Two Wall Street Journal articles that are especially pertinent to patient compliance were published on 20 November 2006 during the AlignMap blog’s holiday hiatus.

Cell Phones Provide Medication Information and Reminders

don’t 4get ur pills: Text Messaging for Health¹ by Rachel Zimmerman explores the use of text messaging on nearly ubiquitous mobile phones as a real time means of conveying information about medical treatment, responding to healthcare queries, and, most significantly for patient compliance, sending reminders about medication doses to patients.

While I have been critical of marketing that promotes reminders of various sorts² to be the complete solution to medication noncompliance or suggests that reminders always result in downright miraculous improvements in adherence rates, I am taken with the notion of cell phone text messaging as a useful tool for patients who have difficulty taking the right medications at the right time (a category in which I frequently find myself when a new medication, such as an antibiotic, is added to my ongoing medication schedule for a one or two week period) and for exchanging information precisely because it requires, for most of us, no new or specialized equipment and fits into our daily routines.

Because I already use an analogous service to text messages to myself about everything from taking out the trash early Monday mornings for the weekly pickup and buying specific items currently on sale at my local grocery to adapting a business presentation in time for a meeting next week, I can see how medication reminders could also integrate into rather than impinge upon ones behavioral patterns. I can also imagine younger individuals, such as my 18 and 21 year old sons who would promptly toss a reminder device that attracted attention to themselves under a passing truck, being comfortable with this type of reminder.

Readers may recognize one service provider mentioned in the article, Intelecare Compliance Solutions, as the group represented by Knight, the author of the Medication Noncompliance Blog:

Patients, Doctors, Dollars, and Communication

Your Doctor’s Business Is Your Business by David Armstrong discusses how patients might best deal with the possibility that their doctor has a potential conflict of interest (e.g., a physician with a financial interest in an orthopedic device he developed might be tempted to prescribe it unnecessarily or a doctor might advise patients to undergo a CT scan at a given facility which he owned). While I certainly see the value of open disclosure on the part of clinicians re special financial considerations they might receive from prescribing a specific treatment, I’m less convinced of the practicality of the course of action promoted by this article. In a framed box entitled “WHAT EXPERTS RECOMMEND,” the recommendations are

Even though I’m a physician myself, I would find it awkward to ask each of my doctors every time they prescribe a medication, operation, physical therapy, etc, if they will personally benefit from that transaction. Using as an example, the treatment I received for my recent hip fracture as an example, I should, according to a straightforward reading of the article, have asked about conflicts of interest when

• My personal physician ordered a diagnostic x-ray from a facility located in a different office of the same medical building as his office
• My personal physician had his nurse obtain blood samples for the hospital admission work-up
• My personal physician referred me to a specific hospital for reparative surgery
• My personal physician referred me to a specific orthopedic group for further diagnosis and treatment
• The orthopedic surgeon recommended a hip pinning rather than other options
• The orthopedic surgeon referred me to a inpatient physical therapist for purchase of an assistive walking device and training in its use as a condition of discharge
• The orthopedic surgeon ordered pain medication for my post-operative use as needed
• The orthopedic surgeon ordered follow-up x-rays of the hip to be done in his office before every follow-up appointment
• The orthopedic surgeon recommended outpatient physical therapy at a specific facility

It seems to me that the real question readers are being prompted to consider is “Is my doctor ripping me off?” And, I think that is a legitimate enough concern; the problem is that if such fiscal treachery is afoot, one would hardly expect the perpetrator to automatically fess up when confronted with a simple question. How useful would it be to ask a car salesman, “By the way, my good man, are you charging me an excessive amount for this automobile and pushing the special undercoating only to build up your own commission?”³

The author of the article, perhaps recognizing this issue, advocates a second opinion if any potential conflict of interest is found. I’ve always pushed my own patients to obtain second opinions to pacify any qualms about my diagnoses or treatment recommendations, but second opinions are themselves often expensive (especially if not covered by insurance) and take time to arrange. Moreover, an expert in the appropriate field whose reputation is blemish-free and who is absolutely independent of potential conflicts may be hard to find on short notice. And, if the course of action recommended in the second opinion differs from the first treatment suggested, does the patient get a third opinion to break the tie? What if it turns out that the doctor providing the second opinion has his or her own financial arrangements that compete with those of the first doctor?

