Medical Adherence: The Physician-Patient Relationship

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[edit] Medical Adherence: The Physician-Patient Relationship

Geoffrey A. Modest

Medical adherence, or compliance, is the extent to which patients follow the suggestions of their health care providers. Lack of compliance is a remarkably common problem. A recent study^[1] using electronic medication monitors has confirmed many prior studies, finding that 50% to 60% of patients are adherent and take their medications more than 80% of the time, 5% to 10% are nonadherent and take medications less than 20% of the time, and 30% to 40% are partially adherent. Adherence decreases with time: more than 50% of newly diagnosed hypertensive patients drop out of treatment within 1 year and 74% by 5 years. In spite of the heightened public awareness of cardiac risk factors, the recent Sixth Report of the Joint National Committee on Hypertension^[2] found a downward trend in hypertension control, with only 27% of hypertensive patients in good control. Twenty percent of patients receiving prescriptions do not even fill them. Dietary interventions seem to be even less effective: only one third of patients are still on the diet after 1 year. Therapy for acute, symptomatic conditions is not much better. The initial medication adherence in patients given a 10-day course of antibiotics for an acute infection, for example, approaches 75%, yet fewer than 25% of patients complete the full course of therapy. In general, therapy for existing medical conditions (secondary prevention) is associated with higher rates of adherence than for potential diseases (primary prevention).

Physicians are no better than 50/50 in estimating the adherence of their patients. The statistics are not much better for patients well known by their physician and selected specifically as likely to be adherent. In general, the patient's age, gender, race, marital status, income level, intelligence, and educational level are not helpful in predicting adherence.

Medical nonadherence has many adverse consequences. It may be directly harmful to patients: not only will the underlying medical problem remain untreated, but patients risk potentially life-threatening overmedication as they are given more and more medications to treat their problem. In addition, nonadherent patients may be seen more often in the office and may receive a more extensive laboratory evaluation (e.g., as the physician searches for reasons for a patient's “ nonresponsive” condition). Estimates of the overall cost of noncompliance exceed $100 billion annually, largely through lost productivity and preventable hospital admissions. One study^[3] found that one third of hospital admissions for congestive heart failure resulted from medication and/or dietary nonadherence.

[edit] ASSESSING COMPLIANCE

The first task for the physician is to suspect that a patient is nonadherent. There are many situations in which adherence is unlikely. For example:

• A patient who misses office appointments or drops out of care
  
• A patient who is unable to state correctly how to take the medications (e.g., the patient who needs to look at the label on the medication bottle to see how many times a day he or she is supposed to take that medication)
  
• A medication bottle with more than the expected number of pills on a return visit
  
• The lack of anticipated clinical response to a therapeutic intervention
  
• A medication level (e.g., serum, urine) below expectation for a given dose of medication
  
• Lack of an expected concurrent medication effect for a given dose of medication (e.g., a patient with a rapid pulse on a high dose of a β-blocker)
  
• A patient who has alcoholism, other substance abuse, or an underlying psychiatric disorder
  

It is important to note that adherence may be erratic. For example, patients typically take medications at a higher frequency just before and just after a visit with a medical provider. Therefore a patient may have a seizure between office visits because of inadequate serum medication levels, yet may have therapeutic levels at the time of the next office visit.

What is the best way to determine whether or not the patient is adherent? It is clear that in order to obtain accurate information as well as to reinforce the physician-patient relationship, the question of adherence must be phrased in a nonaccusatory, open-ended manner. When done in this way, approximately 50% of nonadherent patients will admit it. This subgroup, not surprisingly, is the most responsive to attempts to improve adherence.

Nonthreatening ways to ask the question of medication adherence can be almost as accurate as measuring medication levels.^[4] One approach is to establish the context of medication-taking as a general problem by saying, for example, “Many people have trouble remembering to take medicines. How often do you miss or forget to take your blood pressure pill?” If the patient does not have an expected therapeutic response to a medication, one might comment, “You aren't doing quite as well as I had hoped, and I'm wondering if there are any problems with the medication that I didn't explain?” This would deflect the blame from the patient. Pill counts are reasonably accurate when done infrequently and unannounced, but also run the risk of undercutting physician-patient rapport.

