Originally published December 2013
Physicians work in partnership with patients to achieve optimal care.
But what happens when a patient does not follow a doctor's advice? Addressing non-compliance or non-adherence — when a patient does not adhere to advice for investigative or treatment plans which a physician has set out in the patient's best interests — can be challenging.
Increasingly, the term used in the medical profession is "non-adherence" rather than "non-compliance." This reflects the patient-centered approach to healthcare delivery.
Non-adherent patients are those who seem to agree with the recommendations of their physician, then, for one reason or another, decide not to follow through. Often they do not tell their doctor. Non-adherence may relate to health issues, such as smoking cessation, weight loss, or dietary considerations. It may also include missing appointments, deciding not to follow up on referrals, missing tests, avoiding filling prescriptions, or simply stopping taking medication.
Non-adherence can be dangerous for the patient and frustrating for the physician. While evidence varies, some reports note that, depending on the condition and complexity of treatment, non-adherence by patients may be as high as 40%.1 It can also lead to additional costs to the medical system due to an increase in complications and hospitalization, and as a result multiply the medico-legal risk for doctors. A report published in 2003 by the World Health Organization notes that increasing the effectiveness of adherence may have a greater impact on the health of the population than an improvement in specific medical treatments.2
Patients may not heed the guidance provided by their physicians for several reasons. Changes may be difficult for the patient, either because of other obligations, lack of commitment, interest, or understanding. Patients may not completely comprehend the ramifications of not following through on tests and appointments, or of neglecting to take medications. Socio-economic conditions may mean treatments are unaffordable or living conditions are difficult. Issues of language, culture, or literacy may also come into play.
Between 2008 and 2012 there were 369 closed CMPA medico-legal cases involving patients' non-adherence to treatment. Of these, 157 were legal actions and 191 were medical regulatory authority (College) cases. Nearly 50% of the legal cases and 83% of the College cases were unfavourable to members. While the majority of College complaints were dismissed with concern, remedial actions were identified and documented in the physicians' record. All types of medical practice were identified in the legal and College cases, however the most common was family practice.
The issues identified in these cases were most often administrative, for example the failure to document the patient's refusal of an examination. Cases also involved diagnostic issues, a misunderstanding over what was being communicated between the patient and the physician, or difficulties with the manner in which the physician was communicating the information.
Non-adherence with recommendations for referral
An obese patient with a previous negative cardiac stress test presents to the emergency department (ED) complaining of substernal chest pain following a large meal and heavy drinking. The patient's regular physician takes over care.
An electrocardiogram shows non-specific changes and both the cardiac enzymes and telemetry are reported as normal. Reflux esophagitis is diagnosed and the patient is discharged home.
The following day the patient is re-assessed at the doctor's office. The patient only complains of pain with eating. Esophageal reflux is diagnosed. The physician discusses the patient's risk factors for heart disease — stress and excessive alcohol consumption — and advises the patient to have a cardiac stress test as well as a cardiac and gastroenterology referral but the patient refuses. The physician does not document the discussion or the subsequent refusal.
The patient subsequently suffers a myocardial infarction and dies. Autopsy confirms the cause of death and reveals a 95% obstruction of the anterior branch of the left coronary artery.
Experts are critical of the physician's failure to send the patient for a cardiac stress test prior to or shortly after discharge, and the failure to document his advice regarding referral to a cardiologist and the patient's refusal. The case is settled in favour of the patient and compensation is paid by the CMPA on behalf of the physician.
To reduce the medico-legal risk generated by non-adherence, physicians must be in a position to justify the approach being recommended and demonstrate that the patient was made aware of and understood the risks of non-adherence. Keeping accurate and comprehensive medical records regarding the treatment plan and about the consent discussion is important. A physician is unlikely to be criticized if a competent patient has made an informed decision to pursue a particular course of action.
Dealing with non-adherence — Building the physician-patient partnership
Identifying non-adherence is not an easy task, but understanding the reasons patients do not comply is a good beginning. Having frank discussions with patients and being non-judgmental can be effective in finding out more about the patient's perspective and non-adherence. Many patients need encouragement and need to know that they can discuss any concerns they may have with their doctor. Patients are also likely to react more positively to treatment if they are involved in core decisions and if they understand that the advice given by their physician is personal, and is not a one-size-fits-all solution to their health issue. As well, patients should be made aware of any resources available to help them implement and follow proposed treatment plans or lifestyle changes.
When it comes to prescribed medications, affordability is often a factor in adherence. Doctors should diplomatically ask patients if this might be an issue and can propose less expensive, but effective, alternatives. Side effects may also concern patients, and doctors should discuss the possibilities beforehand so patients understand what action might need to be taken. In some instances patients may have no symptoms (i.e. high blood pressure or high cholesterol), which makes it even more important to discuss the purpose of the medication.
Missed appointments or not following up on referrals are also forms of non-adherence. Doctors may want to implement what are commonly called "tickler" systems. A tickler system reminds the physician and staff of a pattern of missed or cancelled appointments, non-receipt of test results or consultants' reports, or failure to follow up as ordered by the physician.3
A physician may also want to consider creating a checklist that triggers electronic reminders, flags cancellations, initiates follow-up letters for missed appointments or tests, and monitors non-adherence so that efforts to follow up by contacting patients is documented in the medical record.
The bottom line
Consider, as appropriate, the following strategies which may encourage adherence to medical treatment and help mitigate the medico-legal risk engendered by patients who do not follow the prescribed prevention or treatment plan.
Have a frank discussion with patients about why the treatment plan or lifestyle change is important and how best to implement an agreed upon course of action. Explore any barriers to effectively carrying out the plan.
Set up office systems to help identify patients who engage in non-adherence such as missed appointments, cancellations, or failure to follow up on referrals.
Discuss the reasons for non-adherence with patients to better understand any barriers, and then work to overcome the barriers by suggesting alternatives or providing additional information or confirmation.
Document the consent discussion in the medical record, as well the patient's behaviour in terms of adherence.
Members who want more information or additional advice on patient adherence should call the CMPA to speak with a medical officer.
1. Martin, L.R., Williams, S.L., Haskard, K.B., DiMatteo, M.R., "The challenge of patient adherence," Therapeutics and Clinical Risk Management (2005) Vol. 1, no.3 p.189. Retrieved August 16 2013 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624
2. World Health Organization, Adherence to long-term therapies: Evidence for action, 2003, 211pp, ISBN 92 4 154599 2.
3. Richman, D., Ward, P., Fager&Amsler, LLP, "The Noncompliant Patient — A Risk Management Perspective," Spring 2006, Dateline, Medical Liability Mutual Insurance Company