The cost of patient noncompliance — for both medical outcomes and the U.S. economy — has been well documented over the years. Patients who fail to take medication, skip out on appointments, or disregard lifestyle and dietary recommendations reportedly account for 10 percent to 25 percent of hospital and nursing home admissions per year, costing the U.S. health care system upwards of
00 billion annually. That doesn't include another
0 billion in indirect costs from lost patient earnings and workplace productivity. At the same time, complications that arise from not following a prescribed treatment regimen result in an estimated 125,000 deaths per year in patients with otherwise treatable conditions.
Despite the avalanche of statistical data on the topic, however, there remains a surprising lack of consensus on ways that physicians can increase compliance among their patient populations. Perhaps that's because there's no one-size-fits-all solution.
Indeed, the barriers to adherence are as varied as the patients themselves. Some fail to follow through because they fear medication side effects, don't believe that the treatment is working, or feel ill equipped to manage their own health. Others simply forget to fill their prescriptions and take the correct dose at the appropriate time. As researchers delve deeper into the predictive factors for noncompliance, however, a number of new tools and techniques are being developed that can help physicians tailor their treatment plans to individual patients. That, in turn, motivates patients to collaborate in their own care.
Patient motivation is the name of the game in the modern era of patient-centered care, says Anne-Marie Audet, vice president for health system quality and efficiency for The Commonwealth Fund in New York, a private foundation that promotes effective healthcare. "Our system is so much geared toward acute care, but we're moving toward investing in primary care and preventive care which means people will have to be even more engaged in their health," says Audet, noting those patients who fail to participate as medical decision makers could fall through the cracks. "Activating patients is something you can learn, but it's an acquired [skill]. Generally, I think we've failed [as an industry] to really establish the connection between what happens in the small amount of time that people spend in the healthcare system and in the 99 percent of the time they spend outside of it."
Patient surveys
While demographic factors — including age, sex, race, education, and socioeconomic status — appear not to influence adherence levels significantly, research suggests there are certain behaviors that play a role. For example, "many patients with a low level of activation have poor problem-solving skills," says Judith Hibbard, professor of health policy at the University of Oregon, who co-developed a self-assessment tool to categorize patients by how active they are likely to be in their own healthcare. "If the pharmacy is closed or [the patient's] copayment goes up, they're more likely to give up," she says. "Any barrier thrown in their path can throw them off, so knowing that is helpful in terms of making sure those patients get the help they need."
Hibbard's Patient Activation Measure, or PAM, uses 13 questions to assess patients' knowledge, skills, and confidence for managing their health. It produces a score of 0 to 100 and breaks out patients into four progressively higher activation levels. Each level is associated with distinct self-care behaviors and attitudes — the values, motivations, and emotional dispositions that drive those behaviors. The score is sent directly to the physician or healthcare provider.
"Physicians can use [the score] in medical homes as a way to personalize care, consistent with the patient's level of activation," says Hibbard, noting that staff could ask patients to fill out the survey in the waiting room before they're seen. "If they're low activated, they may feel overwhelmed and discouraged because they've had a lot of experience with failure in trying to manage their health. So the physician knows that instead of giving them a list of 17 things, they should start small. Give [patients] permission to focus on one thing first, so you build their confidence and set them up for success." The cost of the survey ranges from 30 cents to $1.60 per patient, per year, depending on how many patients are included in the provider's contract.
Another survey tool, available for free at howsyourhealth.org, gives patients the opportunity to score themselves on their emotional, physical, and economic status, along with their degree of social support and problem-solving skills. Physicians can customize the survey questions to better suit their practice and ask their patients to fill it out before their appointment using a unique code so the results get forwarded to them.
John H. Wasson, a gerontologist and professor of medicine in community family medicine at Dartmouth Medical School, who helped develop the tool, notes howsyourhealth.org also allows patients to set up automated text messages to remind themselves to skip the bacon or take their pills. Physicians receive a summary report of how competent that patient is as a self-manager, and how well they feel their needs are being met in the exam room. Lastly, says Wasson, physicians can use the results to call out a group of patients over a specific period of time, say, the last six months, who reported low levels of competency. "You can send individual patients a reminder of something positive to boost their confidence, or send a blast e-mail to every patient with low confidence levels and tell them that you're holding a group visit or that there's a peer support session at the senior center," says Wasson.
