ENHANCING PATIENT MOTIVATION TO CHANGE Alma Faulkenberger is an 85-year-old female outpatient sitting in the waiting room awaiting an invasive pelvic proce
Alma Faulkenberger is an 85-year-old female outpatient sitting in the waiting room awaiting an invasive pelvic procedure. The health care professional who will assist in her procedure enters the room and calls “Alma
Patient Adherence as an Outcome of Effective Patient Teaching
ADHERENCE VERSUS COMPLIANCE
Previously, health care was provided in the context of a “disease-centered model” in which most decisions about a patient’s treatment were made by health professionals with little consultation with the patient (Stanton, 2002). The focus of the disease model was on the particular illness rather than the patient as a whole (Steckel, 1982). In this model, it was expected that all patients seeking health care would follow or comply with recommendations they received. It was assumed that patients seeking health advice believed that the health professional knew best and, consequently, that they would logically follow recommendations. The possibility that there could be disagreement with the health professional’s recommendations, that recommendations may not be presented clearly or accurately by the health professional, or that the patient did not have the resources to follow recommendations was rarely considered.
The term compliance denotes a power differential between patient and health professional. It suggests that the patient is passively following recommendations and implies yielding to authority, rather than following a treatment plan based on a collaborative effort between the patient and health professional (Osterberg & Blaschke, 2005; Steiner & Earnest, 2000). Not only has the effectiveness of an authoritarian approach been questioned over the last few decades, increasing evidence has shown that this approach most often does not lead to the best health outcomes (Trostle, 1997). Although semantics may seem inconsequential, words used to describe a phenomenon significantly influence how the phenomenon is understood. Words chosen convey an underlying philosophical context. Consequently, because the word “compliance” has an authoritarian connotation, an attempt to diminish the paternalistic nature of the term has resulted in use of substitute words such as adherence, alliance, collaboration, or concordance to describe the extent to which patients follow advice and recommendations provided by the health professional. Although all of these words have been used to describe this phenomenon, the term compliance has largely been replaced by the term adherence. The substitution of the word adherence for compliance has coincided with a change of approach to patient care, an approach that is more patient-centered, focusing on the needs of patients rather than on the goals of the health professional.
A patient-centered approach to health care has shown increased patient satisfaction and better health outcomes (Aday et al., 2004; Balkrishnan, 2005; Balkrishnan et al., 2003; DiMatteo et al., 2002; Meryn, 1998; Sokol et al., 2005; Wagner, Austin, et al., 2001). In this approach, patients are treated as partners, are fully informed about health-related matters, are more involved in treatment planning and decision making, and are encouraged to accept more responsibility for their health care.
Given the positive impact that the patient-centered approach has apparently had on health care, it would seem that nonadherence would be a rare occurrence rather than a continuing healthcare issue. Adherence is, however, a complex and multidimensional issue that includes a multitude of dynamic behaviors and circumstances (Haynes et al., 2002b; Malouff & Schutte, 2004,).
Health professionals, even when attempting to use a patient-centered approach, may not have the awareness or understanding of the complexity of adherence and thus may be unable to fully incorporate strategies into patient interactions that would help patients achieve their optimal health outcomes (Vivian & Wilcox, 2000). Assuming the patient’s condition has been accurately diagnosed and the appropriate treatment prescribed, the only way recommended preventative or therapeutic measures can be effective is if the patient is able to correctly follow recommendations and advice given by the health professional. Consequently, adherence, or more specifically nonadherence, must be identified, studied, and understood (Koltun & Stone, 1986). Adherence is a reflection of good communication and a relationship that is built on respect, active participation, and partnership between patient and health professional, not coercion or manipulation.
EXTENT OF NONADHERENCE
Today, when patients have access to more information than ever before, and advances in knowledge and sophistication of technology for prevention, diagnosis, treatment, or cure of disease have soared, patients continue to experience morbidity and mortality from conditions that could have been prevented or effectively treated. In some instances, treatment failure or iatrogenic causes account for some patient morbidity and even mortality; however, research has shown that in a large number of instances, the cause of treatment failure is that patients simply do not adhere to health recommendations.
