The End of Nonadherence
Improving patient adherence has been a decades-long priority for nearly every health care stakeholder1—except for patients. It is well known that poor medication adherence is responsible for both avoidable spending and avoidable poor health outcomes—yet there have not been adherence marches in the streets demanding that people take their medication as prescribed. Whether or not we as providers choose to hear them, patients are telling us: Nonadherence is a system failure, not a patient problem. In a recent article for Academic Medicine, we introduce the IDEAS framework for optimal team-based prescribing.2 It is our hope that this framework will not only help increase patient-centric prescribing practices, but will also help catalyze a system-wide transformation in how health care stakeholders conceptualize the etiology of nonadherence. It is time to stop thinking about patient nonadherence as a patient behavior and start redesigning the health care system for achievable health.
Ending Nonadherence by Increasing Patient Support
Just like the word noncompliance that came before it, nonadherence is a euphemism for a patient failing to follow a provider-created treatment plan. Imagine how a physician in today’s clinical environment would develop follow-up recommendations after learning that a patient with uncontrolled blood pressure has not been taking her antihypertensive medications. The physician might create a plan to improve patient nonadherence. Often this approach highlights the patient factors that must be causing the perceived failure. For example, a patient is not engaged or motivated enough or they lack the health literacy skills that are required to use health care resources. Furthermore, even if system-level obstacles are identified, it remains the responsibility of the patient to overcome these obstacles. For instance, when a patient cannot afford her medications, she is the one who must navigate the complex health care system to identify potential solutions. Unfortunately, this process likely puts too much burden on patients to change factors that are out of their control. For providers working on the behavioral side of medicine, this mindset is not surprising. It may be human nature to blame others’ behavior on character rather than situational (e.g., system, environmental) factors.3 Care team members, therefore, may be predisposed to conceptualize nonadherence as a patient problem instead of as a system failure.
With some effort and practice care team members can overcome this cognitive bias. First, we as providers could replace the word adherence with terms that highlight the true effort it takes for someone to follow a care plan, such as successful follow-up or treatment accomplishment. As patient activist and cancer survivor Dave deBronkart shared in his book with Dr. Danny Sands, Let Patients Help!, “And if I’m the one who sets the goal of the treatment, I call it achievement, not behaving myself!”4 So in order to successfully identify actionable recommendations for optimal care, care team members want to describe the goal in a way that highlights the system’s responsibility in the success of the care plan. Our suggestion: replace the goal “improve patient adherence” with “improve patient support.” Framing the problem in this way could lead providers to solutions that are more likely to increase a patient’s likelihood of successfully completing a care plan.
Imagine again the physician and patient example from above and think about how the conceptualization of the next steps would change if the care goal was to improve patient support. With this change the onus naturally shifts to the provider, the provider’s team, and the health care system to identify methods for overcoming obstacles to the success of the care plan. That is, how could her team and the health care system better support her in finding success with her treatment plan?
The Beginning of a Better System
It is possible to reframe improving nonadherence as improving patient support given the many patient-centered shifts ongoing in health care. One example of this reframing comes from the Ochsner Health System, which recently implemented the O Bar program to help teach patients how to use the technology available to them in the place where they are receiving care.5 The O Bar changes the care environment default to increase the likelihood of each patient’s success by offering tools (devices and apps) that may be helpful, as well as in-person support from a technology specialist who can teach patients how to set up and use the tools.
As providers, administrators, and payers, we should be asking: Have we provided an environment that makes it easy for patients to identify, interpret, and act on information regarding the affordability, feasibility, and effectiveness of their care plans? Moreover, have we sufficiently supplied our providers with the team and resources necessary to provide this support within the constraints of their time-limited environment? If the answer to either or both of these is no, the environment must change. Reframing the nonadherence problem as a system problem may be the beginning of a solutions-focused health journey for patients and providers alike.
By: Stephanie R. Peters, MS, PsyD, and R. Scooter Plowman, MD, MBA, MHSA, Msc
S.R. Peters is behavioral medicine director, Carium, Petaluma, California.
R.S. Plowman is senior medical director, Proteus Digital Health, Redwood City, California.
References and further reading
1. World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003. https://apps.who.int/iris/bitstream/handle/10665/42682/9241545992.pdf;jsessionid=51AEF0804B008C367D2EE8003C24C3C5?sequence=1. Accessed March 11, 2020.
2. Plowman RS, Peters SR, Brady BM, Osterberg LG. Revealing novel IDEAS: A fiduciary framework for team-based prescribing [published online ahead of print November 26, 2019]. Acad Med. doi: 10.1097/ACM.0000000000003100
3. Howell JL, Shepperd JA. Demonstrating the correspondence bias. Teach Psychol. 2011;38:243–246.
4. deBronkart D, Sands D. Let Patients Help! A “Patient Engagement” Handbook – How Doctors, Nurses, Patients and Caregivers Can Partner for Better Care. Scotts Valley, CA: CreateSpace; 2013.
5. Ochsner Health. O Bar. https://www.ochsner.org/shop/o-bar. Accessed March 11, 2020.