The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow


January 16, 2014

In This Article

Fragmented Care Is a Culprit

Even if doctors had more time to spend with patients and patients were more willing to take their doctors' advice, the healthcare system creates numerous obstacles to subvert their efforts. A major obstacle is fragmented care.

"In decades past, community-based physicians not only authorized a patient's admission to the hospital, they performed regular hospital rounds, supervised overall patient care, and authorized the patient's discharge," notes a report by the New England Health Policy Institute (NEHI).[39] "In theory, medication management was seamless because the admitting physician, the discharging physician, and the 'receiving' physician in the community were the same individual."

That's not the situation today. Patients with chronic conditions now see primary doctors who in turn refer them to specialists. If they are hospitalized, a hospitalist likely as not will take over their care. Many patients are discharged not to their homes but to long-term acute care hospitals, inpatient rehabilitation hospitals, or skilled nursing facilities, where more doctors will prescribe medications for them.

"Transferring patients from short-term acute care hospitals to post-acute providers increases the number of times information needs to be passed between providers and increases the opportunity for errors and medication errors in particular," the NEHI report points out.[39]

Other systemic barriers to compliance include lack of access to healthcare, inconvenience in obtaining prescription refills, wide variations in the cost of the same drugs from one health plan to another, and pharmacy policies that limit prescription size and require frequent refills.

Access to Pharmacy Data Is a Problem

Even in Accountable Care Organizations and integrated delivery systems, with resources far beyond those of the average doctor, care teams typically lack access to pharmacy data, such as the rate at which a prescription is filled and refilled by a given patient.[13] If you knew which of your patients weren't picking up their drugs, you would know who needs help with medication compliance.

"For patients with coexisting conditions who take multiple medications prescribed by multiple physicians, there is a vital need to reconcile the prescribed regimen with what a patient is actually taking and to understand why there is a difference between the two," note David M. Cutler, PhD, and Wendy Everett, ScD, in a 2010 paper.[2] "But optimizing and reconciling medications require substantial investments of time by a skilled healthcare practitioner, as well as electronic data sharing among practitioners -- neither of which is widely available in today's model of healthcare delivery."

Even if time, skill, and electronic data sharing were widely available, the complexity of each patient's barriers, and the ever-shifting nature of those barriers, probably would still thwart many efforts to improve medication compliance.

"Although the multifactorial nature of nonadherence means there will never be a one-size-fits-all solution, interventions ranging from education to elimination of selected copayments to telephone-based counseling have achieved modest improvements in clinical trials," Rosenbaum and Shrank point out.[24] "But even if we had more robust interventions," they write, "we'd lack simple, cost-effective ways of targeting the right intervention to the right patient."


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