Assessing compliance in asthma patients.

Compliance is usually defined as "the extent to which the patient's behaviour in terms of taking medications, following diets, or changing life style, coincides with the clinical prescription" [1]. This is a non-operative description which only refers to the patient, saying nothing about who gives and the quality of what is given, is often used to put the blame on the patient and to reassure the doctor. The first step in assessing compliance should be an accepted definition of non-compliance, i.e. to define what is underdosing, overdosing, and more difficult, erratic dosing. The second step in assessing compliance in asthma implies a correct diagnosis leading to an appropriate treatment, without any unnecessary prescription. Asthma treatment guidelines, defining what is considered efficient, have recently been published [2, 3); it is likely to be fascinating to see how far doctors and patients will comply with these guidelines, and hence see their effectiveness. What can we expect from compliance to an effective treatment? a) Reduced mortality: but even if these deaths are a reality and some perhaps avoidable, they are exceptional compared to the number of patients and practitioners. Furthermore, it is often said that those who die are those who are not compliant; but did they die because they did not take their drugs as non-compliant patients or did they die because there was something else causing non-compliance and, hence, their death? We also know that overcompliance, overreliance on medical prescriptions can kill patients. b) Reduced morbidity: but morbidity is the negative aspect of quality of life which is a very subjective judgment rooted in the person's valuation of health. What the patient feels, what he wants his life to look like and the benefit/cost ratio of compliance, vary from one to another depending on the preferences of each individual. Actually, we do not know the relationship between compliance and the outcome of treatment; hence it is very difficult to measure the clinical benefit of improvement in compliance and to assess if improving compliance is not more harmful than good to those we try to convince. Nevertheless, in practice, there are a lot of methods to assess compliance, each with its interests and limits: 1) medical judgment: usually unreliable; 2) appointments: but failure to keep appointments does not mean that the patient is non-compliant with the regimen; 3) patient's questioning, if confidence is there; it is the "less bad" method when used to find out the reasons of noncompliance; 4) puff, pill or tablet counts with electronic devices tabulating the actual time of usage, but not the