Stop Saying Non-Compliant: A Guide to Strengthening the Clinician-Patient Relationship

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Today’s Wound Clinic or HMP Global, their employees, and affiliates.

Maria Goddard, MD, CWS, FAPWCA began by pointing out that there are differences in the health care space when discussing compliance versus adherence. The phenomenon of patients not following medical advice is not new, but it has significant ramifications on morbidity and mortality. Reports, mostly on medication regimens, estimate 125,000 yearly deaths from a lack of adherence to the prescribed plan.¹ There are overarching impacts as well, such as hospitalizations, complications, and higher levels of care. So, who is responsible? The label of “noncompliance” is problematic, which Dr. Goddard discussed throughout her presentation.

Important Definitions to Know

She continued by outlining key differences in the definitions of compliance and adherence. Compliance focuses on the patient’s behavior matching a provider’s recommendations.² It is more of an order with which the patient is expected to comply. This can put a patient in a position of feeling unheard or devalued. Whereas, adherence is when a patient’s behavior aligns with recommendations agreed upon with a health care provider.² The key difference, she explained, is in the ”agreement.” This involves a conversation and partnership with the patient about care goals, options, and reasoning. Using the correct terms can make significant differences in attitude and outcomes, she explained.

Why Might Adherence to Treatment be Challenging?

The World Health Organization, in 2003, recognized several factors that might impact adherence, which can occur alone or in tandem. These include³:

• Patient-related factors
• Condition-related factors
• Healthcare system/team factors
• Socioeconomic factors
• Therapy-related factors

Patient-related factors. Examples of this type of contributor to nonadherence might include cognitive barriers, difficulty accepting a diagnosis, a distrust of medical professionals, or concerns surrounding stigma or mental health, shared Dr. Goddard. Language challenges may also play a role, she said, such as with non-English speaking patients, or those who have hearing impairments. Tone, eye contact, and other non-verbal language is also important to be mindful of in these cases.
 
One must also consider intentional versus unintentional nonadherence. This concept comes from the patient’s perspective. Intentional nonadherence is active, and a conscious choice, but unintentional nonadherence is passive.⁴ These may overlap. For instance, in compression therapy, she said, intentional nonadherence involves a patient purposefully deciding not to wear their garments due to pain or difficulty in application. However, unintentional nonadherence may occur if a patient’s insurance only covers one pair of compression stockings, and therefore they must go without compression when those garments are being cleaned. Sometimes the care team can support these circumstances with addressing discomfort, helping with resources, or taking advantage of opportunities to improve care.
 
Condition-related factors. The severity of a patient’s disease may play a role, as may comorbid conditions or a history of previous complications. For instance, Dr. Goddard pointed out that patients with significant drainage from venous ulcerations may result in necessity of dressing changes more often than prescribed, which then results in running out of dressing supplies sooner than insurance will provide for.
 
Healthcare system/team factors. It is vital to consider the impact of situations like staffing shortages, inefficient systems, reimbursement challenges, and lack of clinician support. Length and quality of clinical interaction can also be a factor, as it may result in feedback that the patient feels unheard or neglected.
 
Socioeconomic factors. Clinicians should recognize how social determinants of health affect treatment adherence, such as with limited coverage or access to care, challenges in available support, or with health literacy.⁵
 
Therapy-related factors. How frequent or complicated a treatment is may make it more difficult for a patient to adhere to the plan. This, along with potential side effects or adverse effects like pain, may pose challenges to successful execution of a treatment regimen.

Adherence and Wound Care

In wound care specifically, healing a long-standing wound may seem like an unachievable goal, or treatments may seem unreasonable to patients. This is when clear and individualized communication may help, explained Dr. Goddard. Especially when newer or emerging treatments may be best, it is important to involve patients in discussions about the rationale and potential benefit. Reimbursement is also constantly evolving, which increases risk of unexpected denials of coverage.
 
Taking a patient-centered care approach frames the interaction as one of collaboration, and one that recognizes a patient’s wishes and desires for their care.⁶ When formulating such an approach, Dr. Goddard shared that it is important to evaluate the patient’s goals for care and if they align with the treatment recommendations. This alignment, or lack of alignment should be a continuous conversation.
 
Clinicians can also work to improve that collaboration by remaining nonjudgmental in conversations, documenting thoroughly, and doing their best to recognize and reduce bias in their interactions. Assessing and reassessing health literacy is also important.

Points to Remember

Dr. Goddard encouraged the audience to cease using the term “non-compliant” when referring to a patient not following the plan of care. Instead, she stressed the importance of a deeper dive into why this behavior occurs, and helping to address contributing factors where possible. She suggested discussing proposed treatment plans in accessible terms and asking the patient to repeat their understanding back to them. Visual or audio aids can also be helpful. Social service resources are likely of use, as is utilization of the entire care team to help meet the patient’s needs and form that ideal collaborative relationship.
 
References
1.    Ruppar TM, Cooper PS, Mehr DR, Delgado JM, Dunbar-Jacob JM. Medication adherence interventions improve heart failure mortality and readmission rates: systematic review and meta-analysis of controlled trials. J Am Heart Assoc. 2016;5(6):e002606.
2.    Mir TH. Adherence versus compliance. HCA Healthc J Med. 2023;4(2):219-220.
3.    World Health Organization. 2003. Adherence to long-term therapies: evidence for action. Accessed October 18, 2023. .
4.    Bae SG, Kam S, Park KS, et al. Factors related to intentional and unintentional medication nonadherence in elderly patients with hypertension in rural community. Patient Prefer Adherence. 2016;10:1979-1989.
5.    Healthy People 2030, US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social determinants of health. Accessed October 18, 2023.
6.    Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103.