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Evidence-based strategies to foster adherence and improve patient outcomes
M. Robin DiMatteo, PhDDr. DiMatteo is Professor of Psychology at the University of California, Riverside, and has published more than 100 research papers and six books on health behavior change, patient adherence to medical recommendations, clinician-patient communication, and health care outcomes. This article was prepared by Dr. DiMatteo and JAAPA editor in chief Sarah Zarbock, PA-C, and is based on Dr. DiMatteo's presentation at Innovations and Best Practices in Patient Adherence, an invitational meeting sponsored by the Physician Assistant Foundation and the American Academy of Physician Assistants, Washington, DC, April 20-21, 2004.The author's recent meta-analysis indicates that patients do not follow treatment recommendations unless they know what to do, are committed to doing it, and have the resources to be able to adhere.
Patient adherence is a crucial link between a clinician's treatment recommendations and a patient's health outcomes. The financial cost of nonadherence, also called noncompliance, is substantial. In 2000, patients made more than 759.3 million visits for the treatment of medical problems.1 Research has established that the prevalence rate of nonadherence is, on average, 24.8%.2 When this rate is applied to those visits, as many as 188.3 million medical visits in 2000 resulted in patients not following clinical recommendations. The monetary waste associated with nonadherence could be as much as $300 billion a year.2 The ability of patients to follow recommended treatment is influenced by a variety of factors in both positive and negative ways. Factors that can inhibit adherence include medical, economic, and cultural barriers. Other factors can improve adherence, such as social support and effective communication between the patient and the clinician. Nonadherence can confuse the clinical picture, frustrating both health professionals and patients. Clinicians may unwittingly use misleading assumptions about their patients' behavior and make decisions based on wrong information. The net result is a breakdown in trust between the clinician and the patient and an erosion of the therapeutic relationship. Patients' health behaviors and interactions between patients and clinicians take place within the context of a complicated, and often time-pressured, health care system. Health professionals therefore need practical and efficient strategies to help their patients adhere to and benefit from the potentially valuable medical treatments available to them. By understanding the forces that influence patient adherence and how these forces can be modified, all clinicians, including PAs, have an opportunity to improve patients' outcomes. A historical perspectiveThe study of patient adherence dates back to the 1940s. The first paper on patient adherence research was published in 1948 in the Journal of the American Medical Association.3 The term patient adherence was not used, but the relationship between adherence and outcomes was described as "follow-up of health care recommendations" that were made for the care of children in Chicago. In an article in the mid 1950s, the New England Journal of Medicine referred to nonadherence as "the failure to take oral penicillin at home."4 It was not until 1966 that the terms compliance and adherence were first used.5,6 Adherence and meta-analysisMost research on adherence has been based on individual studies. Researchers have recently used a meta-analytic approach, however, to combine these studies in an effort to understand the many predictors and outcomes of patient adherence. Meta-analysis allows for a review and summary of the research results from many studies and a quantification of the relationship between patient adherence and both treatment outcomes and the predictors of adherence, with the goal of making usable recommendations for health professionals. Over the course of adherence research, 63 studies have quantified both adherence and outcomes and found a significant, although not perfect, correlation between adhering and getting better. Other meta-analyses have answered these questions: "How common is nonadherence?" "Who is nonadherent and how can you tell?" "What can a health professional do to improve patient adherence?" A recent meta-analysis of the literature on patient adherence from 1948 to the present has helped create a model to understand what is required of patients to be adherent. This simple model indicates that for patients to follow their treatment, they must know what to do, be committed to doing it, and have the resources to be able to adhere.2 Patient-clinician communicationOn average, 25% of patients walk out of a medical office and do not follow the treatments that have been recommended to them.2 This percentage varies by the type of treatment recommended as well as by the disease with which the patient is challenged. Misunderstanding and forgetting are quite common when patients are in the process of learning what they need to do to take care of themselves. Their involvement in care and their participation in making decisions about it are essential. Patients must be able to ask questions, voice their concerns, and collaborate with