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Study: Patients with High Accountability Have Better Adherence to AD Treatment


In her talk at the Revolutionizing Atopic Dermatitis Conference, Madison Cook, BS, gives tips on how to increase accountability, common barriers to overcome with patients, and more.

Madison Cook, a research fellow at the Wake Forest School of Medicine in the Department of Dermatology, located in Winston-Salem, North Carolina, discussed the importance of adherence at the Revolutionizing Atopic Dermatitis (RAD) Conference held April 9 to 11, in Baltimore, Maryland.1 She explained the lack of adherence can lead to many issues ranging from cost and ineffective treatment to death.

In developed countries, patients with chronic medical conditions have average adherence rates of less than 50% and about 30%-40% of medications for chronic conditions are not taken as prescribed, Cook said. Other results discovered that the use of topical treatments for AD decreases by 70% days after treatment and for both adult and pediatric patients that have the skin condition, only a median of 40% continued adherence after 5 days.

“Adherence to topical medications is especially poor because often patients will say, ‘It’s inconvenient and it’s time consuming to use them,’” explained Cook.

According to Cook, common barriers to adherence include:

  • Fear of adverse events
  • Cost
  • Accessibility
  • Forgetfulness
  • Regimen complexity
  • Provider mistrust
  • Lack of symptoms
  • Lack of accountability

These barriers can be group into 4 categories: patient related, treatment related, disease related, and physician related. Cook continued, stating that lack of accountability is a factor that is often overlooked while treating a patient and she would categorize it as both a physician and patient related factor.

Accountability is a type of psychological-social construct that is a person’s obligation to explain, justify, and take responsibility for one's actions, and to answer to someone, such as a person with more authority.2 An example that Cook used was a student going to piano lessons in preparation for a recital at the end. She explained if the student had a weekly class with the teacher for 12 weeks, most likely they would do very well at the performance. Compared to a student being told they had a recital in 12 weeks, with no teacher or class to keep them accountable, would most likely not do as well.

“Accountability requires a social pressure to be effective,” Cook explained. “It can either be virtual, through telephone or email, or it can be in person.” This knowledge helped create the clinical study on adherence and patients.

The objective of the study that she presented was to characterize the relationship between patients’ perceptions of accountability and adherence to treatment. In total, 35 patients with current or previous history of AD were recruited from the Wake Forest Dermatology Clinic. These patients were given a moisturizer for skin treatment and were told to apply treatment for 3 months. Then, at the 3 months, adherence was assessed, which patients were blinded to until their last physician visit.

Accountability was measured at their first visit and their follow up using the Accountability Measurement Tool (AMT) which is 12 validated statements that scores patients on a Likert scale. It assesses 3 domains of accountability: controlled, autonomous, and general.

Of the original 35 recruits, 29 made it to the end of the trial—6 patients were lost to follow up—with most of the remaining cohort being female (57%) having a mean age of 64, and a mean adherence of 45.6%. The results showed that higher AMT scores were associated with greater adherence (53%) than lower scores (38%) at follow-up (P = .07). Also, there was a positive correlation between AMT scores and adherence rates in patients at the 3-month follow up (r (27) = 0.42; p = .03).

The statements from the AMT assessment that demonstrated the strongest association between adherence rates were:

  • “I am concerned of how I would be perceived if my doctor thought I didn’t do a good job taking my medication.”
  • “An upcoming office visit with my doctor motivates me to follow my doctor’s recommendations.”
  • “I am afraid of disappointing my doctor by not following his/her recommendations.”

In the cohort, patients with higher perceptions of accountability toward their provider had better adherence, Cook said, and had a fear of disappointing their doctor. “It shows that accountability could be something that affects [patient] behavior and motivate adherence,” she said.

Follow up visits can be cost prohibitive but more cost effective methods such as online surveys, questionnaires or messaging through patient portal systems could be utilized.


Cook did not have any relevant disclosures.


Galderma for funding the study and Steven Feldman, MD, PhD, Katherine Kelly, Patrick Perche, Rohan Singh, Esther Balogh, and Irma Richardson for their help with the project.


  1. Cook, M. Patients who feel more accountable have better adherence: a clinical study in patients with xerosis in the context of previous or current atopic dermatitis. Presented at: Revolutionizing Atopic Dermatitis (RAD); April 9-11, 2022; Baltimore, MD.
  2. Definition of accountable. Dictionary.com. Accessed April 11, 2022. https://www.dictionary.com/browse/accountable
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