The Challenge of Noncompliance with Medical Recommendations

Executive Summary

Patients may not comply with medical recommendations because they misunderstand instructions, forget or choose to ignore them. But noncompliance with medical recommendations can result in significant liability and financial risks for the healthcare professional treating the patient. Providers should relay the importance of following medical recommendations and the risks associated with noncompliance of medical recommendations to patients.

Recommended Actions

• Use simple and direct language when explaining medical recommendations and ask the patient to repeat their understanding of the instructions provided.
• Develop an organized plan to continuously monitor the recommended treatment and relay the importance of strictly following the treatment to the patient to help bolster the likelihood of continued patient compliance.
• Discuss potential side effects and risks of stopping a medication or not taking it properly.

Noncompliance with medical recommendations can have a significant impact on a patient’s overall quality of health, resulting in decreased opportunities for prevention, delayed diagnosis and incomplete or ineffective treatment. There may also be significant liability and financial risk to a responsible healthcare professional treating this patient, particularly as patient outcomes increasingly become connected to quality indicators and reimbursement.

Noncompliance also might lead to major economic costs, including additional healthcare expenditures and lost productivity. According to reports, more than 40% of patients may not accurately follow medical recommendations. When treatment requires a more complex regimen, a major lifestyle change, or the patient is otherwise asymptomatic, noncompliance can reach as high as 70%.

Causes of Noncompliance

Reasons for noncompliance may include the patient misunderstanding instructions, forgetting or simply ignoring recommendations. Other patients may actually make an informed decision to decline certain treatments. Common manifestations of patient noncompliance include failure to:

• Keep follow-up appointments
• Complete recommended diagnostic testing or laboratory studies
• Comply with consultation recommendations
• Follow medication instructions and monitoring regimens
• Make behavioral and lifestyle changes (diet, weight loss, exercise, smoking, alcohol)

Several factors may influence the ability and willingness of patients to comply with medical recommendations. These may include characteristics of the individual patient, the nature and symptomatology of their condition, and the specifics of the treatment regimen.

Different patients will have varying degrees of ability to process, understand and make appropriate decisions regarding basic health information and recommendations.

• Cognitive impairment, including memory and concentration, along with psychological aspects such as anxiety and depression, may limit the patient’s ability to understand and remember medical instructions. Large amounts of complex information are more likely to be forgotten. Studies have shown that 40% to 60% of patients were unable to correctly report what the physician expected them to do between 10 to 80 minutes after information was provided. Another study suggested that 60% of patients had some misunderstanding regarding the instructions after a visit.
• Language, cultural differences and age may limit the patient’s ability to understand the reasoning for treatment and instructions.
• Health literacy and understanding of medical terminology varies greatly between patients, and impacts their ability to understand specific directions. Instructions such as “take on an empty stomach” may actually be confusing to some patients.
• Motivation to proceed with treatment and differences in personal health perceptions frequently occur. The perceived risk of a disease occurring later in life for a 30-year-old patient may be difficult to comprehend. Furthermore, the perceived benefit of therapy may not be important if the patient is asymptomatic. Misinformation about the probability of risks with diagnostic testing or treatment, as compared with the risk of not proceeding, may be powerful factors in a patient’s decision.

The characteristics of a potential or confirmed medical condition and the treatment regimen can also affect the patient’s ability or motivation to proceed.

• Goal of therapy. In one study, when treatment was prescribed with an intent to cure a medical condition, 77% of patients demonstrated compliance. When the intent was a future prevention of a medical condition, 63% of patients were compliant. Asymptomatic patients demonstrate a clear reduction in compliance.
• Complexity of treatment plan. When frequency of medication intake is one time per day, 81% of patients complied. When this increased however to 4 times per day, only 39% of patients complied. Furthermore, with a longer duration of therapy, the frequency of compliance reduced to 50%.
• Financial cost.
• Side effects and risks of diagnostic or treatment plan. Patients may discontinue medication without reporting and coordinating adjustments with their medical provider.

Many potential causes may contribute to a patient's noncompliance. The importance of recognizing the issue and addressing this with the patient and family can have a significant impact on the clinical outcome and response to any recommended treatment.

How to Recognize Compliance Problems

The assessment of patient compliance is very difficult. Many patients may not want to disappoint their physician and will not be completely accurate about their degree of compliance. Other patients are not able to accurately evaluate or do not know their degree of compliance. In one study, 10% of patients reported that they were 100% compliant with their medication use. Using pill count methods, however, the use of the prescribed medications ranged from 2% to 130% of the prescribed pills.

