Noncompliance is a serious healthcare problem with far-reaching consequences for both patients and doctors. Today’s patients are better informed about their health than ever before. Or, at least, they think they are. That may be why some of them don’t follow directions.

The significance of the problem is indicated in statistics showing that up to half of all patients fail to follow their prescribed drug regimens, with 5% to 20% of prescriptions never even being filled.

Patient compliance with treatment protocols for coronary artery disease and other chronic illnesses also continues to be poor. A study by researchers at Duke University, published in the January 2006 issue of Circulation, found that just 39% of patients with coronary artery disease consistently followed their physicians’ recommendations for taking aspirin, beta blockers, and lipid-lowering medications.

No Easy Answers
Improving patient compliance defies easy answers. Drugmakers have spent millions developing medications that are more palatable to the public, and today’s treatments are more effective and often have fewer side effects than previous regimens. Patients are also better educated today. But, in the end, patient compliance rates have not improved. “In fact, these factors may actually be contributing to a worsening of patient compliance over time,” writes health researcher Judy Z. Segal PhD, author of “Health and the Rhetoric of Medicine.”

“Noncompliance often has very practical reasons behind it,” continues Segal, who is also an associate professor at the University of British Columbia, Vancouver. “People can be confused about dosing schedules or cannot tolerate side effects. But I think often doctors have failed to persuade patients that complying is in their own best interest. The idea is that people need good reasons, sometimes very specific reasons, for following their doctors’ advice.”

Physicians must always keep in mind that patients are experts about their own lives and experience, but their patients don’t have the same knowledge as they do. Patients have access to a plethora of health information today, but they don’t have the means to interpret it. It is a mistake to think that medical information is the same as medical knowledge.

Segal suggests that one reason patient compliance is not improving may be that, although physicians acknowledge the problem is widespread, they don’t believe it’s an issue among their own patients. It is a fact that many times physicians don’t know if a patient is noncompliant or just nonresponsive.

Patients must trust you to the point that they feel comfortable revealing personal compliance issues. You probably think your patients already trust you; if they didn’t, why would they keep coming back to see you?

Motivating Factors
Many physicians feel there is a certain level of responsibility for patients to follow through and take care of themselves. But how patients feel about the message and the messenger is a decisive factor in their compliance. And, on some level, your noncompliant patients may not be buying into what you are telling them. The biggest motivator for patients today is still the physician.

Compliance generally increases if patients are given clear and understandable information about their condition and progress in a sincere and responsive way.

To a physician it makes perfect sense to say, “I recommend this medication regimen because, left untreated, your hypertension could increase your risk of renal failure, myocardial infarction, and cerebral hemorrhage.” However, it would make absolutely no sense at all to many patients, leaving them more befuddled than motivated to comply with the providers’ recommendations.

One of the most effective ways to enhance compliance is to simplify a patient’s instructions or treatment regimen as much as possible. A shift worker on medication that should be taken twice a day may find it difficult to take the second dose while he or she is at work. Changing a patient’s medication to one that can be taken once a day could help the patient be more compliant with his or her treatment regimen.

You can also boost patient compliance regarding preventive care and check-ups by having systems in place to generate patient treatment or appointment reminders. For instance, you could use a database to track your diabetic patients and contact those whose hemoglobin A1C was not under seven at their last visit and invite them to come in for a follow-up. Also, patients with other chronic conditions who should have a follow-up every three to six months could be similarly tracked and contacted. Patients should always get the sense that their physician cares about them and their health.

Compliance also increases if a physician listens and respects patients’ concerns. Finding out patients’ attitudes and past experiences can deeply affect compliance and save time and problems later. If, for instance, your patient is firmly opposed to taking a particular antibiotic, you could ask the following open-ended questions:

• What are your main concerns about taking this medication?
• What do you think might happen if you take it?
• When you came in today, what were you hoping I might do for you instead of prescribing this medication?

Risky Behavior
Patients who do not adhere to physician instructions or recommended follow-up treatment plans are not only difficult to manage, they often present significant risk management concerns for the physician. Despite their best efforts to educate patients, many physicians are faced with behaviors that indicate patients are putting themselves and the provider at risk by not adhering to the prescribed treatment. Documentation in the patient’s medical record concerning refusal of treatment should include the following points:

• A notation about the information the provider gave to the patient concerning the condition and treatment, including reasons for treatment or a referral to a specialist
• A notation that the patient was advised of the risks and consequences of failing to undergo tests or to see a specialist
• A notation about the patient’s refusal to follow the treatment plan or advice and/or the patient’s signature on a refusal of treatment form
• A notation about the provider’s referral of the patient to a specialist
• Verification that the patient did or did not keep his or her appointment with the specialist.

Patient noncompliance is a frequent cause of patient injury and may result in a claim or lawsuit. But there are no simple answers to this problem. Solutions, for the most part, lie in quality education and communication between the patient and his or her physician.