Once nonadherence has been identified, it is important to ask the patient what he or she believes are the obstacles to taking the medication. Patients, however, may not reveal the true causes, for example, if they are embarrassed to admit that the medication costs more than they can afford.

There is a great deal of literature on issues of medical adherence, with a recent systematic review of the randomized clinical intervention trials.^[5] It is notable that the approaches are so diverse that a true meta-analysis is not possible, with many of the interventions being short term as well as so complex and time-consuming as to be impractical. Given these limitations, the rest of this chapter will present an arbitrary division of many of the reasons that patients may be nonadherent and several of the accepted approaches and interventions to address them.

[edit] MECHANICAL/BEHAVIORAL ISSUES

[edit] Concrete Obstacles

Nonadherence may result if the medications cost too much, the medical appointments are not at convenient times (e.g., the patient has to miss work), the waiting times at the office are too long, transportation to the office is costly or difficult, or the medication vials are too difficult to open (especially true when arthritic patients are given childproof medication bottles). Certain medication formulations might be problematic: adherence rates for inhalers are typically lower than for pills. Obstacles to care, such as unfriendly or unhelpful staff or excessively long waiting times to get an appointment, may translate into nonadherence both for appointments and medication-taking. Solutions to these problems include:

• Arranging office appointments at convenient times
  
• Educating office staff to a pro-consumer orientation
  
• Utilizing less expensive medications or arranging for free medications from pharmaceutical companies when possible
  
• Requesting easy-to-open vials for arthritic patients
  
• Implementing reminder phone calls or appointment cards
  
• Contacting the patient when appointments are missed, since adherence is very poor in patients who drop out of care
  
• Making sure that the physician is seen as accessible to his or her patients
  

[edit] Complex Medication Regimens

Simplified medication regimens are easier for patients, less intrusive, and lead to improved adherence. One study,^[1] which confirmed prior studies, documented improved medication adherence as the medication frequency decreased from three times per day (59% adherence) to one time per day (84% adherence). In addition, a study of diabetic patients found the frequency of medication errors increased from 15% when patients were given one medication to 25% with two to three medications to more than 35% with more than five medications.^[6] It is helpful that the recent Joint National Committee on Hypertension^[2] promoted the use of combination medications. In some cases, medications can be given parenterally or in a supervised way for guaranteed adherence (e.g., intramuscular benzathine penicillin for syphilis, depot injection of fluphenazine for schizophrenia, or directly-observed therapy for tuberculosis). Therefore medication adherence has been shown to improve with:

• Less frequent dosing schedules
  
• Fewer numbers of medications
  
• Directly observed therapy
  

[edit] Forgetting to Take Medications

Forgetting to take one's medications is especially common in the elderly, although it is a problem at all ages. Successful interventions include:

• Cueing medication taking (tailoring the medication regimen) to some personal established habit of the specific patient
  
• Using daily medication dispensers
  
• Using computer-generated medication reminders, especially if medication taking is likely to diminish between office visits
  
• Reinforcing the need to take the medications and reviewing how to do so
  

[edit] EDUCATION ISSUES

A necessary component of medical adherence is that the patient understand exactly what is expected of him or her. In this context, it is important to realize that less than 5 minutes after seeing a physician, the patient forgets 50% of the physician's statements. Patient recall deteriorates as the number of physician instructions increases and if those instructions are embedded in the middle of the interview. Recall is optimized by reiterating the most important physician suggestions at the end of the interview and providing written instructions.