Several methods may help to improve patient understanding, memory and ultimately compliance to medication or recommended diagnostic studies or treatment. One important strategy is to attempt to improve the likelihood of compliance at the very beginning. An explanation of the goals and rationale for therapy using language that the patient can understand helps to set the stage. Educate the patient on the perceived benefits of diagnostic studies or therapy at the onset, especially if the patient is asymptomatic.

Collaborating with the patient may improve adherence to the treatment plan, including frequency and duration of medication intake. Address potential financial limitations or other barriers to lifestyle modifications that may be required. In particular, addressing any misinformation regarding a medical condition or possible side effects at the onset of any treatment recommendations may help to improve compliance. Finally, explain the potential consequences of not following specific medical recommendations.

Additional recommendations at the onset of the recommended treatment include:

• Speak clearly and briefly and be aware of the patient’s health language literacy. Emphasize the most important information early, as patients tend to remember more of what is told first.
• Repeat the information verbally and provide written instructions if appropriate.
• Ask patients to repeat their understanding of the instructions, and if necessary, encourage them to write down these instructions.
• Simplify medical regimens using dosage scheduling charts and pill organizers. Try to coordinate medication schedules with the patient’s usual daily routine.
• Discuss potential side effects as well as the consequences of stopping a medication or not taking it properly.
• Review the optimal way to report any questions or side effects so alterations can be made while continuing to maintain a therapeutic benefit.
• Provide clear recommendations and expectations for follow-up and any required treatment monitoring. Schedule appropriate follow-up either by telephone or through an office visit.

Develop a Plan for Monitoring Compliance

Following the initial diagnostic or treatment recommendations, an organized plan for regular monitoring, continuing education and patient feedback helps to bolster the likelihood of improved patient compliance.

• Encourage open discussion with the patient regarding potential barriers to treatment or side effects. If the patient elects not to proceed with diagnostic testing, consultations or continued treatment, the patient should be encouraged to report this decision to the physician in an effort to modify plans for continued care.
• Utilize support of nursing, social services, pharmacists and family members to reinforce compliance and follow-up instructions.
• During follow-up evaluation, communicating progress with medical conditions may help to encourage continued compliance. This is particularly important in asymptomatic conditions, such as elevated cholesterol or blood glucose levels.
• Follow up with the patient to confirm completion of diagnostic testing or outside consultation. When such recommendations are given, a prospective notation can be made for office staff to later contact the patient to confirm completion.

In some specific situations (i.e., anticoagulation monitoring and treatment), the patient may benefit from a medication adherence contract. This should include an explanation of the use of a medication, potential side effects of altering the dose or stopping the medication, potential for interactions with other medications, side effects that should be reported, and instructions on proper monitoring and potential for dosage adjustments. Clear explanation of an expected follow-up and monitoring schedule as well as how questions can be answered should be included. The physician should give a signed copy of the contract to the patient and the patient’s family or friend and place it in the medical record.

There may be some circumstances in which, after an informed discussion, the patient elects to decline a particular treatment or test. Certainly it is well within the patient’s right to be aware of potential diagnostic or treatment options, but to decline to proceed.

In that case, a signed, written document indicating “informed refusal” may be considered. This document should include the indications for the procedure or the medication and overall treatment plan, the risk and benefits of a particular procedure or medication, potential alternative treatment options, the potential consequences for refusing such treatment, and if possible the reason that the patient declines treatment. The physician should carefully document any such discussion in the medical record and may include a note from a possible third-party witness.

At some point, a patient’s continued noncompliance may begin to affect the physician-patient relationship. A doctor should communicate clear expectations and conditions that a patient needs to meet to continue active treatment. In some circumstances, a decision to terminate the physician-patient relationship may become necessary.

Lessons Learned:

• Consider developing dosage scheduling charts and pill organizers to assist patients in tracking their medical regimens.
• Encourage patients to ask questions and discuss their concerns regarding the recommended treatment to facilitate any adjustments needed to accommodate the patient’s lifestyle.
• Ensure that patients feel comfortable following up with any questions or confusion they have in the days or weeks after their visit.
• Consider providing patients with written explanations of their specific treatment plan for future reference, including information about how to follow up with their physician if they have any questions.

Potential Damages

Failure to describe medical recommendations and the importance of following treatment may cause a patient harm or delayed recovery. The frequency of claims related to patient noncompliance is moderate, but physicians run the risk of contributory negligence for failing to disclose the importance of following treatment plans or miscommunicating instructions.