Why Do We Fail to Adhere to Treatment?


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About 1/3 of patients with acute illnesses fail to follow their doctor’s recommendations for short-term treatment (such as completing an antibiotic course). The rate is even higher among those who suffer from a chronic illness.1 In fact, about 50% of patients fail to adhere to long-term treatment plans.2 This is a little ironic, don’t you think? On one hand, feeling ill leads to actively seeking out medical help and advice; on the other hand, the advice and prescription for medical regimens quickly go out the window after leaving the doctor’s office.

Since there has been a significant increase in the prevalence of chronic diseases, poor patient adherence to treatment has become a major health care problem. More than 90 million Americans live with some sort of a chronic illness3 and these people account for 70% of the annual mortality in the United States.4 Poor adherence to treatment is linked to more than 125,000 deaths each year, not to mention, innumerable and completely unnecessary clinic appointments, emergency room visits, hospitalizations, nursing home admissions and additional diagnostic tests. The estimated annual cost of such unnecessary procedures and treatment complications is anywhere between 13 and 15 billion US dollars, which is a tremendous financial strain.1, 2, 5 To sum up, poor adherence to treatment is costly, complicated, painful and can even cost one’s life. So, why do we do it?

The term adherence suggests that the patient plays an active role in treatment and the healing process.6 No doctor can wave a magic wand and make problems disappears. Usually, healing requires efforts and persistence on the side of the patient, especially when dealing with chronic illnesses. Often times, a major lifestyle change is required, such as changing your diet, exercising or quitting a bad habit. If you’ve tried any of those (or, as in my case, all of them) you know it is a daunting task, which requires will power and patience. What makes matters worse is that it takes a long time before you begin to feel better or experience any other benefits from your efforts. That explains why more than 75% of patients neglect recommended lifestyle changes or are unable to follow through.7

However, noncompliance does not always suggest willful disregard of professional advice. We also see cases of doctor-patient miscommunication, patient’s failure to accurately remember the advice or mere knowledge and skill deficits among patients.6

Failure to Remember

One study8 investigated how many of doctors’ recommendations were actually understood and remembered by patients (and their parents) in a a childhood diabetic clinic. On average, the health-care provided gave about seven recommendations per patient, with both the child and parents present. However, when asked about those, patients and parents recalled only about two recommendations. Shockingly enough, in 40% of the cases, the remembered “recommendations” were never made by the doctor (but were probably some outside information or false memories).

Another study9 observed that patients recalled only about 50% of the physician’s instructions.

When elderly patients suffering heart failure were interviewed, 45% of them could not remember the name of the medication prescribed, 50% could not remember the prescribed dose and 64% could not remember when they were supposed to take it.10

These are just a few examples that show the difficulty of treatment adherence, even when both the patient and health care provider are well-meaning.

Keep this in mind next time you visit your physician. The advice and recommendations they provide may be perfectly clear at the moment, but may soon fade away. There is nothing shameful about taking notes, for example. After all, the faintest ink is better than the strongest memory.

Patient-Doctor Miscommunication

What about the cases when professional advice is so vague that is practically useless? Then patient will be in trouble, even if they remember exactly what the doctor said.

Sometimes, physicians forget that technical knowledge which is a given for them is alien to most of us. Therefore, they may quickly go over diagnosis and treatment, leaving you nodding along, not understanding any of it. In this case, you should not feel intimidated and should not hesitate to ask questions until you clearly understand your situation and recommended treatment. After all, your physician is there to help you.

Other times, health-care providers only give advice in general terms (“Get more exercise” or “Avoid high-fat foods” or “Cut off the alcohol”)6. This is not specific enough for most patient to comprehend and break down in small and measurable steps, so they can measure progress and get more motivated. On the contrary, such a general suggestion can be overwhelming, causing you to give up easily. Other times, people make some change, but it’s hard to know if that is what the doctor had recommended. For example, what does “more exercise” suggest? Taking the stairs instead of the elevator? Walking for 30 minutes each week? Running for half an hour three times a day? Which is it? Make sure you can answer questions like these before you leave your doctor’s office.