Finally, how significant and how specific to a given treatment does that financial involvement have to be to warrant notifying patients? Should the doctor who sells and dispenses mediations within the office list his profit margins for those medications? Does the prescriber who owns stock in a pharmaceutical company have a different obligation to inform clients than the prescriber who helped developed a medication and receives a royalty for every pill sold? Do doctors working for an HMO who receive an incentive for prescribing generic rather than brand drugs disclose that to every patient? Does a doctor who sends patients to a facility that uses a certain type of CT machine on which holds a patent have a different responsibility to disclose his financial arrangement than a doctor who orders CT scans on his patients done in the office with the CT machine his group practice owns and operates?

If the following statements were true, should I have told patients, “I’m prescribing Prozac for your depression, but you should be aware that Eli Lily, the company that manufactures Prozac, …

… pays me a royalty for every Prozac capsule sold because I helped get FDA approval”
… sells these capsules to our pharmacy wholesale and our pharmacy, which our practice owns, charges you a 200% markup when we sell you your medicine I’m prescribing”
… sends a salesman here every month who takes me to lunch where he tells me why I should prescribe Prozac instead of another medication”
… may be in the portfolio of some of the stock funds in which I’ve invested so their profit would benefit me”
… offered second year medical students at many medical schools in 1973 a free, medium quality stethoscope that I accepted”

I suspect few would think that admitting that I accepted a stethoscope from Lily is either necessary or useful, but defining how much financial involvement by a physician merits or requires disclosure is not a trivial task.

My discomfort with this piece, in fact, is not that the problem of a physician’s conflict of interest doesn’t exist but that the simple fixes the article described belies that complexity of the problem.

Additionally, such questions put to doctors are not always benign and may yield negative results, a concern noted in this excerpt:

Readers may also recognize Trisha Torrey as the author of Every Patient’s Advocate, a blog which occasionally appears here at AlignMap.

Disclosure Statement

Ahem, I have not accepted any financial remuneration from The Wall Street Journal, Every Patient’s Advocate, Medication Noncompliance, their authors, or their associated companies for mentioning them in this post.

One possible reason, in addition to my stalwart Midwestern upbringing, my seven years of perfect attendance at Sunday School, the two semesters I spent at Oklahoma Christian College, and my preternaturally staunch moral fiber, for my incredibly righteous stance in this regard is that none of those entities has (yet) offered me any such remuneration. I mean, if someone were to go to the trouble of, say, placing a manila envelope filled with a significant chunk of cash in small, unmarked bills in a locker at the bus station and sending me the locker key, it would be rude not to at least consider taking the money. Or if Mr Murdoch, who could certainly afford it, saw fit to comp me a daily copy of the WSJ, to which I subscribe at the exorbitant, full-price online subscription rate, I would feel obligated to live up to the standards of politeness instilled in me by my mother and to accept that offer as a no-strings goodwill gesture from a fellow publisher.

I freely admit that both of the individual blog authors mentioned do occasionally email me, typically to tell me or ask me about something going on in the wide world of patient compliance or exchange a tidbit or two about our personal lives. Trisha, for example, moved recently, and we briefly discussed the stresses such endeavors may inflict on households. I am only a teen-tiny bit jealous that their businesses were mentioned in WSJ articles and mine wasn’t. Both bloggers have written positive comments about AlignMap or me in previous posts, which is always nice.

