Rethinking patient noncompliance (Part 2)

Allan Showalter, MD

AlignMap

(Continued from “Rethinking patient noncompliance (Part 1)”)

Part 1 of "Rethinking patient noncompliance" focused on the reasons noncompliance with medical recommendations has persisted as an economic and fiscal catastrophe for both individual patients and society since the origins of healthcare itself. Primary among these causes is the contemporary concept of patient compliance itself. While “patient compliance” is a useful statistical measure, it is profoundly flawed as an explanatory model. Further, detection of noncompliance, which pervades every patient population regardless of demographics, diagnosis, treatment, or clinicians, is difficult and rarely accurate. Consequently, decades of research and centuries of clinical experience have failed to produce widely applicable methodologies that significantly, reliably, and enduringly enhance compliance.

Part 2 of "Rethinking patient noncompliance" addresses the means by which revising the model of adherence to treatment could result in historically unprecedented improvements in the proportion of healthcare recommendations effectively completed.

Patient noncompliance: Misunderstood concept - ineffective solutions

The failure to develop pragmatic solutions for noncompliance is, in large part, secondary to the medicalization of treatment nonadherence.

Patient noncompliance is no more than a non-explanatory label assigned to an extraordinarily wide and varied category of non-optimal behaviors patients exhibit in response to medical recommendations. Instances of noncompliance manifest themselves in an infinite variety of forms and stem from an infinite number of causes.

This conventional, convenient, a priori ideological construct of patient noncompliance has, however, been widely applied as an expression of pathology unique to healthcare. Worse, this fundamental misinterpretation has been coupled, in keeping with the medical model, with an obsessive drive, motivated by the morbidity, mortality, and money involved, to formulate a cure.

"...decades of research and centuries of clinical experience have failed to produce widely applicable methodologies that significantly, reliably, and enduringly enhance compliance."

The medical model, its bad press in recent years notwithstanding, has proven an excellent tool for developing effective cures for a vast number of afflictions with a discrete physiological cause. It is hardly surprising, however, that tactics based on a biomedical paradigm have done little to change an ambiguously described behavior that eludes detection, defies measurement, produces unpredictable results in specific cases, and stems from a multitude of combinations and permutations of etiologies.

To fully grasp the state of art of healthcare noncompliance solutions, however, a fifth fundamental percept, in addition to the four listed in Part 1, is necessary:

5. Development of an effective methodology for managing patient noncompliance remains unlikely as long as the strategies being investigated are limited to those already shown to be ineffective.

If that sounds obvious – well, it is. Nonetheless, research and development undertaken at academic centers, government agencies, pharmaceutical companies, clinical organizations, and other entities invested in compliance solutions continue to focus on strategies, such as improved patient education or ameliorating a medication’s side-effects, which share one advantage - intuitive validity, i.e., it seems as though they should work - and one disadvantage - the absence of empirical proof, despite repeated efforts, demonstrating reliable efficacy.

Why are these same methods persistently targeted for research and development in the face of repeated failure? Rather than couch the answer in the terminology of economics, psychoanalysis, learning theory, or some other perspective, however legitimate, instructive, and helpful those elucidations may be, I contend that the best illumination of this phenomenon is provided by one of my favorite jokes:

A passerby sees a drunk under a streetlight, obviously searching for something. When asked, “What are you doing?” the drunk replies, “Looking for my key.” The helpful passerby joins the drunk in his search. Soon, however, it becomes clear that the key is not in the vicinity. The newcomer asks, “Are you sure you lost your key here?” “No, actually I first noticed it was missing when I was walking over there,” the drunk says, pointing to an area a half block away. The perplexed passerby asks, “Then, why are we looking here if you lost your key over there?” Responds the drunk, “Because we can see better here, under the streetlight.”

The point, of course, is that we can’t afford to keep looking for solutions in areas that have repeatedly been shown to be bereft of answers even if those areas are comfortable and familiar to healthcare specialists.

Key Point: Noncompliance is not exclusively a medical issue but a personality trait that manifests in many areas of life. Treating patient compliance as though it’s a straightforward, sui generis phenomenon independent of other human behavior all but eliminates the potential for significant advances in the field.

An aside on paths not taken by "Rethinking patient noncompliance"

Before this article crescendos into its big finish, the author should acknowledge and readers should be alerted to issues absent from this discussion as a consequence of time and space restrictions that are exceptions to the principles set forth in this article. Examples follow.

There are strategies available today that do improve compliance – for specific fractions of the patient population. Most fall in one of two categories:

1. Removal of systemic barriers to compliance. My personal favorite in this class is “Write the prescription instructions in a language the patient can read.” Others include the notions that adherence is likely to be higher if a medication regimen is simplified (e.g., a medication is given once a day rather than four times a day) and that elimination of co-pays may enhance compliance (although results of some studies contradict both of these seemingly obvious ideas). In effect, however, these compliance improvement tactics only eliminate obstacles that, in most cases, are caused by the healthcare system itself and affect only a limited number of patients.