In a 1996 study, 58% of emergency room visits were found to be directly related to nonadherence (Dennehy, Kishi, & Louie, 1996). In another study of reasons for emergency room visits, the high number of visits was found often to be a result of overuse or underuse of medication (Schneitman- McIntire et al., 1996). Since the acknowledgment of the high level of nonadherence more than 50 years ago (Davis, 1968b), the extent to which patients follow recommendations given to them by health professionals has been studied from a variety of perspectives, with a variety of types of recommendations, and a number of acute and chronic disease conditions. As a result of different conditions and associated recommendations, as well as different measures used, adherence rates vary along a continuum from never following recommendations to following recommendations 100% of the time. Regardless of the research approach used, the condition studied, or the measures used, the general consensus is that nonadherence with prescribed therapeutic regimens is, and continues to be, high (Blackwell, 1973; Haynes, 1999; Martin et al., 2005; Sackett & Haynes, 1976). Rates of nonadherence reported range from 15% to 93%, depending on the condition studied and the research methods used (Balkrishnan, 2005). Despite differences in reported adherence rates, nonadherence appears to be widespread with an approximate average of 25% across conditions (DiMatteo, 2004). Generally, adherence rates that are reported as part of a clinical trial demonstrate higher rates than other patients but, even then, adherence rates can run as low as 43% (Claxton, Cramer, & Pierce, 2001). Such findings suggest that a substantial proportion of individuals seeking medical treatment fail to receive maximum therapeutic benefits because of nonadherence to recommendations. The consequences of nonadherence are far-reaching.
CONSEQUENCES OF NONADHERENCE
Nonadherence has far-ranging individual, societal, and economic consequences. As a result of nonadherence, acute conditions that could have been cured may develop into chronic conditions; chronic conditions, which could have been controlled, may develop into debilitating illness; or disease may develop when it could have been prevented. Although considerable time and expense has been used to develop highly effective and relatively safe treatment regimens for multiple diseases, patients continue to be incapacitated or debilitated, or to even die from conditions for which effective treatments are available (Milgrom, Bender, & Wamboldt, 2001; Morrison, Wertheimer, & Berger, 2000). Likewise, although health risks for a number of serious diseases are known, millions of people continue to engage in unhealthy behaviors that predispose them to various diseases.
Consequences of nonadherence can be severe. Osteoporosis, although not always considered a serious condition, can be debilitating and life-threatening. Even though osteoporosis is treatable, nonadherence rates are high and resulting hip fractures take up one out of every five orthopedic beds (O’Connell & Sutcliffe, 2007). Poor adherence to antihypertensive medications has been found to lead to unnecessary complications, stroke, and early death (Chin & Goldman, 1997). Psychiatric patients with schizophrenia who are nonadherent with medications have been found to have an increased risk of rehospitalization, homelessness, and symptom exacerbation (Olfson et al., 2000). Nonadherence with medication for treatment of asthma has been found to be linked to asthma deaths (Birkhead, et al., 1989). Nonadherence in individuals with human immunodeficiency virus (HIV) may result in viral replication and disease progression (Hinkin et al., 2002). Individuals at risk for coronary heart disease who are nonadherent with recommendations may increase their risk of a debilitating and potentially fatal cardiac event (McDermott, Schmitt, & Wallner, 1997).
A variety of factors can contribute to nonadherence; however, a major factor is that patients often simply fail to follow the recommendations they have been given by their health professional. Hence, because of nonadherence, there is significant cost to the individual, to society as a whole, and to the health system in general.
The health benefit of properly treated and controlled disease is obvious. Many disease conditions, complications developing from disease, disability, and/or death resulting from disease can be forestalled or prevented through modifying health behaviors, adopting healthy lifestyles, and adhering to therapeutic regimens (Christensen et al., 2002; Hernandez, 1995; Johnson & Bootman, 1995; Kane et al., 2003; Liberman & Rotarius, 1999; Nicolucci et al., 1996). Adherence with treatment recommendations can also have an impact on general public health, especially in the treatment or eradication of infectious disease, such as tuberculosis or HIV (Freeman, Rodriguez, & French, 1996; Roberts & Mann, 2000). Failure to follow health recommendations has other impacts on society as well. Nonadherence, which results in increased morbidity, mortality, disability, or increased use of healthcare services, causes decreased productivity through lost work days, and drives up insurance and other healthcare costs (Feldman, 1982; Gerbino, 1993;).
Although there are instances in which nonadherence can have positive implications, such as when the treatment does more harm than good (Shine, 2002), in most instances, following recommendations for the treatment or prevention of disease has more positive consequences (Vermeire et al., 2001). The role of adherence with treatment recommendations in the control of chronic disease such as diabetes, heart disease, and hypertension has been shown to decrease morbidity rates and permanent disability, enabling patients to continue to live active and productive lives (Evangelista & Dracup, 2000; UK Prospective Diabetes Study [UKPDS] Group, 1998a).
