Noncompliance

Few situations challenge and frustrate us as the need to deal with residents who are noncompliant with treatment protocols. In a world in which health care dollars are increasingly scarce, we must carefully allocate the resources we have to those who will benefit most. These decisions become far more complicated when patients and residents refuse the care that is recommended.

The consequences of noncompliance with treatment are profound. Estimates of the total annual healthcare costs in the US resulting from patient noncompliance vary from $100 billion to $170 billion to $300 billion. These costs include relapse, readmission, repeated tests and treatments, additional medications required, recurrent infections, drug resistance, and more.

Many reasons have been proposed as explanations for this seemingly self-destructive patient behavior. Lack of understanding of drug or treatment regimen, previous experiences with treatment, fear and anxiety, side effects of medication or treatment, pain and discomfort, cost of copayments or coinsurance, presence of psychological symptoms, cultural bias, and others have been identified.

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 residents, leaving them more confused than motivated to be compliant.

Compliance generally increases if patients are given clear and understandable information about their condition and progress in a sincere and responsive way. One of the most effective ways to enhance compliance is to simplify the instructions or treatment regimen as much as possible. Residents should always get the sense that the members of the health team care about them and their health and respect their concerns. Finding out residents’ attitudes and past experiences can deeply affect compliance and save time and problems later.

Noncompliance with treatment has been a quality issue with which I have long been interested.  I was asked to consult a few years ago with a wound care clinic in a hospital that tracked its patients and found almost 30 percent in varying degrees of noncompliance. After working with them for a while, I implemented a simple depression screening evaluation with all patients and discovered that a large percent of the patient population in the clinic suffered from some degree of undiagnosed depression.  Implementing treatment for the depression reduced the noncompliance rate significantly. 

There are no simple answers to this problem. It is imperative to try and determine the reasons behind the behavior. Solutions, for the most part, lie in quality education and communication between the resident and his or her caregivers.

For more information, see the Massachusetts Medical Asscoation's site: http://www.massmed.org/Content/NavigationMenu2/DifficultPatients/TheNoncompliantPatient/default.htm