By Hall B. Whitworth, Jr., MD in Regulatory

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

Major national economic costs, including additional healthcare expenditures and lost productivity, may also result. It has been reported that more than 40 percent 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 has been reported as high as 70 percent.

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
• Failure to complete recommended diagnostic testing or laboratory studies
• Failure to comply with consultation recommendations
• Failure to follow medication instructions and monitoring regimen
• Failure to 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 the condition being treated, and the specifics of the treatment regimen.

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

• Cognitive impairment, including memory and concentration ability, 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 between 40 to 60 percent 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 percent of patients had some misunderstanding regarding the instructions after a visit.
• Language, cultural differences, and age may limit the patient's ability to specifically understand 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, with the feeling that "it won't ever happen to me." 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. These feelings may be reflected in statements such as: "I'm already on too many medications," or "I feel better, so I can stop the medicine," or "I know someone who had a stroke with that procedure."

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 percent of patients demonstrated compliance. When the intent was a future prevention of a medical condition, 63 percent 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 percent of patients complied. When this increased however to 4 times per day, only 39 percent of patients complied. Furthermore, with a longer duration of therapy, the frequency of compliance reduced to 50 percent.
• Financial cost.
• Side effects and risks of diagnostic or treatment plan. Patients may discontinue medication without reporting and coordinating adjustments with their medical provider.

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

In Part 2 of this series, we will discuss specific points of action to both recognize this problem and measures which may help to further benefit patients' understanding and acceptance of treatment recommendations.