The role of adherence for the individual, consequences of nonadherence can include progression of disease, which could have been forestalled, or development of disease, which could have been prevented. Individual consequences may be experienced with acute conditions, such as an infection, which could have been cured with a short course of medication, but progresses to a more serious condition because treatment recommendations were not followed, or with development of complications from a chronic condition because of nonadherence. In addition, nonadherence may interfere with curing a patient, causing serious complications from a disease that has not been adequately controlled (UKPDSUK Prospective D, 1998a).
Nonadherence has individual consequences in disease prevention as well. Engaging in healthy lifestyle behaviors can significantly decrease the risk of developing a number of diseases such as cancer, heart disease, stroke, or other serious illnesses (Burke & Dunbar-Jacob, 1995; Evangelista & Dracup, 2000). Development of chronic illnesses as a result of the contributions of tobacco use, excessive consumption of alcohol, sedentary lifestyle, or poor dietary practices are well known; however, many individuals fail to heed recommendations to change their behavior and live a more healthy lifestyle.
Although there can be exceptions, for the most part positive health outcomes from treatment rely largely on the degree to which patients follow health advice (Haynes et al., 2000; Horowitz & Horowitz, 1993; Haynes, Montague, & Oliver, 2001). When failure to follow recommendations results in the development of chronic disease, ramifications exist not only for the individual, but also for society as a whole. This also has implications for the effective use of healthcare resources. Nonadherence, which results in increased morbidity, mortality, or disability, causes decreased productivity through lost work days, drives up insurance rates, and places a burden on other social or healthcare programs that may be unable to keep pace with growing demand (Gerbino, 1993; Feldman, 1982).
Patients who seek medical attention but do not follow medical advice overutilize health services by receiving additional care that they may not have needed had they followed original treatment recommendations. The role and importance of patient adherence in treatment of acute conditions is one such example. Acute conditions, such as infections, can often be cured with short courses of medication or treatment. Patient failure to adhere to recommended treatment can result in progression of the condition or development of complications that require increased medical care and treatment with consequences of increased morbidity and, in some instances, mortality (Birkhead et al., 1989). Overutilization of services because of nonadherence taxes limited resources and is not only costly for society as a whole, but can also jeopardize availability of health services for others who may be seeking care. Nonadherence can also have an impact on general public health, especially in prevention, treatment, or eradication of infectious disease. Failure to obtain recommended vaccinations or follow precautions needed to contain disease can result in significant spread of disease. Negligence in adhering to medication regimens important in the cure or containment of conditions such as tuberculosis or HIV can result in producing organisms that become more resistant to treatment (Freeman, Rodriquez, & French, 1996).
Adherence with outpatient therapy is important to reduce patient risk of developing additional complications as well as to reduce costs. Patients who miss appointments misuse the time of the health professional and perhaps have wasted a time slot that could have been used by another patient.
Nonadherence can also interfere with the ability to determine treatment efficacy for various diseases. Measurement of effectiveness of a new treatment is based on the assumption that patients have accurately complied with treatment protocol. If patients have not accurately followed treatment recommendations, it is difficult to determine the extent to which treatment is effective.
Nonadherence not only affects patients’ and society’s well-being, but has economic consequences as well. The financial costs of nonadherence can be high (Aday et al., 2004; Balkrishnan, 2005; Balkrishnan et al., 2003). Expenditures associated with patient nonadherence resulting in increased hospitalizations or additional visits to healthcare providers can cause a large economic burden that has been estimated as amounting to billions of dollars per year (Breen & Thornhill, 1998; DiMatteo, 2004; Martin et al., 2005; McDonnell & Jacobs, 2002; Sullivan, Krelling, & Hazlet, 1990). Ensuring the success of treatment becomes increasingly important as healthcare costs rise. As healthcare costs rise, there is increased tendency to decrease costs by decreasing hospitalization days. Consequently, patients are expected to assume more responsibility for their own care in the home setting. Patients’ failure to follow recommendations in the outpatient setting can result in complications that require increased medical attention or readmission to the inpatient facility. Diagnostic procedures or additional treatments may be needed, which increase not only costs but perhaps risks to patients continued health as well.
Nonadherence produces substantial adverse effects on quality and cost of care directly by disrupting or negating potential benefits of therapies or preventive measures prescribed, and indirectly by exposing patients to unnecessary diagnostic procedures and additional treatment that may otherwise not have been needed.