Footnotes

1. If this article falls in the “subscriber-only” section of the WSJ, readers without such a subscription may be able to access this article by first going to the Digg Connection to this piece and then clicking on that link [back]
2. ”Reminders” include wrist watches that signal the time for medication, dispensers with flashing lights, recorded messages, and overtly noxious sounds, telephone calls, orbs that glow at the appropriate time, and a variety of Rube Goldberg contraptions [back]
3. While a villainous doctor might be more forthcoming and the questioning process more amusing and gratifying if one employed more vigorous interrogation methodology such as that used on TV police procedurals or in the Spanish Inquisition, those techniques could prove off-putting to some healthcare professionals and could tend to taint the relationship between physician and patient. [back]

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Perhaps I should open a category called How About That?

More and more often it seems that I run across interesting items that are pertinent to patient compliance but are of limited immediate use. And, often the findings are congruent with widely accepted assumptions.

And so it is with …

The Difficulty Of Talking About Chronic Disorders

The essentials follow: A just released survey of more than 1,000 adults commissioned by Evercare (a provider of health plans for people who have chronic illnesses, are older, or have disabilities) found that

• 82 percent of respondents said they knew someone with a chronic illness, but only 34 percent were likely to suggest ways for this person to better manage their care. That’s about the same number who said they’d debate politics (37 percent) or religion (33 percent) with a loved one or friend.
• Respondents were more likely to discourage friends or loved ones from buying the wrong house (65 percent), loan them a large amount of money (56 percent), advise them against taking a job they didn’t think was right for the person (48 percent), and tell them their spouse was unfaithful (41 percent).

• The reasons why many Americans are reluctant to offer advice to chronically-ill friends or family include: They think the person has the situation under control (66 percent); they are not a health care professional (31 percent); they don’t want to seem like a nag (31 percent) or rude (29 percent); they don’t believe the person would listen to them (27 percent); or they didn’t think the matter was that important (15 percent).

Commentary

It seems useful for a clinician to know that most of us are uncomfortable talking to friends and families about their chronic disorders (well, let’s make that it seems useful to know that a survey of 1,000 subjects indicates that most of us are uncomfortable talking to friends and families about their chronic disorders). If nothing else, clinicians should understand the difficulties of developing a social support system and the importance of giving patients enough time to tell their stories - since no one else is likely to do so. Beyond that awareness, however, it is difficult to see how it can be used in day to day clinical practice.

Like I said, How about that?

Source: Chronic Illness Often a Taboo Subject: Survey

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A review of my last several posts indicates that I may have passed from maintaining hope for healthcare despite evidence to the contrary to implacable misanthropy without passing through lovable curmudgeon.

And today’s post may confirm that diagnosis.

I discovered Following directions, a post at Pharmer Jane (Pharmer Jane appears to be written by a pharmacist but no actual personal or institutional names are used) last week but had not written about it because it seemed to offer nothing in the way of useful clinical information or insight into human behavior vis-a-vis adherence to treatment.

I’ve recanted that position, however, in the belief that there is value in pointing out to readers that there are still healthcare professionals who “really cannot understand why it is so difficult to follow directions on the prescription bottle” and, further, appear uninhibited about declaiming that view on the Net where God, patients, fellow clinicians, and I can read it.

The title of my post is taken from the first line of of Pharmer Jane’s post. Another couple of excerpts should provide a sense of the post:

Again, this post (and a comment congruent in tone) can be found at Following directions and is sufficiently self-explanatory that no further elaboration is needed.

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Patient and Physician Attitudes in the Health Care Context: Attitudinal Symmetry Predicts Patient Satisfaction and Adherence
Jamie A. Cvengros, Alan J. Christensen, Stephen L. Hillis, Gary E. Rosenthal. Annals of Behavioral Medicine, Vol. 33, No. 3: pages 262-268. 2007


Source #2: Patient-centered Approach Can Backfire ScienceDaily. Aug 14, 2007

The Study

Excerpted from the abstract

The application of statistical models demonstrated that patients were more likely to be satisfied with care and follow medical instructions if they were treated by a doctor whose attitudes toward patient-physician roles paralleled their own.

