In healthcare, compliance, also referred to as adherence, is defined as “the degree to which a patient correctly follows medical advice”. Compliance commonly refers to medication or drug compliance; however, it can also relate to other situations such as self-care, use of a medical device, and therapy. Yet, there is a slight difference between the terms ‘compliance’ and ‘adherence’. Compliance (to obey, to cooperate) refers to a patient fulfilling a promise, such as promising to take their medication. Adherence (to attach, to remain constant), on the other hand, refers to a patient committing to lifestyle changes, such as refilling their medication prescription. Doctors and patients affect compliance, thereby emphasizing that the most vital component in improving compliance is building solid and positive doctor-patient relationships.
Yet, the World Health Organization stresses that the percentage of patient noncompliance is up by 50%. Why is this so? Why don’t patients comply with their doctors? Non-compliant patients are those who agree to follow a doctor’s recommendations and then fail to do so. The reasons for patient non-compliance are rather complex. Researchers have found that several internal and external factors play a role in how patients follow recommendations and instructions given to them by their doctors. Internal factors may include age, social background, cultural values, emotions caused by a disease, etc.; while external factors may include doctor-patient relationships, support from family and friends, health education, etc. Several experts agree that the most common reasons why a patient may not comply with a treatment regime include the following:
- Cost of the treatment is not covered by insurance and leads to more out-of-pocket expenses for the patient;
- The instructions for the treatment regime are rather difficult to follow;
- The treatment regime triggers unwanted side-effects and outcomes;
- The patient is in denial of his or her medical problem until persistent symptoms present themselves;
- The patient does not trust their doctor;
- The patient does not understand the importance of the treatment regime that they are prescribed;
- The patient has had previous / negative experiences with the same treatment regime and they are hesitant to try it again;
Still, there are several other reasons as to why patients may not comply with a treatment regime. Many put their health on the back burner, putting their careers and others first. People think of the future, but not in terms of their health. It is such reasons that can have a powerful impact on decision-making and behavioral changes. Additionally, there are multiple costs to non-compliance, including emotional, physical, financial, and societal. Non-compliant patients may demand extra attention and even challenge your clinical skills and abilities. As a healthcare professional, hidden non-compliance puts you at risk of practicing in ignorance, thus leading to unresolved medical cases. When patients fail to comply with prescribed medications, treatment plans, or necessary lifestyle changes, this can come at a cost to society, resulting in lower health outcomes. “The cost of patient non-compliance is easily in the tens of billions of dollars a year in needless complications and hospitalizations. If we could improve compliance, we'd be well on our way to fixing the healthcare system regardless of what reforms are ultimately passed” said David B. Nash, Internist.
So, what is your responsibility as a doctor to make sure patients comply? Even though they do not have to listen to you, you know that they should. According to a survey conducted among 1000 non-compliant patients, more than 70% revealed that they would be more compliant if they know more about their medical condition and how prescribed medication could help. Another study revealed that over 40% of patients sustain immense health risks due to forgetfulness, ignorance of medical advice, or misunderstanding. If you are dealing with a non-compliant patient, you need to make sure they know that your recommendations are personal to their health, that there are long-term risks when it comes to non-compliance, and that there are several resources available to them to help them comply with your prescribed treatment regime. Additionally, when assessing their level of compliance, it is necessary to look at the doctor-patient relationship. Do you have a trusting and compliant relationship with the patient? An agreeing, reliable, and trustworthy relationship is most likely to yield honest and positive responses. Finally, assessment of the patient’s knowledge and understanding of a particular medication or treatment plan is essential. A complete understanding of why the patient requires or should choose to comply with a particular medication / treatment plan will prove to be effective in targeting the potential for compliance issues.
“There are multiple reasons for non-compliance. Patients may not understand what you told them. I typically ask the patient to repeat back to me what it is he's supposed to do. It's important to explain that if the patient doesn't take the medicine, he's at increased risk for stroke or some other illness. If I suspect the patient is unclear, we give written instructions and may follow up with phone calls. It's important to know if the patient is able to read. I've been amazed over my career at how many patients cannot” said Dr. Donald J Palmisano, Vascular Surgeon/Attorney. As a medical expert, you need to be aware that each patient is different and has their own perception of your recommendations. A patient needs to be given the opportunity to tell his or her side of the story. By listening to their point of view, you can begin to understand their attitudes, beliefs, as well as emotional and physical challenges relating to non-compliance. If your patient can tell you why they are unwilling or hesitant to follow your instructions, then you have a second chance to build a mutual agreement for an effective treatment plan based on their own preference of care.
There is no one type of intervention method that can help improve compliance among all patients. The reality is that improvement depends on customizing intervention methods to match patients’ unique traits, needs and preferences, medical conditions, and treatment regimes. For instance, some patients may require a greater understanding of the medical advice they are given or more moral support from family and friends, while others may simply be unmotivated or have trouble keeping appointments due to unreliable transportation. “It is sometimes hard for the physician to realize that there is an inherent power imbalance in the dynamic between physicians and patients. Physicians are comfortable in the world of medicine, whereas patients are often insecure and anxious in it. Physicians are at work, using professional training and experience to deal with other people's problems, whereas patients are often worried about a problem that affects them immediately and personally” wrote Fred Kleinsinger, Assistant Clinical Professor at the UCSF Department of Family & Community Medicine. For these reasons and more, it is your job to identify potential blockades and pinpoint the exact area where non-compliance could come into focus. Patient non-compliance can be a threat to patients’ health and well-being; however, it can prove to be an economic burden as well.
By acting as an educator, you can improve patients’ knowledge and understanding of treatment regimes. By communicating clearly and effectively, you can help clarify patient issues and develop plans that match patients’ lifestyle and priorities. Ultimately, by building relationships based on mutual trust and respect, you can enable patients to carry out medical advice on their own behalf and improve compliance. Doctor-patient relationships, collaboration, engagement, and participation are all building blocks at the heart of successful attempts to maximize compliance behavior. It is such building blocks that can lead to increased patient satisfaction, optimized health outcomes, and improved patient compliance. “All physicians can do is make sure patients have the information they need to make a rational decision. It's ultimately the patient's choice whether to accept our advice” said Rick Kellerman, Chairman of the Department of Family and Community Medicine at Kansas University School of Medicine.