It is well documented that adherence improves when patients receive a clear presentation of medical instructions from a physician whom they respect. Directions on how to take medications should be unambiguous and medical terminology should be avoided. Instructions should be given as specific, concrete advice and not as general recommendations. When giving dietary counseling for hypercholesterolemia, for example, it is better to find out exactly which foods the patient is eating and give specific suggestions than to generalize that the patient should avoid such foods as eggs or cheese. Information should be given in a relaxed setting, with good eye contact, and responding to the patient's verbal issues and nonverbal cues. In order to impart a consistent message, it makes sense that all recommendations be filtered through one physician, usually the primary care provider. It is counterproductive, for example, to have a specialist make one recommendation and the primary care physician make another. When giving medications, it is best to give specific times of the day that the medication should be taken. In one study, only 36% of patients understood what “every 6 hours” meant. These specific instructions should incorporate the unique needs of the individual patient (e.g., patients may not want to take diuretics in the morning if they must go on public transportation soon thereafter). It is often helpful to give the patient written instructions or pill charts indicating which times to take which medication.

Medication side effects represent a fairly common reason that patients do not take medications. For example, the British Medical Research Council Working Party, in its study of hypertension therapy, found that 20% of its subjects withdrew from the study because of side effects from either the diuretic or β-blocker therapy. Physicians should inquire about common side effects (e.g., constipation with verapamil), as well as possibly embarrassing ones (e.g., sexual dysfunction with diuretics), in case the patient is reluctant to volunteer this information. It is important to phrase the issue of side effects, when possible, in the context that there are other choices of medications available that do not have the same side effects. Since most clinical trials have been done with male subjects, female patients may experience side effects that are not well documented in the medical literature.

Patient education is clearly a desirable goal. Patients who do not understand their physician's instructions take medications less reliably than those who do (15% vs. 60%). It should be pointed out, however, that some studies have shown that successful educational interventions alone do not necessarily translate into improved adherence.

[edit] PSYCHOSOCIAL ISSUES

There is an array of psychosocial issues that undercut the patient's ability to understand and adhere to medical suggestions. Patients who are psychotic, depressed, manic, or paranoid are less likely to take medications and may need the assistance of a case manager. Patient denial may also be a major obstacle. In general, nonadherent patients do not perceive themselves as susceptible to disease or else consider the disease less severe than its reality. Hence it is important to inquire about the patient's understanding of the disease. It is also useful to ask the patient if he or she is/was emotionally close to others with the same disease, since denial may occur when the patient has unresolved issues with that family member or friend. In addition, there are studies documenting that patients who are having difficulty dealing with their life stressors may not take their medications or change their lifestyle as suggested by the physician.

[edit] CULTURAL ISSUES

Everyone comes from his or her own culture with his or her own health belief system. It is important to emphasize that this health belief system, or the patient's explanatory model of what is going on, is often fragmentary, incomplete, and self-contradictory, and changes over time. There are four factors related to the health belief model that help predict whether a person is likely to be adherent: (1) the degree to which the patient is concerned about health issues; (2) the perceived susceptibility to an illness or adverse outcome; (3) the seriousness of the consequences of an adverse outcome through nonadherence; and (4) the benefits and costs of the recommended actions, including emotional costs, inconvenience to the patient, or possibility of adverse effects.

Recommended changes in behavior must be congruent with the patient's health belief system. New health habits (e.g., dietary changes) must be acceptable within the broad framework of that belief system. If a person feels that tuberculosis results from sorcery,^[7] for example, he or she might not take the prescribed medications. It is especially important in patients from non-Western cultures to acknowledge and incorporate, whenever possible, the role of non-Western remedies (see Chapter 12 ). Many people have already tried home remedies or seen traditional healers before coming to see their physician. Simply acknowledging that it is alright to take garlic pills for hypertension may create a more substantial alliance with the patient and lead to more medication taking as well. When it seems inappropriate to incorporate traditional remedies into the care plan, or when the patient seems particularly refractory to necessary Western medications, it is useful to identify the “health expert” of the family. When possible, this person should be encouraged to return with the patient for a group discussion in which the specifics of the health care plan, including traditional and Western approaches, can be negotiated.

