AlignMap

Primary Source: Non-Adherence with Emergency Discharge Prescriptions Corinne Hohl, Riyad Abu-Laban, Peter Zed, Boris Sobolev, Jeff Brubacher, Gina Tsai, Patricia Kretz, Kevin Nemethy, Jan Jaap Bijlsma and Roy Purssell. Acad Emerg Med Volume 14, 5 Supplement 1 194-195.

The Study

1965 Emergency Department patients were screened; 301 of those discharged with a prescription, agreed to participate, and follow-up was successful in 257. Two weeks post-discharge, a provincial prescription dispensing database was used to determine if prescriptions had been filled. Ninety-one patients (35.3%) were non-adherent with 1 or more medications.

The most frequent diagnoses were skin and soft tissue infections, back pain and urinary tract infection. The most common prescriptions were for acetaminophen with codeine (27.2%), ciprofloxacin (8.2%) and cephalexin (6.2%).

Regression modeling indicated a trend towards increasing non-adherence with the prescription of 2 or more medications but not with studied socioeconomic factors.

Non-adherence to medication was associated with a trend towards increased ED revisits.

Commentary

It is worth noting that the non-adherence rate in this study was calculated from a review of filled and unfilled prescriptions; i.e., ninety-one patients (35.3%) did not fill the prescriptions given them in the Emergency Department, establishing a minimum noncompliance rate of 35%. It is overwhelmingly likely that some of those who did have their prescription(s) filled were also noncompliant.

This study is yet another indication that the “common sense” conclusion that noncompliance is less likely when the treatment is for a disorder which is severe or acute. These patients were concerned enough about their health problems to visit an Emergency Department, yet a substantial number (at least 35%) did not follow through with the prescribed medication.

Primary Source: 2 Kings 5: 1-19 (New Living Translation)

The Story Of Naaman – A Parable, But Not About Patient Compliance

While the story of the healing of Naaman, at least the way I learned it in Sunday School, seems directly on point regarding compliance, it is, instead, only a metaphor, based on the cliched notion of compliance as obedience to authority, to explicate acquiescence to God’s will. Still, its use in this ancient parable indicates that even in Old Testament times, patient compliance was a concern.

Second Kings: Chapter 5: 1-19

The Healing of Naaman

1 The king of Aram had great admiration for Naaman, the commander of his army, because through him the Lord had given Aram great victories. But though Naaman was a mighty warrior, he suffered from leprosy.¹ 2 At this time Aramean raiders had invaded the land of Israel, and among their captives was a young girl who had been given to Naaman’s wife as a maid.

3 One day the girl said to her mistress, “I wish my master would go to see the prophet in Samaria. He would heal him of his leprosy.”

4 So Naaman told the king what the young girl from Israel had said. 5 “Go and visit the prophet,” the king of Aram told him. “I will send a letter of introduction for you to take to the king of Israel.” So Naaman started out, carrying as gifts 750 pounds of silver, 150 pounds of gold,² and ten sets of clothing. 6 The letter to the king of Israel said: “With this letter I present my servant Naaman. I want you to heal him of his leprosy.”

7 When the king of Israel read the letter, he tore his clothes in dismay and said, “This man sends me a leper to heal! Am I God, that I can give life and take it away? I can see that he’s just trying to pick a fight with me.”

8 But when Elisha, the man of God, heard that the king of Israel had torn his clothes in dismay, he sent this message to him: “Why are you so upset? Send Naaman to me, and he will learn that there is a true prophet here in Israel.”

9 So Naaman went with his horses and chariots and waited at the door of Elisha’s house. 10 But Elisha sent a messenger out to him with this message: “Go and wash yourself seven times in the Jordan River. Then your skin will be restored, and you will be healed of your leprosy.”

11 But Naaman became angry and stalked away. “I thought he would certainly come out to meet me!” he said. “I expected him to wave his hand over the leprosy and call on the name of the Lord his God and heal me! 12 Aren’t the rivers of Damascus, the Abana and the Pharpar, better than any of the rivers of Israel? Why shouldn’t I wash in them and be healed?” So Naaman turned and went away in a rage.

13 But his officers tried to reason with him and said, “Sir,³ if the prophet had told you to do something very difficult, wouldn’t you have done it? So you should certainly obey him when he says simply, ‘Go and wash and be cured!’” 14 So Naaman went down to the Jordan River and dipped himself seven times, as the man of God had instructed him. And his skin became as healthy as the skin of a young child’s, and he was healed!

15 Then Naaman and his entire party went back to find the man of God. They stood before him, and Naaman said, “Now I know that there is no God in all the world except in Israel. So please accept a gift from your servant.”

