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The gap between best care and usual care is large for many important diseases. In particular, poor adherence remains a significant, inadequately addressed, cause of the care gap. About half of all patients with chronic diseases stop refilling prescriptions by one year. Several effective interventions are available and adaptations of clinical trials practices offer promise for further improvement. Poor adherence is a remedial problem in healthcare quality and its improvement and accountability offer shared opportunities for providers and patients. There is a large gap between best care, defined as the optimal use of proven efficacious therapies in whole populations at risk from any disease, and usual care, the actual level of efficacious care being provided (Montague et al. 1997). This gap in patient care has four main causes: diseases may not be diagnosed, efficacious therapies may not be prescribed, access to therapy may be restricted or patients may not adhere to prescriptions. Irrespective of causation, the ultimate result of care gaps is the same--less than optimal clinical outcomes and associated lost opportunities for improved quality of life and productivity. Systematic approaches to improving prescribing practices are increasing, and there is much debate around improving patients' access to care. Poor diagnosis is judged to be relatively uncommon, leaving decayed adherence as the major under-addressed cause of care gaps and a major opportunity for improvement. This paper reviews the scope and causation of sub-optimal adherence, evaluates improvement strategies and explores a best-practice benchmark.

Broadly defined, disease, or health management, is a focused application of resources to improve patient outcomes; its premise: things can be better. In particular, the gap between what best care could be, and what usual care is, can be reduced and, consequently, care and outcomes can be improved. This paper reviews the evolution of the partnership/measurement paradigm of disease management and considers its value in sustaining Canadian healthcare. Lessons from ICONS (Improving Cardiovascular Outcomes in Nova Scotia), a major public-private health partnership of physicians, nurses, pharmacists, patients and their advocacy groups, government and industry, are highlighted. Launched in 1997, ICONS' proof-of-concept phase ended in 2002. Due to its positive impact on the cardiovascular health of the population and its integrated and accountable administrative processes, ICONS became an operational program of the Nova Scotia Department of Health. This successful community-based partnership represents a major achievement in organizational behaviour in the arena of primary healthcare. It supports optimal care as evidence-based and seamless, recognizing the patient as the nucleus. It should be considered for other disease states and constituencies where the goals are closing care gaps and delivering the best health to the most people at the best cost.