[edit] GENERAL APPROACH

The cornerstone to educating a patient with regard to a disease and its management is to assess the patient's understanding. A wealth of important information is provided by simply asking patients to explain, in their own words, their understanding of the disease and its therapy. This provides a quick check that the instructions were given in a clear manner, in language the patient can understand, and in a culturally congruent way, and that there were no evident obstacles to that understanding (e.g., depression or denial). Patients should be encouraged to ask questions and express confusion. Physician monologues are much less useful than interactive communication with patient participation. This communication is optimized with good eye contact and with the use of personal language. Instructions should be phrased specifically to the patient and not as generalities (e.g., “It would be helpful if you could…” instead of “People with hypertension should…”).

Many nonadherent patients make conscious, considered, “intelligent” decisions to be nonadherent. It is important for the physician to understand the patient's perspective. Eighty percent of patients in one study stated they understood that patients with hypertension are unable to tell when their blood pressure is elevated, yet 92% of these same patients believed that they themselves could tell when their blood pressure was elevated. In a study of partially adherent patients, 18% feared that taking medications regularly would lead to a worsening of health status and 22.5% feared side effects of medications. Furthermore, patients may believe (and correctly so) that the medication prescribed is incorrect or that their particular case is different from the “average case” on which data on therapy are based.

Case management strategies—often organized around nursing personnel and associated with intensified patient education, frequent telephone calls to educate and “check in” with the high-risk patients, and home visits—have been shown to dramatically improve health status and patient quality of life and decrease expensive resource utilization, especially in patients with coronary artery disease, congestive heart failure, hypertension, and asthma. One study,^[8] which used an asthma outreach nurse as the case manager only 8 hours a week, achieved a 79% decrease in emergency room visits and 86% decrease in admissions for 53 children followed 2 years. Newer studies in individuals with the human immunodeficiency virus (HIV), where medication adherence is so crucial, have found benefit from individualized case management consisting of close home-based and telephone contact performed routinely and soon after any medication adjustment.

[edit] PHYSICIAN-PATIENT RELATIONSHIP

The key issue with medical adherence revolves around the nature of the physician's relationship with the patient. In this regard, the use of the term compliance is problematic since it connotes an authoritative and paternalistic relationship with the patient.^[9] Less value-laden terms such as medication taking or adherence are more neutral and reflect better a concept of shared goals.

It is clear from several studies that the content of the physician-patient relationship has a direct bearing on medication taking. For example, a study showed that mothers give more prescribed medication to their children when they believe that their physician is understanding and friendly and interacts in a manner that is satisfying to them. Patients take medications at increased frequency when they are given by their primary care physician instead of by a covering or emergency room physician, presumably reflecting the strength of the physician-patient bond in therapy.

The patient should believe that there is an atmosphere of openness of communication, a mutual respect in which the physician has listened to his or her concerns and addressed them. Patients follow physician advice more often when they think the encounter was long enough and allowed for them to deal with their agenda as well as that of the physician.

The physician should also involve patients in their own care. There have been several important studies that suggest that empowering patients in monitoring their disease leads to improved medication taking. Even in selected “noncompliant” patients, self-monitoring of blood pressure was associated with a 20% to 30% improvement in documented medication taking. Similarly, studies have shown improved medication taking with the use of physician-patient agreements, wherein the physician and patient collectively target medical problems and negotiate a mechanism to resolve them. The patient is encouraged to choose specifically which of the behavioral changes he or she thinks is personally most appropriate. For example, the patient might decide such things as the best time to take a medication or the relative role of diet vs. medication. The physician might then negotiate an appropriate goal blood pressure and the frequency of office visits, teach the patient empowering activities (e.g., doing home glucose monitoring), and, whenever possible, establish guidelines for the patient to modify his or her own therapy. The recent asthma guidelines^[10] emphasize that adequate asthma therapy requires a partnership between the physician and patient. Of note, adults enrolled in an asthma self-management strategy to deal with asthma exacerbations had a threefold decrease of asthma readmissions over a 32-month period.^[8] This view of adherence is an interactional one, based on mutual understanding, rapport, and trust, and allows the patient to assume some responsibility for his or her own health.

