Health Systems

_{Are Your Patients Taking What You Prescribe?
A Major Determinant: Clinician-Patient Communication
By Lee Jacobs, MD}

_{Making the Case}

_{Chances are that many patients you saw today will not do what you suggested or take what you prescribed!}

_{It is well established that adherence of patients to prescribed therapy for a variety of diseases is rarely more than 60%.¹ This includes studies in HIV,² child and adult asthma,³ diabetes,⁴ hypertension,⁵ and post myocardial infarction (MI) care.⁶}

_{Taking medications exactly as prescribed is especially critical in HIV care, in which patients must take their antiretrovirals 95% of the time to get complete viral suppression.⁷ What is considered acceptable adherence (60%-80%) for other chronic illnesses is certainly not good enough for HIV.}

_{The Reasons for Poor Adherence}

_{Why your patients do what they do ... or why your patients don't do what you want them to do!}

_{The many studies of adherence to therapy consistently list various combinations of the following explanations:⁸}

• _{Logistic issues--access to care; transportation.⁹}
• _{Perceptions of health benefits from the therapy; concern about side effects.¹⁰}
• _{Social and cultural--including practical and emotional support.¹¹ Beliefs.}
• _{Complexity of treatment regimens¹²--eg, number of daily doses; dietary requirements.}
• _{Patient's condition: Depression;¹³ patients over 75 years.¹⁴}
• _{Communication and relationship with health care provider.^15,16}

_{It is probably important to stress that clinicians cannot predict who will adhere, because there is no definitive characteristic of an adherent individual. Gender, ethnicity, marital status, personality traits, and educational level fail to predict adherence.¹⁷}

_{It is also well established that clinician-patient relationship and communication is the major determinant as to whether the patient will follow the advice or take the medication prescribed. Examples of study conclusions on the pivotal role of communication include:}

• _{The most important factor in predicting adherence is the level of clinician-patient relationship.¹⁸}
• _{The principal determinant of best health outcomes of asthmatics was a partnership relationship with a doctor.¹⁹}
• _{Patients only follow recommendations that they really believe in and those they actually have the ability to carry out.²⁰}
• _{Clinical therapies do not exist in vitro; they exist in a contextual environment that includes the patient-clinician relationship; and this relationship modifies therapeutic effectiveness.²¹}
• _{Women who perceived that their physician had some enthusiasm for mammography were more than 4.5 times more likely to have the procedure done.²²}
• _{Over 50% of the patients forgot what the doctor had said five minutes after the conversation.²³}

  	Adherence Defined
  	Adherence is the extent to which a person's behavior (medications, diets, lifestyle changes) coincides with medical or health advice.25

_{Improving Patient Adherence}

_{It's not the power of the pen, but rather the power of the ear!}

_{So what can be done to improve the likelihood that your patient will take the medicine that you write on the prescription pad? Listen to the patient. You can use your communication skills to probe each of the variables implicated as causes for poor adherence. This central role of clinician-patient communication is demonstrated in the following schematic:}

_{Central Role of Communication in Adherence}

_Conclusion

	Contrasting Terms26
	Compliance: Implies patient follows doctor's orders, is less informed, and has little or no input. Adherence: Focuses more on patient commitment to the regimen. Is based on reasonable negotiations and more patient empowerment than compliance. Concordance: Is based on notion of patient equality and respect for patient autonomy, the desired relationship in a therapeutic alliance between the care team and the patient.

_{Finding solutions to address the alarming high rate of poor adherence has to become a priority for the health care community. However, very few trials have been undertaken to study interventions to improve adherence.²⁴ As suggested in this model, it is recommended that future research focus primarily on team member and clinician communication skills with the patient that would reveal possible barriers to adherence and result in a much more effective and truly shared decision.}

 

Interregional Clinician-Patient Communication Leadership Group (IRCPC) Mission:

The Mission of the IRCPC is to ensure that excellence in clinician-patient communication is a distinguishing feature of our members' care experience throughout Kaiser Permanente, is accepted as a critical aspect of clinical practice, and is recognized as a major contributor to our organizational success.

