Improving Patient Compliance and Outcomes : Communication is the Key

As Physicians, it is easy to become frustrated when we see patients in the office who have stopped taking a carefully crafted treatment regimen or have continued to engage in smoking or other self destructive habits.   A CHF patient may have spent a week in the hospital with IV diuretics, meticulous medication adjustments, dietary counselling and left on a “text book” perfect set of meds only to return to the ER a week later with decompensated CHF and on no meds.  This is certainly a significant public health issue that contributes to the rising cost of healthcare.  It is estimated that non compliance results in an estimated $100 billion dollars and 10% of hospital admissions in the US today.  Why does this happen?  What can we as healthcare providers do to impact this problem?
Patients and doctors today are confronted with enormous challenges when it comes to sticking to a treatment regimen.  Disease states are often complex and overlapping.  It is not uncommon to see patients in my EP clinic who are taking more than 10 different medications.  In addition to the 2 page medication list many patients also have a carefully prescribed diet, an exercise regimen and frequent doctor’s appointments.  Many of these patients are elderly and may live alone with minimal support.  Adherence to a complex set of treatment regimens becomes difficult if not impossible.  It is clear that as compliance decreases, the success of therapy decreases exponentially.  Lack of compliance results in readmission to the hospital, and progression of disease along with associated increases in morbidity and mortality.  

A manuscript by Mcdonald, et al published in JAMA in Dec 2002 reviewed all relevant published RCT of interventions to improve adherence to medications.  In the analysis 49% of the interventions resulted in increased medication adherence and only 17% resulted in improved treatment outcomes.  Many of the interventions to improve compliance involved phone calls, staff reminders and post-doctor visit counseling.  Thus, most interventions were labor intensive and were not terribly effective in changing outcomes.  In another review in Clinical Pharmacy and Therapeutics from 2001, Vermeire, et al found that factors related to poor compliance included psychiatric disorders, duration of treatment (longer duration results in decreased compliance), number of medications (and their cost) as well as the frequency of dosing.  Not surprisingly, the complexity of the regimen was shown to predict poor compliance and the doctor-patient relationship really seemed  to be an important variable in predicting higher adherence rates.  Traditionally, physicians have taken a very paternalistic approach to counseling patients about treatment plans.  Today, it is clear that there must be a shift to a “partnership” with shared responsibility between doctor and patient.

In this presidential election year, there is much discussion as to how best to reform healthcare in order to reduce cost and improve outcomes.  Politicians have recommended sweeping changes to our healthcare system at high cost to taxpayers.  Maybe more cost-effective changes to improve healthcare may be those that focus on improving compliance through strengthening the doctor-patient relationship. It is clear that lack of compliance results in poor outcomes, increased cost and lack of successful treatment.  As physicians, we must understand that the doctor-patient relationship is central to solving this problem.  We must involve patients in shared decision making and work to understand each individual patient’s perspective and circumstances that may impact adherence to a particular treatment plan.  We must treat the patient as a partner in care.  We must consider factors that may impede our ability to achieve high levels of adherence such as psychiatric illness, financial stress, family circumstances and support mechanisms.  Most importantly we must individualize treatment plans and foster two way communication in order to promote success.  

2 responses to “Improving Patient Compliance and Outcomes : Communication is the Key

  1. This is such an interesting post. It brings to mind how challenging it is for physicians to impact a behavioral change, especially given the very short time a doctor and patient spend talking to each other. In my work, I help managers work better with their employees — and they have the extraordinary benefits of working alongside each other, day in, day out. Yet still, the changes are difficult and sometimes never happen. So it’s very easy for me to see how patients can walk out of a doctor’s office and never take the necessary steps. And it’s not because they don’t want to, it’s hard. If it were easy, they probably wouldn’t be facing the issue to begin with. Thanks for your post that highlights the importance of finding ways to solve this.

    • Thanks so much for taking the time to post a reply to my blog. Working together with patients to achieve success is often challenging. As I mentioned, the key is to communicate effectively and to work in concert with the patient. This is applicable to business as well (particularly when managing large numbers of employees). I find that partnering with patients (rather than preaching to patients) tends to provide much better rates of compliance. Again, thanks for your thoughtful response.

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