Commentary

Perhaps the most significant implication of these findings is the unsurprising conclusion that no single approach to the roles of the patient and the physician in the healthcare dyad works best for every patient. While the consensus for the past several years has been that treatment should be patient-centered, this study suggests that some patients prefer a doctor with a more traditional style, even if that crosses the line into “paternalistic” and may be more likely to follow the treatment plan if seen by such a physician.

It should be noted that a limitation of the study is that it relied on the patients’ self-report to rate compliance. A similar study with alternative means of measuring adherence (e.g., prescription refill records) is underway.

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At Digital Doorway, Keith, a Registered Nurse working “with the Latino community in a New England city, caring for individuals with HIV/AIDS, diabetes, addiction, and sundry illnesses related to lives rife with trauma and the intergenerational effects of poverty,” has posted “Of Course I Take My Meds!,” in which he relates a simple patient compliance scenario, one surely re-enacted in a multitude of forms hundreds of times each day in various healthcare settings.

Nothing dramatic takes place. A patient complains that her asthma has worsened. Alert to the likelihood that the patient may not have taken her medications as prescribed, thus provoking this exacerbation, Keith asks her “Which medicines have you been taking?” She steadfastly claims to have followed her dosing schedule. A quick check of refill dates and a cell phone call to the pharmacy, however, reveals that the patient has not refilled any prescription in the past six months. The patient admits as much, attributing it to the cost of the pills. After a bit of encouragement and counseling, the patient, the story implies, agrees to resume taking the medication.

Commentary

As I’ve noted, there is little drama here. And, in fact, I don’t believe that every patient will respond positively, as this patient did, to rather straightforward confrontation on her noncompliance.

The key messages from this vignette, however, are helpful:

• Maintain vigilance for noncompliance as a potential cause of suboptimal outcomes
• Know the patient and the approach to which he or she best responds: In this case, the patient responded to low-level confrontation plus taking her hand and ending with a hug.
• Be persistent; Keith didn’t stop investigating simply because of the patient’s denial
• Look at the data (e.g., prescription refills, the pills themselves, the pharmacy records, reports from family members, etc)
• Go the extra mile; Did I mention that Keith was visiting the patient in her own home?
• Be realistic: the penultimate line of the story is “I remind myself to pay this patient a visit in about thirty days and see what meds she hasn’t refilled yet.”

While the summary of the post is described as “a nurse’s best defense against burn-out,” I suggest that these qualities are invaluable for anyone dealing with patient noncompliance: Patience, persistence and a sense of humor

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Ken Farbstein at Patient Safety Blog - Telling Our Stories has posted a special case of noncompliance at He Had A Secret Plan: A Patient Compliance Story.¹

The pertinent issues are the patient’s mistaken belief that his successful program of exercise and dieting obviated his need for medications prescribed to treat his heart condition and, more significantly, the patient’s decision not to inform his physician that he had unilaterally begun the rigorous diet and exercise program and terminated his drug regimen.

The message is clear: failing to communicate changes in a treatment program to ones clinician places one at unnecessarily high risk for little discernible benefit.

This story is a poignant companion piece to How To (Correctly) Not Take Medications As Prescribed, a post on the AlignMap blog suggesting that patients who discontinue their medications but inform their physicians of this change are, by my pragmatic conceptualization of the principle, “in compliance.”

Footnotes

1. Published April 27, 2007 [back]

• None Found

Empathy - It’s Not Just For The Good Times

Jodi Halpern, Empathy and Patient–Physician Conflicts, Journal of General Internal Medicine Vol 22, No 5/May, 2007, 696-700.

Dealing With Patient-Clinician Conflict

The author points out that clinicians have a penchant for thinking of empathy as operative only in those relationships with patients that are successful and marked by a tone of mutuality when empathy is even more important in dealing with problematic relationships, especially when anger is present on both sides.

