More on Noncompliance-Reply

Commenting on the study by Fletcher et al, Drs Jones and Russell properly point out a number of theoretical and methodologic problems. They echo my concern for the many practical difficulties of serial pill counts, but long-term "average pill utilization" hardly offers a suitable alternative. Many outpatients have frequent adjustments in dose or dosing scheduling over time, making average consumption almost meaningless. More importantly, there is little import in diagnosing poor compliance six or 12 months after the fact, when prompt diagnosis and positive reinforcement are more effective if given immediately.

I share their distress with the term "over 100% compliance," since many medications carry greater risks from overdosage than underdosage. Hulka et al1 have previously distinguished between defects in comprehension and defects in action, in terms of both insufficient and excessive consumption. Certainly taking the correct number of tablets in no way ensures that they were taken at the