Is patient adherence responsible for health quality and safety?

A while back I did in a post where I asked the question, What can patients really expect from their physicians today? In that post, I wondered at the fact that many patients still have a high degree of trust in their physician in spite of the quality and safety problems attributed to physicians in the press.

For example:

  • On average, US adults receive only 50% of recommended care
  • Up to 30% of adults are walking around with undiagnosed hypertension and diabetes
  • 66% of people with hypertension do not have it under control
  • Up to 20% of discharged hospital patients will be readmitted with 30 days even though they are considered preventable

Physician responses to the post make a prima facie argument that patient non-adherence is to “blame” for these safety and quality issues.

Physician Comment #1

“It would help if these data were accompanied by information on how many had been advised of their problem but failed to follow up. I read a study recently that showed only 50% of insured patients follow their doctor’s advice to obtain colonoscopy.”

Physician Comment #2

“Up to 30% of adults are walking around with undiagnosed hypertension and diabetes. How many of these patients have been told but are in denial… I cannot begin to tally up the number of patients told they have DM and ‘forgot about it.’”

The truth is that the quality of physician-patient communication is significantly correlated with patient adherence.  According to a 2009 study in Medical Care, there is a “19% higher risk of non-adherence among patients whose physician communicates poorly than among patients whose physician communicates well.”

For example research shows that:

  • 50% of patients walk out of the physician’s office not knowing what they were told or are supposed to do
  • Physicians often over estimate the topics and duration of what they have talked about with their patients
  • Telling patients once that they have diabetes, need a colonoscopy, need to lose weight, etc… is usually not enough to get the patient’s attention or buy in
  • Patient’s filter what they hear from their doctor in a variety of ways that physicians usually know nothing about, i.e., the patient’s health beliefs, values, previous experience and illness explanatory models

Anecdotally, the tone of the physician comments to my post suggests that their attitude towards non-adherent patients isn’t what you would call respectful … or patient-centered.   Attitudes like this are easily detected by patients and are not very conducive to build patient trust and adherence.

What’s the Solution?

  • Over time, get to understand your patient’s health beliefs, previous experiences, illness explanation, etc. with a goal of understanding their apparent non-adherence.
  • Help patients understand how or where their thinking may be inaccurate using evidence they can understand.
  • Repeat important messages during the same visit as well as across future visits.

The time you spend doing the above will be compensated by the time you save once you and their patients are on the same page.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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  • BladeDoc

    As a trauma surgeon, I don’t really have a dog in this fight but you realize your last sentence is utter b.s. right? Internists get paid (poorly) per visit no matter how long it is. Spending a great deal of time achieving the goals you outlined, even if you assume it’s possible, in the hope of easier visits in the future is useless in purely economic terms (I’m not arguing that it might be better for the patient mind you). But trying to pretend that it’s a “win-win” is blatantly untrue. Unless of course you jettison the 3rd party system in which case I’m with you all the way.

    “Patient-centered care” is a last ditch attempt to pretend that people can get customized attention and service in a bureaucratic 3rd party payer (TPP) system. It too will fail and because people refuse to understand that in a TPP system they are NOT the customer, they are the product we will continue the slide to a single payer (the ultimate TPP).

  • HJ

    I would suggest you write it down

  • Steve Wilkins

    Blade Doc,

    Thanks for your comments. The last time I checked, physicians determined what billing codes to use for a visit, A number of Medical Home pilots are now reimbursing physicians 30% to 40% more for extended patient visits associated with patient care planning, patient education and the like,

    Not sure why Patient centered care is such a red flag for many doctors, All the concept implies is that you listen to and where practical honor the patient ‘s preferences and concerns. Where’s the problem with that? The evidence clearly shows that patient center care leads to better outcomes, increased patient adherence and increased patient satisfaction. Again, where’s the problem?

    I would be happy to provide you with the evidence supporting the above claims. The evidence is compelling to those who’s mind are open to new ways of doing things. I would also welcome thoughts for how things should be improved rather than the continual complaining that so often occurs after the train has left the station.

    It would be interesting to do a study of outcomes of patients where the independent variable was “physician optimism” about the current state of medicine.

  • BladeDoc

    In the best of circumstances PCC is as you’ve outlined in the studies highlighted. But in an environment where the planned saving in the new healthcare plan is achieved by primarily cuts in medicare followed closely by cuts in payments to providers (39%) it is hard to believe that their will be a sustained increase in payments to provide PCC.

    To most physicians, rightly or wrongly the term PCC is at best bureaucratic doublespeak for attempting to increase the payer mix of the hospital by increasing the amenities provided. The label has been sprayed around by people who have never taken care of a patient in their lives like air freshener in a room where a cirrhotic patient with a GI bleed is laying in a pool of melena, and with the same effect.

    And of course the study you’ve outlined would show that patients do better in a system where the physicians are optimistic. Likely because physicians are more optimistic in a system that’s not going to pot.

  • Wellescent Health Forums

    From personal experiences and those of my wife, I get the impression that getting doctors to provide this sort of time in communicating and understanding their patients would take a significant mind shift. My wife has Rheumatoid Arthritis and more often than not, she wants me to go with her on her visits to her rheumatologist so that we can play tag team with one another against the doctor in order to get all of her questions answered and make sure she understands the answers.

    Part of this has to do with the way that doctors get paid, but part of it would also seem to be the way that they are trained in treating the medical condition and less so, the patient. Having the patient understand does not necessarily seem all that important in some cases especially when the doctor is not asking the patient to specifically be involved.

  • Steve Wilkins

    I just read where Internists and Family Practitioner generated an average of $1.6 million in revenue per hospital in 2009. Surgeons overstating their findings regarding patient/consumer demand to support a policy position or agenda that just isn’t true.generate even more. It stikes me as odd why physicians have not figured out how to leverage this power to create more satisfactory work conditions at their primary hospital.

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