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December
2001
Persistent Prompting
At the American
Heart Association's annual scientific meeting last month, it was
reported that two-thirds of people who take effective cholesterol-lowering
drugs are not benefiting as much as clinical trial evidence indicates
they should.
Why is this?
Patients apparently are not taking their pills. "It's extremely
difficult to get people to do anything on a routine basis,"
according to lead investigator Dr. Dennis L. Sprecher of the Cleveland
Clinic.
But it isn't
just the patient who is recalcitrant.
I recently
attended a forum on outcomes research where results of a Harris
Interactive survey were released. Not surprisingly, physicians who
responded to an online set of multiple-choice diagnostic questions
often gave the wrong advice on basic diagnoses for which clear evidence
is available. Further, they made frequent misattributions about
where there is and is not good evidence for their decisions. We're
not talking anthrax or some tropical disease, either. The questions
were asked about treatment of stroke, asthma, diabetes and preventive
exams like PSA.
It seems odd
that people have so much trouble changing longstanding practices
based on credible new information, whether they are clinicians or
patients, especially since it is so easy to do on matters much less
vital. Once recycling rules were established, how long did it take
us to put the bin at curbside on the right day? How long does it
take for us to decide to stay home one night each and every week
to watch our favorite TV show? Or to get up at the same time every
morning so we can get to work at an acceptable hour?
What makes
these routines work is the presence of persistent reminders in our
environment -- fliers from local government, chats around the water
cooler or the buzzer of a clock radio. Our task now is to re-organize
how primary health care is delivered to provide ready access to
evidence-based guidelines and information about the unique needs
and preferences of each patient.
Just as an
alarm clock can prompt us to wake up on time, the Cleveland Clinic
study found that prompting can help people take their cholesterol-lowering
pills. The investigators hired high school students to call patients
once a month to remind them to take their statins -- possibly the
first time high school students were actually paid to promote drug-taking.
Compliance rose 25 percent.
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