial quality and extracted data. The analysis for the narrative part was performed by one reviewer (EV), the meta-analysis by two reviewers (EV, JW). Main resultsTwenty-one studies assessing interventions aiming at improving adherence to treatment recommendations, not to diet or exercise recommendations, in people living with type 2 diabetes in primary care, outpatient settings, community and hospital settings, were included. Outcomes evaluated in these studies were heterogeneous, there was a variety of adherence measurement instruments. Nurse led interventions, home aids, diabetes education, pharmacy led interventions, adaptation of dosing and frequency of medication taking showed a small effect on a variety of outcomes including HbA1c. No data on mortality and morbidity, nor on quality of life could be found. 1 Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus (Review)

Summary Background and objective:  Pharmacists are now adopting a crucial role in the management of chronic illness in primary care, providing diabetes care and advice. This review aims to show whether a range of diabetes care interventions delivered by pharmacists is successful in improving adherence to medication. Methods:  The studies reviewed formed a subgroup of a Cochrane review on interventions to improve adherence to medication in people with type 2 diabetes. Search terms were ‘type 2 diabetes mellitus’ and ‘compliance’ or ‘adherence’. Studies were included if they assessed adherence to medical treatment specifically, rather than other aspects of self‐management. Out of the 21 studies selected for review, five described an intervention delivered by a pharmacist. Results and discussion:  Two studies reported on attempts to improve adherence focused on the taking of medication. A system of reminders and packaging improved medication adherence, but measuring medicine taking through pill counts or Medication Event Monitoring System was not effective. Three studies evaluated pharmacist‐led integrated management and education programmes designed to improve glycaemic control for under‐served patient populations. They all succeeded in lowering glycated haemoglobin, but it remains unclear whether this resulted from improved patient adherence. Conclusion:  This review indicates a potential benefit of pharmacist interventions to improve medication adherence in diabetes, especially in providing patient education.

BackgroundOver the past years concerns are rising about the use of Evidence-Based Medicine (EBM) in health care. The calls for an increase in the practice of EBM, seem to be obstructed by many barriers preventing the implementation of evidence-based thinking and acting in general practice. This study aims to explore the barriers of Flemish GPs (General Practitioners) to the implementation of EBM in routine clinical work and to identify possible strategies for integrating EBM in daily work.MethodsWe used a qualitative research strategy to gather and analyse data. We organised focus groups between September 2002 and April 2003. The focus group data were analysed using a combined strategy of 'between-case' analysis and 'grounded theory approach'. Thirty-one general practitioners participated in four focus groups. Purposeful sampling was used to recruit participants.ResultsA basic classification model documents the influencing factors and actors on a micro-, meso- as well as macro-level. Patients, colleagues, competences, logistics and time were identified on the micro-level (the GPs' individual practice), commercial and consumer organisations on the meso-level (institutions, organisations) and health care policy, media and specific characteristics of evidence on the macro-level (policy level and international scientific community). Existing barriers and possible strategies to overcome these barriers were described.ConclusionIn order to implement EBM in routine general practice, an integrated approach on different levels needs to be developed.

BackgroundTherapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition.MethodsA systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method.ResultsThe final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), “who” (physician, patient or system), “how and why” (mechanisms and reasons), and “appropriateness”. Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation.ConclusionsOur data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.

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