16 But Elisha replied, “As surely as the Lord lives, whom I serve, I will not accept any gifts.” And though Naaman urged him to take the gift, Elisha refused.

17 Then Naaman said, “All right, but please allow me to load two of my mules with earth from this place, and I will take it back home with me. From now on I will never again offer burnt offerings or sacrifices to any other god except the Lord. 18 However, may the Lord pardon me in this one thing: When my master the king goes into the temple of the god Rimmon to worship there and leans on my arm, may the Lord pardon me when I bow, too.”

19 “Go in peace,” Elisha said. So Naaman started home again.

1. 2 Kings 5:1 Or from a contagious skin disease. The Hebrew word used here and throughout this passage can describe various skin diseases.↩
2. 2 Kings 5:5 Hebrew: 10 talents [340 kilograms] of silver, 6,000 shekels [68 kilograms] of gold. ↩
3. 2 Kings 5:13 Hebrew: My father.↩

Primary Source: “Medication Errors in the Outpatient Setting: Classification and Root Cause Analysis.” Friedman AL “Medication Errors in the Outpatient Setting: Classification and Root Cause Analysis.” Arch Surg 2007; 142:278-283.

Additional Source: “Medication Errors in the Outpatient Setting — Invited Critique” Makary MM “Medication Errors in the Outpatient Setting — Invited Critique” Arch Surg 2007; 142: 284.

The Study

93 liver, kidney, or pancreas transplant patients were followed for 12 months, during which 149 medication errors were found.
Among these patients, the average number of prescribed medications was 10.9.

One-third of the errors were severe enough to have an impact on the graft’s survival. Nine graft rejections and six transplant failures were among the results of those errors.

The errors were divided into categories:

• Patient error – 56%¹
• Prescription error – 20%
• Delivery error – 13%
• Availability error – 10%²
• Reporting error – 8%³

The sources of error were also designated:

• Patients – 68%
• Pharmacies and other sectors of the health care team – 27%
• Finances – 5%

Commentary

The contrast between the scientific and sophisticated technologies necessary for a successful transplant and creating medications to support the survival of that transplant patient and the systemically flawed methodologies responsible for those medications actually being used correctly by the post-transplant patient is striking and dramatically highlights the importance of improving adherence.

I am less impressed with the classification scheme. Given the that the patient’s use of the right medication at the right time is the final common pathway and the complex communication pathway that conveys healthcare instructions, warnings, and exceptions to the patient, the surprise would have been if “patient error” were not the leading category of error.

1. Failure to accurately use an available prescribed medication↩
2. Inadequate medication for a 24-hour period↩
3. Failure to provide adequate information to identify the type, dose, or frequency of a medication↩

The Value of Brief Physician Interventions

Source: Kaner EFS, et al. Effectiveness of brief alcohol interventions in primary care populations (Review). The Cochrane Database of Systematic Reviews 2007, Issue 2.

As is often the case, this chief virtue of this Cochrane Review is its authoritative confirmation of a concept already verified by several studies.

After reviewing 21 randomized controlled trials with 7,286 participants, Eileen Kaner, the lead author, summarized the findings thusly:

More specifically, the results indicated that a single, brief intervention, typically as short as five minutes, decreased alcohol intake by an average of four drinks per week.

The target group consisted of patients who were heavy drinkers but not alcoholics.

Commentary

While the Cochrane Review dealt with alcohol use, parallel studies (although not a Cochrane Review) have demonstrated that brief interventions can have positive effects on smoking.

My clinical stance, equally influenced by cynicism and pragmatism, has been that, given the catastrophic risks of smoking and excessive drinking and the brief amount of time required for such an intervention, even a success rate as small as, say, 5% justified, if not mandated, that these issues be addressed in the office. This Cochrane Review reaffirms that notion.

One result of patient compliance is rendering treatment outcome somewhat of a numbers game. Just as more sales calls result in more sales and more at-bats result in more base hits (assuming the participants are competent), the more patients to whom a clinician recommends a decrease in drinking or a cessation of tobacco use, the more successful clinical outcomes.

And, we now know that those recommendations can be made efficiently without sacrificing effectiveness.

The Scene

During the fourth season of Seinfeld, Dr. Reston, Elaine’s manipulative psychiatrist, has whisked her to Europe. He breaks an embrace with her on a balcony in Paris and assumes a thoughtful, concerned stance. Elaine asks “What is it?”

The psychiatrist replies, “I was just thinking about this patient of mine, … just wondering if he’s taking his medication.”

