How to Enlist Patient Compliance

Physicians are increasingly frustrated by new government policies, insurance changes, financial difficulties, but perhaps the toughest issue to address is increasing poor patient compliance. The truth is that even the best-designed management program (eg, insulin therapy) will continue to be compromised if patients fail to follow through. Furthermore, noncompliance has increasing financial implications in this area of tight monitoring of healthcare costs. This column offers practical tips to identify the barriers to compliance and help patients become more active participants in their healthcare (Table).

Barriers to Compliance

Compliance is a 2-part action: Both the behavior of the patient as well as the physician should be considered. Keep in mind that patients are rarely either completely compliant or totally noncompliant, and that noncompliance should be recognized as neither intentional or unintentional. 

• Lifestyle changes. Many patients find it easier to take a prescribed  medication than to comply with recommended lifestyle changes—eg, adherence to a regimen calling for changes in caloric intake or exercise.

• Patient error. Inadequate refrigeration, mixing of insulin, and irregular mealtimes can put patients at risk for various hypoglycemic reactions. 

• Medication. On average, 50% of new medication users fail to take at least 80% of the prescribed dose in the first year.¹ Since percentages vary per study, a systematic review of antidiabetic therapies found adherence rates between 36% and 93%.¹ Even the physical properties of an oral drug—ie, size, shape, and color—can affect behavior. Small, round tablets maybe difficult for patients with arthritis to grasp. Older patients with visual or cognitive impairments often rely on the physical properties of medication to identify each drug. The biggest concern is when patients use generic substitution of drugs, which can alter the properties of the medication. 

Why Noncompliance?

Over the years, I have tried various strategies to promote and sustain patient compliance. Unfortunately, patients increasingly balk at doing the routine mechanics—eg, checking blood glucose levels, following a restricted diet, and taking medication on time. 

Many patients display latent hostility at the suggestion of a calorically restricted diet and/or the prescription of oral medication or insulin as it interferes with their lifestyle. Similarly, recommendations to adhere to meal schedules, limit dietary caloric intake, and pay close attention to possible weight gain along with increased physical activity are often problematic. Many patients do not understand that it helps to carry glucose on their person to treat the possibility of hypoglycemia. 

Primary care physicians may also be confronted by a poor attitude as patients feel like they are the victim of a family history of diabetes or a family incidence of other metabolic or endocrine disturbances. They may displace anger, hostility, and impatience because their physician asks for additional tests and support staff try to schedule future appointments.

The Patient and Physician Interaction

Digital patient records have changed the doctor–patient appointment dynamic. Today, many physicians greet their patients with a computer in hand and spend time making notes in the file rather than devoting their attention to the patient. Remember that educating your patient is a key factor to improve patient compliance. In addition, reassessing therapy options and encouraging motivation are essential.

Patients tend to be most compliant when they are self-assured, active participants in their healthcare. It takes time and effort to help the patient integrate a complex regimen into all aspects of his or her life. The process involves short- and long-term interactions, where the patient provides background information about lifestyle and habits, and the physician offers medical knowledge and understanding. This is further complicated since the patient is often greeted by a nonphysician medical personnel, such as a physician assistant, who will collect medical history, review medications, and prescribe diets. 

Make sure to use the limited time you do have with your patient to establish good rapport and spend sufficient time discussing various aspects of care. 

Practical Pointers to Improve Patient Compliance

• Encourage your patient to record blood glucose readings in a daily journal and to bring their records, as well as monitor, to their office appointments. At each visit, review the monitor results. 

• Good control of diabetes requires a lifelong commitment to a regimen of medication, diet, and exercise. Remind your patient that there is no “medication holiday.” Patients should also be encouraged to promptly report any possible complication of therapy. 

• Limit the number of monitor determinations to 2 a day. The more times per day a patient uses his monitor, the less likely he will be to comply with the total regimen.

• Schedule adequate time for discussion and education during your patient appointments. Encourage the patient to ask questions. Consider writing a memo reiterating instructions for the patient to later use as a reference.

• Since many patients with diabetes are on a multidrug regimen, suggest that your patient organize the daily dose in a weekly pill organizer. Also, remind the patient to monitor the number of refills available and the number of pills remaining in the bottles to avoid last minute refill requests over the phone. All medications, both diabetic and cardiovascular, should be recorded on a memo sheet and kept in their wallets or handbags in the event of emergency.

• Memory joggers can aid compliance, particularly for older patients with deteriorating memory and cognition. Various electronic devices and palm recorders can signal the time for taking medication dosages.

• Remind patients to avoid certain foods, to be aware of their daily caloric intake, and to limit the amount of alcohol when they take certain medications. Use your office visit to warn against tobacco use and over-indulgence in alcohol. 

• At each visit, review an updated list of all the patient’s medications, including both prescribed as well as over-the-counter drugs, vitamins, and herbal products. This minimizes confusion and reduces the risk of drug interactions. Also, remind the patient about drug allergies he or she may have had in the past.

It is obvious that good medical care is complicated and takes time and considerable effort. While other members of your medical staff may assist in maintaining patient care, a physician’s personal attention goes a long way in ensuring patient compliance. ■

Compliance is a 2-part action: Both the behavior of the patient as well as the physician should be considered. Keep in mind that patients are rarely either completely compliant or totally noncompliant, and that noncompliance should be recognized as neither intentional or unintentional.

Rachmel Cherner, MD, is an associate clinical professor of medicine at Thomas Jefferson University in Philadelphia, PA. He is also an endocrinologist in private practice in Willow Grove, PA.

Reference:

1.Blackburn D, Swidrovich J, Lemstra M. Non-adherence in type 2 diabetes: practical considerations for interpreting the literature. Patient Pref Adherence. 2013;7:183-189.