Ill Communication: The Problem of Patient Noncompliance

Since the 1970s, medical experts have been conducting studies, dispensing surveys, and performing hours of research in an attempt to make sense out of the enigma that is patient compliance—or more accurately, the lack thereof. They’ve sought answers to such questions as “Why don’t patients adhere to physician’s orders?” “How often does this occur?” and “What can be done to remedy this situation?”

According to the results of a survey of pediatricians conducted by the Committee on Practice and Ambulatory Medicine in 2000, 8% of patients “usually fail to take medications as prescribed,” with nearly a quarter reporting that noncompliance “occurs often” and 40% saying that “such failure occurs occasionally.” The same survey revealed that 89.9% of pediatricians agree that lack of compliance with a prescription regimen interferes with the ability to control a medical condition. A report published in Family Practice Management in March 1998, entitled “Patient-Centered Care for Better Patient Adherence,” asserts that noncompliance “accounts for almost 6 percent of hospital admissions.”

Why Don’t Patients Comply?

Judging from this data, it’s apparent that noncompliance occurs and is a real problem. But before we explore the best approaches to use with patients who don’t adhere to medications, instructions, or advice, it’s important to understand why a disparity exists between what physicians recommend and what patients actually do.

The first reason—and this may come as a shock to some medical professionals—stems from a lack of basic understanding. According to an article written by Peter Jaret that was published in the February-March 2001 issue of Hippocrates, as many as 90 million Americans don’t possess the literacy skills that are required to understand discharge instructions, consent forms, oral instructions, and prescription labels they receive from physicians. In elderly patients, mild cognitive impairment can also be a factor, making it difficult for patients to comprehend or remember what they’re supposed to do. And even when they do understand the instructions, they still may decide that they don’t need the medication. According to a survey distributed by Upjohn Co., 20% of respondents failed to have a prescription filled during a period of 12 months, and of these individuals, 51% said they didn’t believe they needed the medication. Similarly, a study on unfilled prescriptions conducted by the AARP found that 21% of respondents didn’t think the medication would help them, 22% were concerned about side effects, and 14% cited affordability as the reason for noncompliance. Other barriers to compliance, according to the American Academy of Pediatrics, include frequency of dosing schedule, unpleasant taste of medication, side effects, duration of dosing schedule, lack of continuity in adult supervision of prescription regimen, and parental perception of medication effectiveness.

How Can We Improve Patient Adherence?

Because patients’ reasons for failing to adhere to treatment plans are so varied, many experts suggest that “multiple approaches are required to improve long-term compliance,” according to Jaret’s article in the February-March 2001 issue of Hippocrates, in which he provides a list of steps that can be taken to help alleviate “the stubborn problem of poor compliance.” Those steps, according to Hippocrates and a few other sources, are as follows:

1. Use facts to assure patients that the treatment plan is necessary and effective

Although scare tactics can provide patients with short-term incentives, they can also lead to defeatist attitudes and cause pa-tients to give up. Rather, states Jaret, it is better to “carefully explain to the patient the potential consequences of not treating his or her condition, and offer persuasive evidence that your treatment plan can work.”

2. Explain to patients exactly what they should expect from the treatment

When prescribing medication to patients, Jaret suggests that physicians carefully review what the drug does, how it should be taken, what the side effects are, what patients can do if they experience side effects, and how the drug’s progress will be monitored.

3. Listen — it’s that simple

The less talking a physician does, the more patients are encouraged to ask questions and the more they tend to absorb and remember. Family Practice Management suggests phrasing questions “in ways that elicit information efficiently” and making sure not to interrupt patients while they are talking.

4. Test your patient’s knowledge and mental state

An effective way to do this, according to Family Practice Management, is to “have patients repeat what they’ve been told about their illness and treatment plan,” and to demonstrate any techniques they’ve been taught, such as injecting insulin or using a peak flow meter,” which in turn helps physicians to decipher whether patients are capable of following regimens.

5. Recruit family and friends for assistance

Patients with strong social and familial ties “typically comply better than socially isolated individuals,” writes Jaret. “Obviously you can’t create a social network for isolated patients, but you can help by asking a family member to attend the office visit when you intend to discuss treatment options. With elderly patients, adult children can be encouraged to check up and make sure that regimens are being followed.

6. Keep medication regimens simple

According to a study cited in Hippocrates, adherence in hypertensive patients improved from 59% to 84% when dosing regimens were reduced from three times a day to once daily. Not all drugs can be taken once a day, and some drugs have complicated dosing schedules, but still, says Jaret, “the more you can do to limit the number of drugs a patient is taking and to choose those with the simplest dosage regimens, the better your chances of achieving adherence to the treatment plan.

7. Anticipate and resolve potential obstacles

If patients have experienced difficulty in the past with medications, discuss with them ways to make compliance easier. If you’ve advised a patient to make dietary changes, have a list of cookbooks or recipes ready or have the number of a nutritionist to whom the patient can be referred.

8. Instill reminders into the treatment plan

Take advantage of the many technologies that are available to assist patients in remembering to take their medications, such as programmed calendars in computers, electronic beepers, watch alarms, automatic dispensers, pill boxes with programmable reminders, and of course, the old fall back of colored labels for pill bottles.

9. Include a plan to monitor compliance

Schedule follow-up visits in advance, or implement a telephone reminder program. The Merck Manual of Diagnosis and Therapy, in a chapter dedicated to “Patient Compliance,” takes things a step further by suggesting that physicians communicate with the patient’s pharmacist to make sure he or she is taking the proper amount of the prescription, or better yet, refer patients to support groups that will reinforce treatment plans and provide patients with suggestions on how to cope with various roadblocks they may encounter.

10. Ask your patients how they are doing

It may seem repetitive, but according to Jaret’s article, it is crucial to ask patients how they’re doing when it comes to adhering to medications or other instructions. Even if they aren’t completely candid, “studies have shown that patients’ self-reports are as good as almost any other indicator of compliance.”

Conclusion

Finally, remember that “patients are more likely to comply if they have a good relationship with their physician, in which they are included in the decision making and the physician shows concern that they comply,” according the Merck Manual. As technologies continue to advance and the rapid evolution of the medical Internet continues to inspire patients to take a proactive approach to their treatment plans, it will become more and more important that the physician retains his or her position as the final word in a patient’s healthcare regimen. Whether it’s referred to as compliance, adherence, or simply cooperation, the concept of communication and understanding between a patient and physician can signal the difference between a patient who takes his pills when he remembers—doing only the bare minimum—and a patient who stays on top of his medication, avoids certain foods, and takes an active interest in his treatment plan. After all, when it comes to the relationship between physicians and patients, effective dialog can be one of the strongest medications.