2. Reminders and organizers. Integrating pill organizers and dispensers, buzzers, lights, telephone calls, email, text messages, or other mechanical means of facilitating that the right medication is taken at the right time into the lives of the right subgroup of patients can significantly alleviate unintentional nonadherence.

And, some aspects of patient compliance are unique to healthcare, medical ethics, for example, preclude a clinician employing certain tactics to induce a client’s adherence to treatment although those same techniques might have a legitimate place in selling sports cars.

Finally, there have also been isolated efforts recently to develop patient compliance strategies not routinely used in medical environments, such as incentives for adherence and the use of patient segmentation to select the optimal compliance enhancement tactic for a given patient. (In the spirit of disclosure of biases and potential conflicts of interest, I want readers to be aware that I helped develop a patient profiling system and maintain a business interest in it.)

"Noncompliance is not exclusively a medical issue but a personality trait that manifests in many areas of life."

None of these points materially alter the facts described and contentions formulated in this paper.

Employing a Copernican perspective to find compliance solutions that work

Whenever I find myself disconcerted about the lack of progress in patient compliance in the past century, a period during which great advances were made in almost every other aspect of healthcare, I seek solace by putting this disappointment in context. After all, Ptolemy proposed a model of the cosmos which positioned the Earth at its stationary center with the moon, sun, planets, stars, and such revolving around it. The Ptolemaic System held sway for 1,500 years, yet it turns out to have been wrong.

On the other hand, the current notion of patient compliance has been predominate only fifty or sixty years.

Still, freeing ourselves from the healthcare-centric model of noncompliance now –rather waiting another 1,400 years for the Copernicus of compliance to appear – would seem to convey benefits to humankind sufficient to warrant the effort.

While a full exposition of a revised concept of patient compliance and the consequent benefits is beyond the scope of this paper, two examples of specific changes in our thinking about patient compliance and their advantages serve to indicate the potential gains:

1. Do away with the restrictions implicit in the contention that healthcare compliance is unique.

One might hypothesize from the preceding points that the current theories of medical compliance, whether formal schools of thought or de facto beliefs, and the enhancement interventions derived from them have been perpetuated simply because no alternatives exist.

In this instance, however, one would be wrong.

Not only are there promising alternatives but those alternatives are well known, in place, and working successfully – in other fields.

Compliance and noncompliance are integral issues in many areas of human endeavor other than healthcare. The legal system is, in fact, built around the notion of citizens complying with laws. Politicians work to bring us into compliance with their ideas to garner votes. Adherence is an essential element in educational institutions, military units, and professional guilds. And, of course, marketing focuses on convincing potential buyers to comply with recommendations to purchase a particular product or set of goods.

Consequently, those sets of strategies that have been effective in achieving compliance in nonmedical fields may also serve the same function if adapted to healthcare.

2. Change the compliance game from clinician vs. patient to clinician &amp, patient vs. problem being treated

The most promising – and challenging – strategic shift in patient compliance is bringing the goals of patients, clinicians and other stakeholders into alignment.

The lack of such alignment now and its potential advantages are illustrated by the observation, supported by significant research and clinical experience, that such that patients frequently lie, by commission or omission, to doctors about following healthcare recommendations, such as taking a medication, testing blood glucose levels, exercising, etc. Clearly, the goals of the patient and the goals of the doctor are not in alignment in this situation. Decreasing the number of patients who feel compelled to lie to their clinical team about inadequate completion of treatment recommendations alone could dramatically lower costs and morbidity &amp, mortality.

"The most promising – and challenging – strategic shift in patient compliance is bringing the goals of patients, clinicians and other stakeholders into alignment."

Similarly, clarifications of the ethical, legal, and pragmatically necessary responsibilities of clinicians, patients, and other stakeholders could lead to increased transparency, trust, and mutuality, which could, in turn, lead to an increased proportion of successfully completed treatment plans.

Conclusion

The key to overcoming the unnecessary economic costs, suffering, and deaths caused by patient noncompliance is recognizing that those of us in the healthcare industry have for too long subscribed, perhaps for no better reason than cultural and professional narcissism, to an inadequate and inaccurate model of treatment adherence.

Or, as Pogo more elegantly phrases it, "We have met the enemy and he is us."

About the author:

Allan Showalter, MD is a psychiatrist who became interested in patient compliance during medical school in the 1970s. After reading extensively about the topic and observing how instances of noncompliance played out in his private practice and in the hospital and outpatient environments he oversaw administratively, Dr. Showalter became convinced that the prevailing compliance theories and adherence-enhancement methods had to be revised if significant improvements were to take place. For the past four years, Dr. Showalter has been writing about patient compliance at AlignMap.com.

How can the pharma industry tackle patient noncompliance?