clinicians toward the goal of adherence to their health care regimens. The therapeutic relationship plays a major role in adherence, and both clinician and patient must communicate in partnership in order to build trust. The efficacy of verbal communication depends on using words that the patient can fully understand. PAs should speak carefully and clearly with patients, regularly checking patients' understanding of what they have been told about the treatment they need to follow. Nonverbal messages, including the practitioner's facial expressions, body orientation, and eye contact, are essential ways to emphasize important points and to communicate interest, concern, and rapport. The combination of the right words and thoughtful, supportive body language contributes to the communication of empathy, active listening, and willingness to compromise in relating to patients. Patients' beliefs can be valuable determinants of adherence and should be considered carefully for communication to be effective. Many patients have their own cognitive models of illness, which may need to be reconciled with the treatment regimen. Some patients have concepts about their illness that may interfere with their ability to accept what is recommended and may contribute to their disbelief in the importance of their treatment. Patients may also have varying beliefs about their susceptibility to or the severity of their illness. Some with limited resources may do their own calculations about the expected benefit of treatment versus the financial and other costs. Cultural factors play a critical role in patient adherence. Respecting cultural perspectives is an essential contributing factor in developing trust in the clinician-patient relationship. The relationship between adherence level and treatment efficacy tends to be negative. That is, patients tend to be less adherent to the very treatments for which adherence is most effective. Sometimes the most effective treatments may be the most difficult to follow, however, and research suggests that treatment difficulty (such as the complexity of medication dosing schedules) can contribute to nonadherence. When patients are required to take several different medications, or to take many doses each day, their adherence is likely to be lower than if their treatment can be made less complex. Thus, finding the simplest regimen that is the most effective can contribute positively to patient adherence. PAs should try to keep treatment plans as simple as possible so they can be incorporated into the patient's daily life. Social supportSocial support plays a vital role in health and quality of life. Research has demonstrated strong effects of social support on patient health.7 People who have strong support networks that include others who love and care for them tend to be healthier than those who do not. Recent research on social support demonstrates a strong relationship between research findings and clinical applications, providing an arena in which health professionals can do much to increase patient adherence. One important key to achieving patient adherence involves helping to strengthen patients' levels of social support. Support networks for patients have been evaluated from the standpoint of both structure and function. Results have demonstrated that married people and those who are living with someone are slightly more likely to be adherent than those who do not have "structural social support." What makes the biggest difference to adherence, however, is the availability of practical and emotional support (including having someone to provide transportation to medical visits or reminders to take medication and having someone who cares about the patient and offers encouragement). PAs can have a major impact on their patients' adherence by helping them to obtain and maintain the practical and emotional support they need to comply with treatment. When attempting to improve compliance, clinicians should determine the patient's available support system, especially the degree of practical support. Role of the familyFamily cohesiveness and family functioning are variables that have very large effects on patient adherence.7 The odds of adherence are more than three times higher for a patient who is part of a cohesive family than for one who is not. Family conflict can also reduce patient adherence, perhaps because conflict can drain patients' energies and focus their attention away from their care. Stated simply, roughly 27% more patients will be adherent if their families are cohesive than if they are not. PAs can spend time with patients and their family members, as necessary, in order to determine the level of family functioning. Frank discussions with patients regarding their planned efforts to follow the recommended treatment should include inquiries regarding the role of the family and the degree to which its members are likely to be helpful to patient adherence or to make adherence more difficult. DepressionPatient depression is another variable that can strongly interfere with adherence. Studies on adherence among medical patients who also have untreated depression demonstrate a significant correlation between the two.8 Among every 100 depressed patients, 63 can be expected to be noncompliant and 27 compliant compared to