 

_{Acknowledgment
The author thanks Joan Guilford, MPH, from the Georgia Region's Business Consulting Group, who assisted with the development of the illustration.}

_References

1. _{Sackett DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes RB, Taylor DW, Sackett DL, editors. Compliance in health care. Baltimore: Johns Hopkins University Press; 1979. p 11-22.}
2. _{Wu A. Report from Buenos Aires: lessons in adherence. Hopkins HIV Report 2001 Sep;13(5):9-11.}
3. _{Rand CA. Comprehensive review of the history, contect, issues and measurement of adherence. In: Asthma Adherence Workshop report. Melbourne (Victoria): National Asthma Campaign; 1997. p 12-5.}
4. _{Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care 1999 Dec;22(12):2011-7.}
5. _{Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Eng J Med 1998 Dec 31;339(27):1957-63.}
6. _{Horwitz RI, Viscoli CM, Berkman L, et al. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990 Sep 1;336(8714):542-5.}
7. _{Paterson D, Swindells S, Mohr J, et al. How much adherence is enough? A perspective study of adherence
   to protease inhibitor therapy using MEMSCaps [abstract]. 6th Conference on Retroviruses and Opportunistic Infections, January 31, February 4, 1999, Chicago, IL. Available on the World Wide Web (accessed July 8, 2002): www.thebody.com/confs/retro99/session15.html}
8. _{Elliott WJ, Maddy R, Toto R, Barkris G. Hypertension in patients with diabetes. Overcoming barriers to effective control. Postgrad Med 2000 Mar;107(3):2932, 35-6, 38.}
9. _{Markson LE, Turner BJ, Cocroft J, Houchens R, Fanning TR. Clinic services for persons with AIDS. Experience in a high-prevalence state. J Gen Intern Med 1997 Mar;12(3):141-9.}
10. _{Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients' adherence to antidepressant therapy. Med Care 1995 Jan;33(1):67-74.}
11. _{Stanton AL. Determinants of adherence to medical regimens by hypertensive patients. J Behav Med 1987 Aug;10(4):377-94.}
12. _{Gordis L. Conceptual and methodological problems in measuring patient compliance. In: Haynes RB, Taylor DW, Sackett DL, editors. Compliance in health care. Baltimore: Johns Hopkins University Press; 1979. p 23-45.}
13. _{DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000 Jul 24;160(14):2101-7.}
14. _{Shimp LA, Ascione FJ, Glazer HM, Atwood BF. Potential medication-related problems in noninstitutionalized elderly. Drug Intell Clin Pharm 1985 Oct;19(10):766-72.}
15. _{Bartlett EE, Grayson M, Barker R, Levine DM, Golden A, Libber S. The effects of physician communications skills on patient satisfaction: recall, and adherence. J Chronic Dis 1984;37(9-10):755-64.}
16. _{Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med 1995 Apr;40(7):903-18.}
17. _{Meichenbaum D, Turk DC. Facilitating treatment adherence: a practitioner's handbook. New York: Plenum Press; 1987.}
18. _{Toelle B, Peat J, Dunn S. A qualitative analysis of patient adherence with the Australian Asthma Management Plan. Respirology 1998 Oct;3 Suppl:A42.}
19. _{Anderson, J. Patient behaviour and attitudes to asthma. In: Asthma Adherence Workshop report. Melbourne (Victoria): National Asthma Campaign; 1997. p 51-3.}
20. _{DiMatteo MR. Enhancing patient adherence to medical recommendations. JAMA 1994 Jan 5;271(1):79, 83.}
21. _{Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet 2001 Mar 10;357(9258):757-62.}
22. _{Fox SA, Siu AL, Stein JA. The importance of physician communication on breast cancer screening of older women. Arch Intern Med 1994 Sep 26;154(18):2058-68.}
    
23. _{From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain and Merck Sharp & Dohme; 1997. Available on the World Wide Web (accessed July 9, 2002): www.concordance.org/about/Concordance.pdf.}
24. _{Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews 2002;(2). Most recent update 26-2-2002.}
25. _{Sackett DL. Introduction. In: Sackett DL, Haynes RB. Compliance with therapeutic regimens. Baltimore: Johns Hopkins University Press; 1976. p 1-6.}
26. _{National Asthma Council Australia. Asthma adherence: a guide for health professionals. South Melbourne (Victoria): The National Asthma Council Australia; [1999?] Available on the World Wide Web (accessed July 9, 2002): www.nationalasthma.org.au/publications/adherence/index.html}
27. _{Hippocrates. On decorum. In: Jones WH, translator. Hippocrates, with an English translation. Cambridge (MA): Harvard University Press; 1923. p 267-301.}