As it turns out, the patient, “Crazy Joe Davola,” has not taken his medication and becomes psychotic. Wikipedia recounts his course following his unilateral termination of medication.

The Moral

Once you’ve seduced one of your patients and taken her to Paris, it’s too late to worry about another patient’s medication compliance.

Reference
Seinfeld. Season 4; Episode 3. “The Pitch”
First Aired: September 16, 1992

Life – With Diabetes – Goes On

Since I last wrote about Living With Diabetes,¹ that blog has added more posts to its conveniently categorized “Compliance” section.

As I noted previously, these blog entries provide useful insights into a patient’s perspective on compliance that are not often available to a clinician during a treatment session.

I’m especially taken with an observations on the difference between disagreeing with a treatment recommendation and noncompliance as limned in these excerpts from Patient Gripe – Bariatric Surgery Suggestions

For good measure there are a couple of comments that enthusiastically endorse this notion.

So do I.

I have long promoted, especially in How To (Correctly) Not Take Medications As Prescribed, differentiating between noncompliance (whatever that term means these days) and a communicated and acknowledged non-execution of a specific treatment recommendation.²

While all manner of humanistic, sociological, and ethical principles can be invoked in support of this idea, my primary argument is based on clinical pragmatism:

The opportunity cost (in this case, the potential loss of improvements in the patient’s health that the recommendation would have hypothetically caused) of the patient not following the recommendation is more than compensated by the elimination of (some of) the changes patients unilaterally and surreptitiously make in the treatment plan. Because these deviations from the presumed treatment plan are unknown to the clinician, they are especially likely to lead to mistaken diagnoses and erroneous evaluations of treatment outcomes (e.g., a physician may assume a patient’s infection is resistant to the prescribed medication or that the original diagnosis was wrong because of lack of response when the actual cause was the patient not filling the prescription), which, in turn, lead to delays in or prevention of improvements in the patient’s health, geometric increases in healthcare expenditures, and damage to patient and clinician morale and the patient-clinician relationship.³

Clearly, there are situations in which coerced compliance is justified; e.g., the treatment of deadly, highly communicable diseases and the treatment of patients with serious disorders who are cognitively unable to realistically appraise their condition. In the majority of cases, however, automatically categorizing a patient who refuses a treatment recommendation as noncompliant, with all the connotations that term carries, is, at best nonproductive, and is likely to inhibit – and perhaps destroy – treatment.

The Life With Diabetes posts can be found at Living With Diabetes On Compliance

1. See From The Patient’s Point Of View↩
2. Yes, “communicated and acknowledged non-execution of a specific treatment recommendation is a particularly awkward construction, but a more felicitous phrase, devoid of loaded words, doesn’t come immediately to mind.↩
3. See the “Complex, Cascading, Cumulative Costs” Section of Complex, Cascading, Cumulative Costs↩

Carol Shields is one of the writers I most admire. She authored ten novels, including The Stone Diaries, which won the Pulitzer Prize for Fiction as well as the Governor General’s Award as well as four collections of short stories, a number of plays, several books of poetry, some literary criticism, and a biography of Jane Austen.

In a post on my personal blog,¹ I wrote

Carol Shields CBC Interview

I recently happened onto an interview Shields gave to the CBC which the network’s guide describes thusly: In February 2000, she [Carol Shields] spoke candidly to Writers & Company host Eleanor Wachtel about her illness and how it changed her writing.

It is a poignant, gracious, unsentimental dialog that addresses living with cancer, pursuing ones passion despite the deadly diagnosis, writing with ones head and heart, and being human.

I include it here for the especially well articulated insight it provides into what it means to deal with a chronic, deadly disorder every day and the consequent impact on adherence to treatment.

The interview can be found at CBC Interview: Carol Shields on living with cancer

Footnotes

1. Other posts on my personal blog also include Carol Shields, including Carol Shields and Neruda at the Heck Of A Guy Internet Sunday Salon and Carol Shields On Living, Writing, Cancer, and Julie↩
2. Julie was my much-beloved, fiercely smart, extraordinarily sexy wife, who died in 1999 from cancer diagnosed the week of our wedding nearly 20 years earlier. She was also a prize-winning writer. This blog includes many other posts about her and the unlikely but true story of our romance (See Julie FAQ) as well as several of her short stories and other pieces (at Julie’s Writings and Unpublished Julie.↩

Primary Source: Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Catz, Sheryl L.; Kelly, Jeffrey A.; Bogart, Laura M.; Benotsch, Eric G.; McAuliffe, Timothy L. Health Psychology. 19(2), Mar 2000, 124-133.