This article goes on to define empathy as engaged curiosity about another’s particular emotional perspective and to describe five methods for fostering empathy when dealing with conflicts with patients.

1. Recognizing one’s own emotions
2. Attending to negative emotions over time
3. Attuning to patients’ verbal
4. Recognizing nonverbal emotional messages
5. Becoming receptive to negative feedback

Commentary

While the specific recommendations appear, at on the surface, to be too simplistic to resolve the more complex contretemps that can exist between patient and physician, they are, at the least, steps in the right direction. Moreover, the author’s pointed reminder that empathy is a tool to be used rather than a description of a relationship’s mood is invaluable.

Finally, contentiousness between patient and clinician must result in resolution rather than a Pyrrhic victory for one side or another, especially since noncompliance is the likely attendant outcome.

This s a brief, well constructed paper that offers almost immediate returns on the reading. I recommend it not only to clinicians but to patients with chronic conditions whose health or even life may depend of their skills in negotiating with their doctors.

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A Patient Compliance And Literacy Problem
Or A Failure In The Healthcare System?

Introduction

Despite federal mandates to translate prescriptions,¹ the technical capacity to do so, and the rather obvious clinical need for prescription information in the language of non-English speaking patients , many pharmacies in New York City do not provide translated labels,according to an April 27, 2007 presentation by Linda Weiss, PhD, at the annual meeting of the Society for General Internal Medicine held in Toronto, Ontario, Canada.

As Dr. Weiss notes:

Study Parameters and Results

Of the 2186 New York City pharmacies licensed in 2006, 200 pharmacies were surveyed.

“Health literacy is the strongest predictor of a person’s health status,” Ann Zweber, RPh, director of assessment and senior instructor of pharmacy practice at Oregon State University in Corvallis, told Medscape in response to a request for independent commentary. She was not involved with this study.

“If patients do not understand their medical condition and how to manage it, including how to use their medications, they are more likely to suffer from poor health outcomes,” Dr. Zweber said.

Translation Capacities

Even those pharmacists who provided translated printed information did so only when they happened to notice a patient having difficulty with English (54%) or if specifically asked (33%). Less than 20% of the pharmacies surveyed had protocols to systematically identify patients who need might need translated labels; less than 10% had signs indicating that translated materials were available.

Commentary

First, I recommend reading the article, which also includes speculation about the reasons pharmacies appear less likely than other healthcare providers to offer translated information, thoughts about informal strategies by some pharmacies to provide patients information in their own language, and services being developed to provide more sophisticated and specialized translation services.

Although, as the authors note, the research has limitations,² its revelation that a large proportion of a randomly selected sampling of pharmacies lacked a systematic means of providing clinical information to a patient in his or her own language is astounding. My contention, in fact, is that this problem transcends issues of patient compliance and patient literacy.

Conceptualizing a patient as noncompliant because of a failure to following instructions provided in a language that patient doesn’t comprehend may meet some technical definition of compliance but certainly has little in common, for example, with a patient who unilaterally changes a medication dose because of side-effects or another who never has a prescription filled because of distrust of doctors.

Similarly, a recent immigrant who speaks only Spanish may somehow be described as functionally illiterate in an environment dominated by users of the English language, but describing the problem in terms of “health illiteracy” risks misrepresenting the problem as a deficit on the part of the patient when, given the rather easy availability of translation software, the primary responsibility rests upon the pharmacies.

As one of those doctors who are reflexively resistant to government “interference,” I have fastidiously looked to - well, to anyone else but government solve problems in the healthcare system. In this case, however, I am foursquare in favor of an approach that first addresses enforcement of the altogether reasonable regulations that all healthcare providers, including pharmacies, provide materials translated into an language understood by the patients served.³

Source: Pharmacies May Not Always Translate Prescription Labels for Non-English Speaking Patients Laurie Barclay, MD Medscape Medical News 2007.


