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  • Compliance- A Medical Management Conundrum

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    A 65 year old patient I began seeing few years ago started out in our first encounter proclaiming that she is as healthy as one can be.  She exercises regularly, eats a balanced diet, has a positive outlook in life, and has never been told she has any medical conditions other than extensive precancerous and cancerous skin lesions for which she receives close dermatological care.  In her youth, she was a sun bather and now, exactly the opposite, she stays away from the sun like it’s the plague.  Her weight is low-normal range, has excellent blood pressure readings, and always upbeat.  When we ran the first battery of tests, we found her bone mineral density to be very low.  This came as a shock to her.  We discussed treatment options, including weight bearing exercises, vitamin D supplementation, bone resorption inhibitors, and hormone replacement therapy.  She wanted to think about it further before committing to any ‘aggressive’ treatments.  As years went by and her bone loss progressed, we continued to discuss management, and each time she would agree to some of the recommendations, but not all of them, then on follow up exams, she reported not following through on any of the recommendations.  In our last encounter, 3 1/2 years after our initial meeting, I asked her frankly, why are you not following through with medical advice, and her response was, “I just feel so healthy, and I’m doing all the right things”.  And there was the crux of the patient compliance issue.  She was nonadherent because she didn’t connect with the diagnosis.   She didn’t feel she has osteoporosis, therefore she couldn’t bring herself to follow through with recommendations.

     

    Compliance with or adherence to a medication regimen means how likely is a patient to follow through on the recommendation of their physician, and the consensus is that 80 percent compliance is an acceptable benchmark.  One of the most important determinants in patient outcome is the extent to which they comply. Reports of medication-related hospital admissions show that up to 69 percents at a cost of $100 billion a year are due to poor medication adherence.  We can have the most accurate diagnostic testing, the best treatment modalities, and a solid physician-patient relationship, yet, if our patients don’t actually put them to use, we will not see the desired outcomes.  Compliance does not mean shake your head yes when you’re in the doctor’s office, take the prescription, and then as soon as you leave the front door, think “Well, forget about that plan, I’m not going to take this pill.”

    Drugs don’t work in patients who don’t take them -C.E. Koop

    Medication Nonadherence

    Cost of medication, forgetfulness, lack of information and emotional factors are typical reasons cited by patients for not taking their medications.  Ready access to internet has raised new issues with patient compliance as many patients justify and corroborate their doctor’s advice on WebMD or some other online medical advice rendering site.

    Research shows medication compliance is higher among patients with acute conditions.  However, persistence among patients with chronic conditions is disappointingly low, especially after the first 6 months, and with more frequent medication dosing.  Good luck asking a patient to take a pill three times per day for the rest of their life.  Even in clinical trials, where patients receive close attention, rate of adherence can be as low as 48 percent.
    Here’s an interesting breakdown of a study conducted in 2002 using a medication-monitoring device:

    • 1/6 come close to perfect adherence to a regimen
    • 1/6 take nearly all doses, but with some timing irregularity
    • 1/6 miss an occasional single day’s dose and have some timing inconsistency
    • 1/6 take drug holidays three to four times a year, with occasional omissions of doses
    • 1/6 have a drug holiday monthly or more often, with frequent omissions of doses;
    • 1/6 take few or no doses while giving the impression of good adherence

    How Physicians Interact with Noncompliance

    Turns out, physicians are terrible at recognizing noncompliance and even worse at interventions trying to improve adherence.  So what is the best way to give medical advice? How do we effectively relay news about a health condition, and convey confidence in our proposed treatment plans? What is the psychology of patients’ complying with medical recommendations, especially when the psychological reasoning is further deteriorating their disease state? There is an actual psychiatric diagnosis associated with this condition, called psychological factors affecting other medical conditions (PFAOMC).

    Noncompliant Patient. A descriptor worth ditching?

    When you label a patient noncompliant, we automatically stigmatize their future relationship with their physicians.  Before so doing, a physician should first address these important questions:

    • Did my patient understand the diagnosis, its immediate and long term consequences?
    • Did I fully explain all the risks, pharmacotherapy and benefits of the medication or supplement regimen, and the risks or benefits of alternative therapies?  
    • Are there any social and psychological biases we need to address, such as stigma regarding diagnosis, past experience such as a close family member with same condition? 

    Finally, 

    • Have I built a relationship with my patient to convey trust? 

    Once we thoroughly evaluate all of these important issues, and patient’s compliance is still an issue, we don’t stop there.  We need to delve deeper, ask questions about their understanding of their illness, their expectation of treatment outcomes, “What do you think causes osteoporosis?”, and “How does it affect you?”, “It must be hard to take so many medications.” Taking medical advice to heart requires deep understanding and joint decision making.

    Scolding, threatening, or shaming tactics are hugely unsuccessful, though I must admit I have found myself resorting to some of them on one or two occasions.  One incident stands out: a hypertensive patient came in to the office 3 months ago with a blood pressure of 187/101, and expressed candid resistance to taking his second BP medication.  I told him I do not want to be his doctor if he comes in to the emergency room with a stroke.  The next session, his blood pressure was 150/90, because he started to take the prescribed regimen.  Perhaps, his adherence will not last, but at least for the time being, he’s out of the danger zone.

    Final Thoughts

    Nonadherence contributes to worsening disease, death and increased health care costs. Surely as a physician and as a community member who cares about optimal health outcomes, believes in the science of medicine, we should not accept the astoundingly high rate of failure to comply with medical advice.    Physicians should always look for noncompliance, convey logical reasoning of treatment regimen, try to make the regimen more simple, and customize it to patient’s lifestyle, each and every time bringing in patient choices in the medical decision making.  As always, I am open to hear your thoughts about this very important discussion either here in this forum or in our next encounter.

    In good health and sound advice,
    Yazdani, MD

    References:

    1. Psychological factors affecting other medical conditions: Management. James Levenson. Uptodate,
    2. Adherence to Medication. Lars Osterberg and Terrence Blaschke. NEJM 2005; 353:487-497.
    3. The electronic medication event monitor: lessons for pharmacotherapy. Urquhart J. Clin Pharmacokinet 1997;32:345-356
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  • Posted by Kayla on December 7, 2017, 7:46 pm

    I agree that medical management is very important for patient compliance. My grandfather is very old and usually forgets to take his medicine regularly. My dad suggested having medication management and shared this article. It says that research shows medication compliance is higher among patients with acute conditions. However, persistence among patients with chronic conditions is disappointingly low.

    Reply →
    • Posted by Nasime Yazdani, MD on December 18, 2017, 6:44 pm
      in reply to Kayla

      Thank you for tuning in Kayla. Compliance is difficult and even more so in the elderly, because they tend to have memory deficits too. Your grandfather is lucky to have a supportive family to help him manage his meds.

      Reply →
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