Non-compliance with medical therapies and recommended lifestyle changes are estimated to cost upwards of $100M per year in the United States, while also resulting in increased hospital and nursing home admissions. Despite the serious impact of this issue and the issuance of very clear cardiovascular disease-specific treatment guidelines, most reasons for patient non-compliance remain poorly understood. That may partially be due to the use of the term “compliance” itself, which implies a patriarchal relationship between the physician and the patient, one in which the patient plays a very passive role. The term “adherence” to medical recommendations is perhaps more apt, reflecting the likely more appropriate partnership that physicians should develop with their patients, encouraging them to play a more participatory role in decision making about medical care.
Some well-known factors that appear to lead to lack of adherence to medical regimens are: the features of the disease being treated (asymptomatic diseases are likely to lead to poorer adherence), the side effects of the therapy being utilized, the complexity of the therapy (“polypharmacy”, cost of therapy), underlying patient issues such as phobias or psychiatric disorders, and even socioeconomic status. However, the most important variable in determining a patient’s adherence to medical regimens and guideline-based therapy appears to be the nature of the doctor-patient relationship. Poor communication by a physician regarding the disease process, regarding the purpose and potential side-effects of therapy, and about the expectations of therapy are key factors that are imperative in any interaction between the physician and the patient. Some studies have demonstrated that patients fail to recall up to 50% of their discussions with their physician shortly after the visit.
With respect to cardiac patients, a large percentage of people with cardiovascular disease are asymptomatic, yet require various degrees of treatment to halt progression of their underlying problem. The asymptomatic nature of their disease may lead the patient to believe that the medications are unimportant. Many of the patients who are symptomatic, such as people with congestive heart failure, are often on six or more medications, including diuretic drugs which cause annoying frequent urination, but also ae able to prevent hospitalizations. Poor adherence may often be unintentional, usually occurring in the elderly, or with medications that have to be taken multiple times a day, as the patient may inadvertently skip doses which can be detrimental.
Consolidating a patient’s medical regimen by giving fixed dose combination medications in one pill can cut down on the problems that arise from having to take too many medicines, decreasing the burden of polypharmacy. Regular communication with the patient’s pharmacist, with current and frequently updated pharmacy information, can improve compliance, and prevent easily avoidable medication errors while improving adherence. Moving to a more collaborative model of healthcare delivery, however, is the intervention likely to result in the biggest impact on improved adherence with guideline-based therapy, medication adherence, and behavioral changes. There is no substitute for sufficient time spent educating the patient about the risks, benefits, and importance of their physician’s therapeutic recommendations. Preserving patient autonomy is paramount in the treatment process.
In short, while there are a multitude of factors that lead to poor adherence with medical therapy, and many suggested strategies for dealing with this important issue, there is no substitute for a good “bedside manner”. Physicians who attentively listen to their patients and addresses their concerns, while carefully educating them about the reasons for their decisions and the disease process being treated, are likely to have the highest success with patient adherence. Patients should be strongly encouraged to ask questions, gain a thorough understanding of their illness, and leave the office satisfied that they are adequately educated and prepared to make an informed decision about adherence to their physician’s recommendations.