the 50-50 split one would expect by chance.9 Given the high rate of comorbid depression in medical illness and the high rate of nonadherence in chronic care, this identified link provides an important opportunity for the health professional to intervene with effective treatment that may improve adherence. Patient depression is probably also related to social support issues because depressed patients often withdraw from their social support network. When the effects of depression and social support on adherence are combined, clinicians have an important opportunity to help their patients. By placing a greater emphasis on screening for depression, particularly when they suspect that the patient is not following the treatment regimen, PAs can determine which patients might need additional assistance. The two variables—depression and family dysfunction—taken together have a high correlation with patient adherence. Clinicians can immediately apply an understanding of this correlation to their relationships with patients. Screening for both depression and family dysfunction, and offering to help facilitate a supportive network for the patient, can do much to improve adherence. Other determinants of adherencePatients' demographic characteristics (their gender, age, and even education) tend to be less important than social/family support and depression in predicting adherence. A meta-analysis of demographic factors shows small average effects.2 The one demographic factor that does seem to make a moderate difference in adherence is income. Patients who cannot afford their treatments face serious practical barriers to their care. Finally, the relationship between the health professional and the patient has been shown in many studies to have a strong effect on adherence.10 Trust, communication, and caring are among the most important factors in establishing a therapeutic relationship that fosters patient adherence. The Medical Outcomes Study by the RAND Corporation provides important evidence that health professionals' experience of their jobs can actually affect their patients' adherence.11 This study examined patient and physician characteristics in predicting adherence to medication, diet, and exercise recommendations. The study found that the best predictor of patient adherence was physician job satisfaction, probably mediated through communication. Physicians who were unhappy in their jobs had patients who were less adherent than did physicians who were happy in their jobs. Thus, the health and well being of health professionals have important consequences for patient care. ConclusionA thorough review of the literature provides several practical suggestions that PAs can use to help their patients adhere to treatment regimens. • Remember that you are unlikely to foster adherence by trying to convince patients that treatment is good for them. The key to increasing adherence relates more to a partnership based on communication that builds trust in the relationship. • It is important to talk with patients about their understanding of the regimen and explore with them their beliefs regarding their illness and treatment. • Keep the treatment regimen as simple as possible, fitting it into the patient's life. • Determine the patient's available social support, particularly the degree of practical support that can be used as well as the degree of family cohesiveness. • Consider screening for depression. Carefully determine any problems with patient hopelessness, cognitive dysfunction, family conflict, and withdrawal from social support. Help patients identify and activate their internal and external resources with the aid of resources in the social and clinical environment. • Finally, strive to enjoy your relationships with patients so that your communication with them is positive and supportive.
REFERENCES 1. Centers for Medicare and Medicaid Services. Statistics, data and research information. Available at: http://www.cms.hhs.gov/researchers/statsdata.asp . Accessed August 5, 2004. 2. DiMatteo MR.Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. March 2004;42:200-209. 3. Hardy MC. Follow-up of medical recommendations. JAMA. 1948;136:20-27. 4. Mohler DN, Wallin DG, Dreyfus EG. Studies in the home treatment of streptococcal disease. I. Failure of patients to take penicillin by mouth as prescribed. New Engl J Med. 1955;252:1116-1118. 5. Wilson MA. The influence of the diet prescription and the educational approach on patient adherence to sodium restricted intake. Med Times. 1966:94:1514-1522. 6. Davis MS. Variations in patients' compliance with doctors' orders: analysis of congruence between survey responses and results of empirical investigations. J Med Educ. 1966;41:1037-1048. 7. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. March 2004;23:207-218. 8. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101-2107. 9. Rosenthal R, DiMatteo MR. Meta-analysis: recent developments in quantitative methods for literature reviews. Annu Rev Psychol. 2001;52:59-82. 10. DiMatteo MR, Reiter RC, Gambone JC. Enhancing medication adherence through communication and informed collaborative choice. Health Commun. 1994;6: 253-265. 11. DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. March 1993;12:93-102.
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