Editorials represent the opinions
of the authors and JAMA and not those of
the American Medical Association.
Challenges for Improving
Reasons for this gap are not always clear, but some compo-
nents are obvious, including failing to identify patients in
need of treatment, not properly initiating treatment, fail-
ing to provide proper drugs at proper doses, and neglect-
ing to involve the patient in the choices inherent in care.
Lack of persistence with adherence to prescribed treat-
ments is a critical part of the gap.2A sustained high level of
lows medications shown to be effective in clinical trials to
chronic conditions. For instance, adherence rates to cho-
Despite its importance, adherence to therapy is an indi-
vidual patient behavior that is difficult to objectively mea-
and the potential for adverse effects. Barriers to target for
optimal adherence include adverse effects, polypharmacy,
frequent (more than once daily) dosing, and high costs.
Health care systems and clinician barriers include insuffi-
cient access to physicians, lack of trust between clinician
and patient, and in some cases, physicians’ negative atti-
of guideline-recommended care.9,10Due to this complex-
herence rates have been refractory to simple interventions.
Successful interventions are often labor intensive and mul-
tilayered. They often show limited efficacy11and generally
target only one disease or risk factor.
Interventions that successfully improve adherence gen-
as patient reminders, more frequent clinic visits, or tele-
Ross J. Simpson, Jr, MD, PhD
OR CHRONIC MEDICAL CONDITIONS, SUCH AS HYPER-
cholesterolemia and hypertension, a wide and per-
ber of pills consumed per day and by reducing medication
costs.7-9Pharmacists are often involved in assessing adher-
improving drug regimens.12-16Direct counseling of pa-
tients by pharmacists may be particularly promising be-
cause of pharmacists’ specialized training and knowledge
of medications and availability to patients.
In this issue of JAMA, Lee and colleagues17report the re-
cation adherence for patients with multiple chronic medi-
cal conditions, including hypertension and elevated
for poor adherence. They received care at a military hospi-
tal and its affiliated retirement home. The study consisted
of a sequential observational and a subsequent random-
ized trial of a comprehensive pharmacy program with edu-
cational and structural components. The educational com-
ponent included intensive and frequent counseling by a
pharmacist. The structural component involved packaging
of medications in blister packs that contained each pa-
tient’s daily medications. After a 2-month observation pe-
riod during which medication adherence was assessed by
pill counts, 174 patients were enrolled in the 6-month in-
tervention phase, during which they received pharmacist
counseling and were given their medications in individual
blister packs. Following this intervention phase, 159 of the
patients were randomized by blocks (based on their ob-
and ongoing counseling or to return to usual care without
either continued counseling or availability of the dispens-
ing blister packs.
After 6 months of the intervention, the percentage of pa-
tients classified as adherent increased significantly, from
61.2% at baseline to 96.9%, with associated modest reduc-
tions in systolic blood pressure and low-density lipopro-
adherence persisted (95.5%) in patients assigned to con-
tinuing counseling and the blister packs, whereas those in
See also p 2563.
Corresponding Author: Ross J. Simpson, Jr, MD, PhD, Sixth Floor Burnett-
Womack, 99 Manning Dr, University of North Carolina at Chapel Hill, Chapel Hill,
NC 27599 (email@example.com).
JAMA, December 6, 2006—Vol 296, No. 21 (Reprinted)
©2006 American Medical Association. All rights reserved.
by ChristopherButtery, on December 5, 2006 www.jama.comDownloaded from