Compliance can cut costs, speed patient recovery

Patients need support system as well as education

Two-thirds of CHF patients do not comply with recommendations on diet, smoking cessation, reduced alcohol consumption, and prescriptions, according to the American Heart Association (AHA) in Dallas. In fact, half of Americans with all chronic diseases do not follow their physicians’ medication and lifestyle guidance. Prescriptions are taken improperly, 80% of patients don’t exercise enough, and only 50% of men and 68% of women recognize regular checkups as important to staying well.

"CHF costs a lot," says Randall Williams, MD, director of the CHF Program at Evanston (IL) Hospital. "And 75% of that cost is driven by hospitalizations. Sixty percent of those hospitalizations are attributed to patient noncompliance — problems with medications, diet, or self-monitoring — or to patients not notifying their providers that they are having an exacerbation." Failure to recognize symptoms is a major factor in decompensation.

Many factors affect compliance, according to the AHA, among them how easy it is to incorporate a doctor’s recommendations into the patient’s routine, the cost of care and medications, and the complexity of getting prescriptions refilled. But physicians play a role as well. Many do not incorporate compliance strategies into their practices. Some lack the skills or resources to provide counseling services, or when they do, they are not adequately reimbursed for them.

Last year the AHA launched a three-year Compliance Action Program that educates physicians, pharmacists, payer organizations, and patients. (See special quizzes for physicians and patients on compliance, pp. 41-42.)

Williams relates information about a case in point that is representative of compliance as a patient behavioral issue: A 63-year-old male with a disjointed social network and an estranged wife and grown children was hospitalized six weeks ago with CHF. He was started on a course of treatment, then discharged on therapy with instructions on how to take his medications and on lifestyle issues and dietary restrictions.

"However, he was discharged without being placed in a support system to make sure therapies were effective or that he was taking them in the recommended way," Williams says. Six weeks later he returns with an exacerbation of CHF.

"That patient typifies patient compliance-related problems," Williams says. "He was told he had CHF and needed to follow recommendations, yet no network was put in place to make sure that when he went home he would be monitored. No system would catch a problem in an early stage if the man’s health started to deteriorate." No strategy was implemented for him to change his behavior. The patient received education about what was wrong and what he needed to do and watch for.

"But as important as the education component — that just gets you in the game — is to set up a plan to keep track of the patient and reinforce what you’ve taught." If the reinforcement is not working, institute a way to catch problems early so the patient doesn’t show up in the emergency department (ED), he says.

"When a CHF patient presents in the ED, there is an 85% to 95% chance that he will be admitted to the hospital rather than treated and discharged." In the case of other chronic diseases such as asthma, patients are typically discharged from the ED. CHF patients typically show up in the ED, and then are in the hospital for several days, he says.

Adherence to a treatment plan is a major goal in managing CHF. "CHF patients are treated with multiple medications, and the combination is vital in creating the therapeutic synergy that keeps things under control. But diuretics play an important role in preventing fluid accumulation, and fluid overload is the cause of many exacerbations," says Williams. Patients sometimes have trouble taking their diuretics, especially if they’re told to take it at the wrong time of day, and they have to make multiple trips to the bathroom during the night.

"Also, patients sometimes are noncompliant with their diuretics if they are on the go. The holidays are particularly vulnerable times for patients to be noncompliant. They are not careful about diet, and they tend to travel more than usual," he explains.

Williams says smoking is the most difficult to modify of all chronic behavior. "That represents a crossroad between good sound clinical care and the issues of real world behavior interventions. You have to learn which patients have potential problems in terms of their willingness to adopt the best behaviors, and you have to come up with strategies that match those needs."

[To order a "Physician’s Compliance Tool Kit" and/or a patient education brochure "Knock Out America’s Hidden Health Threat," call the AHA at (800) 242-8721.]