[edit] FAMILY AND COMMUNITY APPROACH

Sickness of one family member has a ripple effect throughout the family (see Chapter 6 ), as well as in the broader community of the patient (e.g., work, friends). There are obvious benefits to involving the family in the care of the individual attempting behavior modification. It is extremely difficult to change a person's diet, for example, if the cook of the family is not involved, or to get someone to quit smoking when others at home smoke. Furthermore, a study with multiple educational interventions^[11] found the most dramatic effect on appointment keeping, diet, weight control, and blood pressure occurred in the subgroup assigned to family involvement, much more so than in the patients assigned to either small group discussions or in-depth exit interviews. Family members in that subgroup were given a booklet describing how they could provide support for the patient in controlling hypertension. The chosen family members understood that the patient needed to take the medications even when he or she was feeling well, made a commitment to help the patient remember to take the medications and keep appointments, and identified at least three concrete ways that they could assist the patient in taking medications. Therefore sometimes the most significant approach to nonadherence is simply to ask the patient to invite key family members to discuss the patient's problem and involve them in the solutions. It is often important to involve the patient's broader community in the care as well. Many community-based organizations are available. Group discussions with other people afflicted with the same problem (e.g., self-help groups dealing with smoking cessation) have been shown to improve behavior modification. In addition, recruiting the help of the local pharmacist or visiting nurse can significantly improve compliance. These professionals often have a detailed understanding of whether a patient is refilling his or her medications at appropriate intervals or if there are problems with any of the medications (e.g., a visiting nurse may know that the patient will not take diuretics because the patient has arthritis and the bedroom is physically distant from the bathroom). Sometimes physicians can be involved in discussing changes in the patient's work structure with the employer (e.g., changing the lunchtime of a diabetic patient so that he or she eats at an appropriate time each day). Sometimes physicians can help promote larger community-oriented approaches (e.g., encouraging the creation of smoke-free institutions).

[edit] PRIMARY PREVENTION STRATEGY

It is better to prevent problems with medication taking than to attempt to detect and change them. In principle, when initiating a therapeutic regimen, the following points will minimize problems:

• Simplified medication regimen
  
• Brief, explicit, personal instructions repeated at the end of the encounter
  
• Medication regimen tailored to the individual's needs and habits
  
• Printed instructions and education material
  
• Development of physician-patient rapport (e.g., when possible, changing medications should be avoided on a first encounter with a patient)
  
• Asking the patient to verbalize his or her understanding of the disease process and the therapeutic regimen, in order to correct misunderstandings
  
• Use of medication containers with compartments to organize multiple medications and minimize the risk of medication errors
  
• Asking the patient to bring in his or her medications (“brown bag review”), asking what he or she is taking and how, reviewing misunderstandings, and getting rid of old medications
  
• Enlisting family members/community support (including pharmacists, case managers)
  

[edit] SUMMARY

There are several recent review articles on the subject of medical adherence^{[5][3][12][4]} and the cultural issues involved.^[7] The key to adherence is an individualized approach. Most patients do take medicines appropriately. However, a substantial minority do not. When a problem is identified, the physician can screen for the simple, mechanical obstacles, such as complexity of therapeutic regimen, cost of medications, or side effects. If the problem lies beyond those issues, simply asking the patient what his or her understanding of the disease and its therapy is will indicate if there is a significant educational deficit. The problem often lies in some aspect of the relationship between the physician and the patient. For whatever reason, the patient may not be able to “hear” what the physician is saying, and/or the physician is unable to “hear” the real issues of the patient. An important step here is conceptualizing the encounter as an interactional one, with open communication and open negotiations leading to empowering the patient in the broader context of his or her family and community.

[edit] REFERENCES