Knowledge and Technical Skills Deficits

Quite often, treatment involves behaviors and procedures performed by patients, that require some level of skillful administration (insulin injections, glucose testing, using an inhaler, etc). Many researchers have studies these disease management behaviors in patients and have found out that even when people were certain they did everything right, there were mistakes than tempered effective treatment.6 A study of asthmatic children11 observed that 93% of them used a deficient meter-dose inhaler (MDI) technique and their parent were also unaware of it. Among adult asthma patients, more than 75% made at least one technical error in the MDI process (even after having received previous training)12. Glucose testing errors and deficient insulin injections have been documented multiple times among children and adults with diabetes.13 After closely studying parents who were giving factor replacement therapy to their hemophiliac children, numerous administration errors were recorded even after years of experience.14 This is not tho say that parrots and patients don’t care, but simply shows how easy it is to make mistakes and be inadvertently non-compliant with treatment. Just keep that in mind and take any steps necessary to get trained and repeatedly supervised by professionals.

You can never be too careful with matters of health. It is the single most important thing we possess, so cherish it and take good care.

If you would like to learn more about adherence to treatment and disease prevention visit the Center for Disease Control and Prevention.

References:

1. DiMatteo, M. R. (1994). Enhancing patient adherence to medical recommendations. Journal of the American Medical Association, 271, 79-80.   2. Rapoff, M. A. (1999). Adherence to Pediatric medical regimens. New York: Kluwer Academic/Plenum Press.   3. Centers for Disease control and Prevention. (2004). Chronic disease prevention.   4. Centers for Disease control and Prevention. (1999). Chronic Diseases and their risk factors: The nation’s leading cause of death.   5. Mistry, S. K., & Sorrentino, A. P.  (1999). Patient nonadherence: The $100 billion problem. American Druggist, 216, 56-62.   6. Johnson, S. b. & Carlson, D. N. (2004). Medical Regimen Adherence: Concepts, Assessment, and Interventions. Handbook of Clinical and Health Psychology, Vol. 2. American Psychological Association, Washington, DC.   7. Epstein, L.  & Cluss, P. (1982). A behavioral medicine perspective on adherence to long-term medical regimens. Journal of Consulting and Clinical Psychology, 50, 950-971.   8. Page, P., Verstraete, D. G.,  Robb, J. R., and Etzwiler, D. D. (1981). Patient recall of self-care recommendations in diabetes. Diabetes Care, 4. 96-98.   9. Falvo, D. & Tippy, P. (1988). Communicating information to patients: Patient satisfaction and adherence as associated with resident skill. Journal of Family Practice, 26, 643-647.   10. Cline, C. M., Bjorck-Linne, A. K., Israelsson, B. Y., Willenheimer, R. B., & Erhardt, L. R. (1999). Non-compliance and knowledge of prescribed medication in elderly patients with heart failure. European Journal of Heart Failure, 2, 145-149.   11. Winkelstein, M. L., Huss, K., Butz, A., Eggleston, P., Vargas, P., and Rand, C. (2000). Factors associated with medication self-administration in children with asthma. Clinical Pediatrics, 39, 337-345.   12. Larson, J. S., Hahn, M., and Ekholm, B. (1994). Evaluation of conventional press and breath MDI technique in 501 patients. Journal of Asthma, 31, 193-199.   13. Perwien, A., Johnson, S. B., Dymtrow, D., and Silverstein, J. (2000). Blood glucose monitoring skills in children with type 1 diabetes. Clinical Pediatrics, 39, 351-357.   14.  Sergis-Deavenport, E. & Varni, J. W. (1983). Behavioral assessment and management of adherence to factor replacement therapy in hemophilia. Journal of Pediatric Psychology, 8, 367-377.

 

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