Footnotes

1. All healthcare providers receiving federal funds are, by legislation, required to offer language services to limited English proficient patients [back]
2. E.g., the data were collected “through a relatively brief telephone survey (shorter than 5 minutes), preventing probing any item in detail; and reliance on self-report, which most likely biases the findings toward overestimation of pharmacy translation practices.” [back]
3. Yes, the regulations must be practical. Not every pharmacy in southwest Missouri can provide labels written in an obscure dialect spoken only by the last 83 members of an isolated tribe living on a tributary of the Amazon. That kind of exception, however, should not be confused with a New York pharmacy not offering prescription levels in Spanish. [back]

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Interest In Health Literacy Grows

Two major newspaper stories in the past month addressed health literacy, one of the major causes of patient-clinician miscommunication, which in turn often leads to inadequate treatment plan execution, a phenomenon typically included under the aegis of patient compliance.

Sources:

‘Doctor-ese’ often stumps patients Jane E. Brody New York Times 4 Feb 2007

A Silent Epidemic Sandra G. Boodman Washington Post 20 Feb 2007

The Points Made In These Articles Are Straightforward

1. Impaired Health literacy is a national healthcare problem of huge proportions. According to the Institute of Medicine, more than 90 million Americans of all ages, races, and income and education levels, are unable to adequately understand basic health information.¹

2. Poor health literacy results in poor adherence to prescription instructions, infrequent use of preventive medical services, increased hospitalizations and visits to the emergency room, and worse control of chronic diseases. The consequences are poorer health and greater medical costs.

3. Doctors fail to speak to patients in plain English (or Spanish or Chinese or any other language) and fail to make sure that patients understand what they are told and what they are supposed to do and why.

The disconnect between the offerings from healthcare and the capacity of patients is noted in a 1999 report by the American Medical Association which found that consent forms and medical information are typically written at the graduate school level while the average American adult reads at the eighth-grade level. Worse, a 2003 survey completed by the U.S. Department of Education found that over 40% percent of adults read at a fifth-grade level or lower, and 5 percent are not literate in English (in some cases because it is not their first language). Math skills are similarly lacking.

The Impact Of Low Health Literacy Is Equally Clear-Cut

These excerpts are characteristic:

Primary Problems

Fixes

These newspaper reports included several specific recommendations for clinicians as well as patients to improve communications, many of which come with the imprimatur of the Joint Commission which recently presented 35 recommendations to address this problem, along with the implication that such suggestions might become future Joint Commission requirements for healthcare facility accreditation. Examples follow:

The advice for the patients is clear – be proactive or risk poor healthcare.

Also mentioned is a Pfizer-sponsored program called Ask Me 3 that was designed by the Partnership for Clear Health Communication, a coalition of national health and literacy groups. The program encourages patients to ask three simple questions and to be sure they understand the answers: What is my main problem? What do I need to do? Why is that important?

Commentary

I’ve summarized and excerpted material from these articles at length to point out (1) the importance of the problem, (2) the growing urgency demonstrated in the press, professional organizations, and regulatory agencies for a solution, and (3) the solution being promoted.

While the severity of the problem and the mounting pressure for a solution are, it seems to me, clear cut, the only solutions offered are incomplete.

Doctors, for example, are unlikely to find that “none of this [i.e., the suggested improvements in communication techniques] should take more than a few minutes,” as the experts quoted approvingly in the New York Times article declare, to be reassuring. By simple arithmetic, “a few minutes” added onto each appointment in a busy day, assuming the estimate is accurate, accumulates into “a few hours” added every week.

Even more problematic is the contention that every patient has, within himself or herself, the capacities to be a “patient expert” on his or her disorders and a self- advocate with the interpersonal skills to assure that the right information (whatever that might be) is provided and understood without being so confrontational that the relationship with the clinician is jeopardized. Neither clinical experience or personality studies would seem to support this hypothesis.

What is to be done for those individuals who cannot, especially in the sick role, assume this proactive stance?

The current Patient Literacy campaigns do not seem to take this issue into consideration, let alone provide pragmatic answers. I believe, however, that there are potentially useful responses, some of which I will be addressing in forthcoming posts.