Secondary Source: Social Support and Confidence Predict AIDS Patient’s Adherence to Complex Medication Regimens Healthlink 2000-03-29.

The Study

Logistics
Excerpted from abstract:

Results
Of all the factors examined only patients’ confidence and their perceptions of social support independently predicted adherence. (Overall, nonadherent patients were also more likely to be depressed and have more side-effects than adherent patients, but these did not independently predict compliance/noncompliance.)

Implications
According to lead author Sheryl L. Catz, PhD, Our findings suggest that patients with limited emotional support should receive mental health and support services not only to improve psychological functioning but also, potentially, to enhance treatment adherence. Interventions that enhance a persons’ perceived confidence in adhering to treatment regimens also seem particularly important, especially at the time when the therapy is initiated.

Commentary

Evidence that social support and self-confidence have a positive impact on adherence is heartening.

My only cautionary note has to do with the implications drawn.¹ The finding that patients who are more self-confident and feel themselves more supported by peers and family are more adherent to treatment does not necessarily mean that interventions designed to imbue less confident and more isolated patients with these traits will render those individuals more adherent, even if the interventions are successful. Learned self-confidence may or may not be equivalent to “naturally occurring” self-confidence. As usual, more research is necessary.

Footnotes

1. The authors, it should be noted, set forth these ideas as hoped-for speculations, not fact.↩

Tempted To Noncompliance

Today’s post focuses on the penchant of a significant fraction of the population to choose the offerings of charlatans and shamans over those of scientific healthcare, leading all too often to noncompliance with medical treatment.

This excerpt from Prayer, Faith Is Fine, published in the Swazi Observer characterizes the problem.

Commentary

While this story is set in Swaziland, it is not difficult to imagine variations taking place throughout the world, including those countries with far more resources in the areas of healthcare, communication, and education. The thriving enterprises of mysticism, quackery, pseudoscience, and straightforward scams in the U.S. is testimony that national borders are no protection from such dangers.

To read this article is to be reminded that patient noncompliance is caused not only by miscommunication, side-effects of treatment, medication fatigue, and other miscues within the patient-clinician-interface but also by patients who opt out of the system of scientific healthcare altogether, preferentially placing their beliefs in one of the many available alternatives.

While I am aware of the limitations of scientific healthcare and willing to accept the possibility that some other system could prove as beneficial or more beneficial to mankind, I see little compelling evidence indicating that such a theoretical system currently exists. Until such evidence is revealed, I maintain that a fundamental requirement for compliance is the patient’s participation in the best available scientifically supported medical care and, consequently, that those of us involved in providing that medical care have the responsibility not only to practice our techniques carefully and skillfully but also to unapologetically promote the proven effectiveness of those techniques and insist that alternative healthcare methods similarly back up their claims of effectiveness.

The complete article from the Swazi Observer can be found at ~Prayer, Faith Is Fine~

Unanticipated Roles In The Drama Of Patient Compliance

In It’s what you signed up for at Codeblog, Geena explores the dilemma she and other nurses face in achieving patient compliance.

Geena describes “encouraging my post-op patient to cough and deep breathe all shift” and her frustration and disappointment when, at the end of the shift, it is apparent that, despite her provision of pain medication, proper instruction, and empathic persuasion, the treatment goal was not reached.

The post’s title, It’s what you signed up for, is derived from the point made by another nurse during a discussion about this all too common situation:

The appropriateness and effectiveness of various tactics (e.g., good cop/bad cop) are also considered. It was another standard strategy, however, dissolved the reluctance of Geena’s exemplar patient to participate fully in treatment:

Commentary

In oversimplified terms, patient noncompliance, even if transient, brings the nurse’s (or any healthcare professional’s) philosophical commitment to patient autonomy into conflict with the importance of successfully executing the treatment plan.

The clinician’s role is also, however, influenced by multiple other factors, including but not limited to the following:

• Practical matters, such as limited time, staff, and other resources
• Professional and regulatory requirements
• Personal and professional expectations
• Local and cultural mores
• Environmental modes (nursing is typically expected to intervene more directly and forcefully, for example, in the case of a noncompliant ICU inpatient than with an resistant outpatient)
• The severity of the patient’s disorder
• The patient’s age, personality, attitude, and intelligence

My modification of the title of Geena’s post from It’s what you signed up for to Who Signs Up For What in the title of this post has two referents:

1. I understand the use of It’s what you signed up for as shorthand for “the patient has the final responsibility for following or not following the treatment plan,” but it is not a trivial point that much of the time patients don’t know what they’re signing up for. Some patients, for example, are unconscious, delirious, demented, intoxicated, too young, unable to communicate, or otherwise incapable of understanding or legitimately consenting to necessary treatment. Even intelligent, educated, attentive adults, however, cannot anticipate every requirement of treatment. I’ve been present at more than a few discussions of impending operations that would require some type of postoperative chest physiotherapy similar to that described in the Codeblog post to decrease the risk of pulmonary complications; in none of those discussions was the patient told, “The day after your chest is ripped open and then sewn back together, we’ll expect you to perform some respiratory calisthenics that will result in excruciating pain – for
your own good.” And, even if a patient signs an informed consent documents with such information in the fine print, how many operative candidates who know that the proposed surgery is necessary for a cure or palliation of their disorder, who are overwhelmed by an avalanche of data, and who may be worried about survival can be said to understand the details of what they are signing up for?

2. Who Signs Up For What also makes explicit the underlying theme of Geena’s post. It’s what you signed up for applies not only to patients but also to nurses, doctors, respiratory therapists, and all healthcare professionals. Garnering patient compliance is, as the cliche has it, part of the job description. My contention is that, like the postoperative patient facing a deep breathing exercise, we healthcare professionals may not have known exactly what we were signing up for.

In any case, It’s what you signed up for offers a useful perspective on patient compliance and raises some fundamental questions every healthcare professional would do well to address.

Compliance, the 10 April 2007 entry in the the Got Liver? blog is also the most recent addition to my informal collection of posts offering insight into treatment adherence based, at least in part, on the writer’s personal experience.¹

The author of Got Liver? explains his motivation thusly,

The Got Liver? Compliance post specifically addresses the transplant candidate’s preparations for and commitment to compliance with the medications, testing, and other portions of the pre- and post-transplant treatment plans. While this process, as seen from the transplant recipient’s point of view, is enlightening and the entire post is worthwhile reading, I found one section especially surprising.

I had been cognizant of transplant-associated compliance problems such as the economic costs of adherence, the difficulties of following the strenuous requirements of treatment protocols, and the ethical issues involved in ranking potential recipients for the too-few organs available based on the anticipated compliance capacity of the candidate (along with physiological criteria, age of the patient, and other factors). I was not aware, however, of the appqrently significant number of candidates who are openly and vehemently noncompliant, as described in this excerpt:

This post is an interesting take on a healthcare scenario in which compliance is, all too literally, a life and death matter from somebody who has been there.

Footnotes

1. Other posts in this group include the following:
   The Misdiagnosed Patient
   There is a fine line between being a Squeaky Wheel & a Pain In the Butt
   Looking At Patient Compliance From Both Sides Now↩

Primary Source: Family history of diabetes, awareness of risk factors, and health behaviors among African Americans. Baptiste-Roberts et al. Am J Public Health. 2007 Mar 29

Secondary Source: Better Diabetes Awareness Doesn’t Equal Better Habits for Some Blacks
Glenda Fauntleroy Health Behavior News Service

The Study

The study population consisted of 1,122 African-American adults, none of who was diagnosed with diabetes but 36 percent of whom reported that an immediate family member had type 2 diabetes.

Among that subgroup with a family history of diabetes, “nearly 60 percent had a better-than-average awareness of the diabetes risk factors” compared to 47 percent of the the control group (no family history of diabetes) who history demonstrated that level of awareness.”¹

This larger proportion of individuals with family histories positive for diabetes, aware of the risk factors was not reflected in positive health behaviors. For example,

Possible reasons proffered for this discrepancy and corrective actions recommended included:

On the other hand, those subjects with diabetic family members were more likely to consume 5 or more servings of fruits and vegetables per day and to have been screened for diabetes.

Commentary

This article is one more indication that informing a patient about his or her disorder and its treatment is insufficient to assure adherence to treatment.

It is notable that the conclusion of the primary article itself is African Americans with a family history of diabetes were more aware of diabetes risk factors and more likely to engage in certain health behaviors than were African Americans without a family history of the disease while the review of that article, using the same data, observed that a patient’s greater awareness didn’t necessarily translate into healthy behavior.

Perhaps the most useful take-home message is the observation of Kate Lorig, R.N., a professor at Stanford University’s Patient Education Research Center,

Footnotes

1. The awareness scored was based on participants being shown “a seven-item list and asked whether any of the factors increase a person’s risk of developing diabetes. All seven items on the list are risk factors for diabetes — minority race or ethnicity, overweight, family history of diabetes, sedentary lifestyle, older age, high-calorie diet and diabetes during pregnancy.”↩