Footnotes

1. The Journal of General Internal Medicine August 2006 [back]

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Power to the Patient! Improved communication and transparency are key to improving pharma’s relationship with newly empowered patients and patient groups. Jeannine Nolan. May 1, 2006

Written from Pharma’s point of view, this article focuses on the dilemma patient empowerment presents in Europe:

The solutions are, as the subtitle suggests, communication and transparency. While some of the material deals with regulatory agencies and restrictions that are specific to Europe, the article is worthwhile read, in large part because the author rejects the notion of corporations seeking direct access to patients while controlling the flow of information, attempting, in effect, to have their cake and eat it too.

Commentary

I’ve become especially interested in the notions of open communication and transparency as I have come across more and more examples of high compliance rates or other “researched proven” adherence enhancements that are kept hidden beneath the screen of “proprietary information” or depend on atypical definitions, criteria, or statistical interpretations. Some data must, of course, remain shielded to protect trade secrets; fair play, however, would dictate that one doesn’t trumpet research findings as proof and then refuse to disclose the research.

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Patient and provider assessments of adherence and the sources of disparities: evidence from diabetes care.
Lutfey KE, Ketcham JD. Health Serv Res.2005 Dec;40(6 Pt 1):1803-17.

_____________________

The authors surveyed 156 pairs of patients and their physicians from two Midwestern subspecialty endocrinology clinics, focusing on the correlation of each patient’s perception of his or her adherence to treatment with the attending physician’s perception of that patient’s compliance.

The primary finding was that the difference between the clinician and patient estimates of adherence was significantly greater if the patient were black than if the patient were white, but the direction of the variation of a provider’s assessment from a black patient’s assessment was random; i.e., clinicians did not show a tendency to assess the black patient as being either more adherent or less adherent than the patient’s self-evaluation.

The authors conclude that “providers appear to rely on observable cues, particularly age and race, to make inferences about an individual patient’s adherence,” and suggest that further investigation of the cognitive processing of providers, “particularly in terms of distinguishing between prejudice and uncertainty,” could provide clinically useful information.

Commentary

It’s heartening to find such an investigation of cultural and racial differences that eschews reflexive, implicit accusations of racism in favor of scientific observation. And I, for one, believe that improvement in patient-clinician communication is far more likely to be the consequence of providers learning to correct their misinterpretations rather than attempting to somehow become more “culturally sensitive.”

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Avoiding Tests Until It’s Too Late
By Benjamin Brewer, M.D.
The Wall Street Journal
May 30, 2006

Dr. Brewer points out and gives examples of a problem every practicing clinician will recognize – patients who, for many different reasons – avoid screening tests, sometimes with disastrous results.

Especially useful are his observations that

Getting [patients] to perceive a need and spend money and time on something they’d rather not do takes education and encouragement. … For now, salesmanship remains my main tool when it comes to screening tests. Patients need to be aware of what is needed and be proactive in asking their doctor for help.

Tracking is a daunting job for a primary-care office, where we have patients of every age, with multiple conditions of varying severity. It involves integrating results from multiple providers of care. There’s added staff time and expense to manage the process. I don’t get paid for any of the behind-the-scenes work unless the patient comes in for the test. After figuring in staff time and computer costs, I’d be lucky to break even when a person does come in for screening. Some insurers pay for screening, some don’t, and some do only for certain conditions or certain time intervals. … with the exception of a few pilot programs, commercial insurers, Medicare and Medicaid don’t cover this added work outside of the traditional office visit. … If insurers want to compensate doctors based on performance, they can expect some doctors to drop patients that won’t come in for follow-up or recommended screening tests.

Dr. Brewer’s views point toward my own contention that implementation of treatment plans, including participation in screening programs, is unlikely to significantly improve until there is an alignment of all healthcare stakeholders – clinicians, patients, healthcare systems, and payers.

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